**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed to protect the residents' right to be free from sexual abuse by another resident for 3 of 6 (Resident #1, Resident #6, and Resident #9) sampled residents reviewed for abuse. At an unknown date and time between [DATE] - [DATE], Resident #1 who was severely cognitively impaired was sexually assaulted by Resident #6. Resident #6 who was moderately cognitively impaired was found naked from the waist down and had climbed into his roommate's bed (Resident #1) and attempted sexual intercourse. Certified Nursing Assistant (CNA) C observed that the lights were off, the curtain was pulled between A and B bed, and Resident #6 was on top of Resident #1 (B bed). CNA C screamed for assistance. Licensed Practical Nurse (LPN) A and CNA K arrived to assist CNA C. It took the 3 staff members to remove Resident #6 off Resident #1. Resident #6 remained in the facility without any documented supervision until his discharge on [DATE] at 11:03 AM. On [DATE], Resident #9, who had a BIMS of 15, reported to Family Member (FM) O while she was visiting the facility, that Visitor P had touched her inappropriately. Resident #9 reported Visitor P leaned in for a kiss and grabbed her breast. Resident #9 reported Visitor P had touched her inappropriately every Monday, Wednesday, and Friday during bingo activity. FM O contacted a family friend (Named Lieutenant #1) who contacted Visitor P, who admitted to touching and sexually assaulting Resident #9. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to perform a thorough investigation related to Resident #1's sexual abuse, placed all residents at risk. The facility's failure to adequately supervise and manage Resident #6's sexual behaviors put Resident #1 and other vulnerable residents at risk for serious harm, serious injury, serious impairment, or death. The facility's failure to protect Resident #9 from sexual abuse resulted in sadness and anxiety. The facility's failure to recognize and evaluate Visitor P's continued visits and inappropriate touching placed all residents at risk for serious harm, serious impairment, or death. The Regional Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy for F-600 on [DATE] at 2:48 PM, in the Conference room. The facility was cited at F-600 at a scope and severity of J, which constitutes Substandard Quality of Care. A partial extended survey was conducted from [DATE] through [DATE]. An acceptable Removal Plan, which removes the immediacy of the Jeopardy for F-600 was received on [DATE]. The Removal Plan was validated onsite by the surveyor on [DATE] through audit review, medical record review, observation, review of education records, and staff interviews. The IJ began on [DATE] and was removed on [DATE]. The facility's noncompliance at F-600 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility policy titled, Patient Protection and Response Policy for Allegation/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated [DATE], revealed .Abuse.will not be tolerated by anyone, including staff, patients.friends, visitors or any other individual in this center. The patient has the right to be free from abuse.Abuse.the willful infliction of injury, unreasonable confinement, intimidation.Sexual Abuse.non-consensual sexual contact of any type with a patient that includes but is not limited to, sexual harassment, sexual coercion, or sexual assault.The center [facility] will provide supervision and support services designed to reduce the likelihood of abusive behaviors.All supervisory partners who receive reports of and/or identify inappropriate behaviors will take immediate steps to correct such behaviors.The right to report a concern or incident is not limited to a formal, written grievance process but includes any verbalized complaint to any center partner.The center will not retaliate against any partner who makes a report.Patients with needs and behaviors that might lead to conflict with partners or other patients will be identified by the Care Planning team, with interventions and follow through designed to minimize the risk of conflict.Identification of patients whose personal histories render them at risk for abusing other patients or partners.Assessment of appropriate intervention strategies to prevent occurrences.Any patient event that is reported to any partner by patient, family, other partner or any other person will be considered an allegation of.abuse.Any complaint of sexual harassment, sexual coercion, sexual assault, or inappropriate touching.Any partner having either direct or indirect knowledge of any event that might constitute abuse.must report the event immediately.not later than 2 hours after forming the suspicion if the events that cause the suspicion involve abuse.It is the policy of this facility that abuse allegation.are reported per Federal and State Law.The Administrator or Director of Nurses will determine the direction of the investigation once notified of alleged incident.The investigation is conducted immediately under the following circumstances.When it is identified that an alleged incident may have occurred.As soon as any partner has knowledge and reports an alleged event.When there is a question as to whether to conduct an investigation, it is best to do so.The results of all investigations will be completed within five working days of the incident.Staff will respond immediately to protect the alleged victim.Any individual found to be in danger of injury will be removed from the source of the suspected abusive behavior including but not limited to room or staffing changes.to protect the patient(s) from the alleged perpetrator.Medical and emotional support will be made immediately available to any individual suffering.alleged abuse.Examining the alleged victim.physical examination or psychosocial assessment if needed.alleged sexual abuse.evaluation of whether the patient has the capacity to consent to the sexual activity.Increased supervision of the alleged victim and patients. 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses which included Dementia, Delirium, Paroxysmal Atrial Fibrillation, Blindness (left eye), and Adult Failure to Thrive. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had severe visual impairment, and poor short-term and long-term memory. Resident #1 required substantial/maximal assistance with toileting, shower/bathing, dressing, and bed mobility. Review of the Progress Notes dated [DATE], revealed .6:40 AM Resident's wife.notified of incident. [Resident's wife] Will come in this AM, to check on him. MD [Medical Director] and management staff notified as, well. Review of the Progress Notes revealed no physical assessment or notes for Resident #1 related to an incident on [DATE]. Review of the Census revealed Resident #1 had a room change on [DATE] at 8:21 AM. 3. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses which included Diabetes Mellitus, Dementia, Traumatic Brain Injury (TBI), and Schizoaffective disorder. Review of the Physician's order for Resident #6 dated [DATE], for Resident #6 revealed an order to record behaviors and interventions in care assist resident tasks every shift, day and night. Review of the Psychiatric Progress Note for Resident #6 dated [DATE], revealed .Others observed [Named Resident #6] displaying a suspicious demeanor and other signs of paranoid process .He has verbalized some grandiose ideas regarding his finances .He moved rooms today due to conflicts with his roommate. He reports a verbal altercation with his previous roommate .Increase Zyprexa [antipsychotic medication used to treat mental health conditions such as Schizophrenia] . Review of the Resident Orders for Resident #6 dated [DATE], revealed an active order for wanderguard [a device to monitor and prevent at risk residents from wandering out of designated areas] placed to left ankle and inspect skin under wanderguard every shift day and night. Review of the quarterly MDS assessment dated [DATE], revealed Resident #6 had a BIMS score of 9, which indicated moderate cognitive impairment. Resident #6 had physical behaviors toward others on 1-3 days of the assessment period. Resident #6 required supervision with dressing, toileting, personal hygiene and could walk independently 50 feet with two turns. Review of the Progress Notes for Resident #6 dated [DATE], revealed .was more confused trying to get out through the breakroom door .He had left his walker behind .redirected only to come back a few minutes later trying to get out again . Review of the Progress Notes for Resident #6 dated [DATE], revealed a change in condition noted for exit seeking more often, increased confusion, and difficult to redirect in certain conditions. On [DATE] at 2:52 PM, the Physician was notified and gave a new order for Olanzapine (antipsychotic medication given to treat certain psychiatric disorders) 2.5 milligram (mg) every AM and psych consult on next visit. Review of a typed statement completed by the Administrator dated [DATE], revealed .DOSS [Director of Social Services] and Administrator were called on the night of [DATE] [2024] in regards to [Named Resident #6] on top of [Named Resident #1]. DOSS and Admin arrived to center after patients had been separated. Upon interviews with staff [Named Resident #1] remained asleep in bed during the entire event. [Named Resident #1] was fully clothed and had blankets on top of him. [Named Resident #6] had attempted to climb in bed with [Named Resident #1] and did not want to exit the bed, requiring multiple staff members to assist him. [Named Resident #1] was assessed and had no injuries. [Named Resident #6] was escorted to the dining room where he was notably confused. When questioned by Administrator he stated that he had not seen his roommate for several hours today and had been on the porch for most of the day. Room change was provided for [Named Resident #1] and an inpatient psych referral was sent for [Named Resident #6] . Review of an undated written statement completed by CNA C revealed, .I put [Named Resident #1] in bed cause [because] He was ready to lay down. I went to check on him to make sure he was still in bed. I knock on the door and find [Named Resident #6] on top of him. I asked him to get down off of him and he refused to get down off of him. I stay by the door hollering for the nurse to come down to the room to help me to get [Named Resident #6] off of his roommate . Review of the Progress Notes for Resident #6 completed by Social Services dated [DATE] at 10:19 PM, revealed, This staff made referrals to [Named Psychiatric Facility #1 and Psychiatric Facility #2] due to behaviors for inpatient psych evaluation. He [Resident # 6] was accepted at [Named Psychiatric Facility #2]. All needed paperwork was sent .they [Psychiatric Facility #2] is setting up transport .Nursing was given contact information to call report . Review of the Resident Orders for Resident #6 dated [DATE], revealed an order to transfer to [Named Psychiatric facility #2]. Resident #6 was discharged to Psychiatric facility #2 on [DATE]. Review of Psychiatric Facility #2's Nursing Assessment for Resident #6 dated [DATE], revealed .Pt [Patient] is A&O x2 [Alert and oriented to person and place] .independent with ADL's [Activities of Daily Living] .Pt verbalizes he lives at home alone and he was having sex and they broke in on him Review of Psychiatric Facility #2's Psychiatry Progress Note for Resident #6 dated [DATE], revealed .Patient seems very confused and has difficulty giving information. Patient is wandering into other patient's rooms. Patient was found sleeping on other patients bed . Requires frequent redirection . Resident #6 was readmitted to Facility #1 on [DATE]. Review of Resident #6's care plan revealed a focus for behaviors, at risk for complications related to Schizophrenia, Dementia, and TBI revealed an approach with start date [DATE], .Resident will have a private room . Review of the Psychiatric Progress Note for Resident #6 dated [DATE], revealed Pt [patient] was treated inpatient psych after some inappropriate behaviors that could not be redirected and was readmitted on 10-3 [[DATE]] . Review of the care plan with goal date of [DATE], revealed, .Will not exhibit inappropriate sexual behavior/comments .Will not harm self or others .Will not use abusive verbal language .thru 90-days from .last review . During an interview on [DATE] at 12:50 PM, Anonymous Staff Member M stated, .[Named Resident #6], I have witnessed him make inappropriate comments to other staff members, he will pat his private and motion for them to come to his room.the staff found him in the bed with his roommate, he also done this at the psych unit.he was not clothed.the staff made written statements and staff were asked to change the statements.his roommate wasn't very verbal, his wife would visit.he stayed in his room most of the time.Anonymous Staff Member M did not elaborate on who had asked them to change their statements. During an interview on [DATE] at 10:40 AM, the Administrator stated, .myself and the [Named DOSS] came in that night [on [DATE]] This surveyor asked the Administrator to explain what sexual abuse entails. The Administrator stated, .I would have to read the definition in the policy.I am not the abuse coordinator. The facility policy on sexual abuse was read to the Administrator. The Administrator was asked if this altercation between the 2 residents (Resident #1 and Resident #6) would be considered sexual abuse. The Administrator stated, .[Named Resident #6] had on a diaper. The Administrator was asked if she witnessed the altercation. The Administrator stated, No. The Administrator provided 2 statements (1 statement from CNA C and the other was her typed statement) related to the altercation. The Administrator stated, .I assume his [Resident #6's] intent was to get in bed.you slept with someone your entire life, then you go to a twin bed. The Administrator was asked why Resident #6 was transferred to the psych facility after this altercation. The Administrator stated, .increased behaviors, getting in his roommate's bed, increased confusion. The Administrator was asked what time this incident occurred. The Administrator stated, .I don't remember the time exactly.I don't know why the nurse didn't document [referring to charting the incident].[Named Resident #1] had a room change [after the incident] and a partner [staff member] stayed outside the doorway for [Named Resident #6]'s room.I would have to look in the computer to see what was done after he returned to the facility. The Administrator was asked why she and the DOSS came to the facility that night. The Administrator stated, .because the staff said it required more than one person to remove him [Resident #6] from the bed.I just live down the road.[Named Resident #1] could not recall anything, he was asleep during the entire event.I know we had more than those 2 pages [referring to written statements from the staff present] about the incident.[DOSS] made a referral at 10:19 PM due to his [Resident #6] continued confusion.obviously we didn't want [Named Resident #6] to continue that behavior.think the [DOSS] done [did] some extra visits with [Named Resident #1] .[Named Resident #6] was moved to a private room. The Administrator was asked how she would feel if another male got into the bed with her. The Administrator stated, .I would be surprised if it woke me up.wife [of Resident #1] never told me anything about [Named Resident #1] reporting he was raped. The Administrator was asked if she interviewed [Named Resident #1] she stated, .I remember interviewing him. Resident #1's typed interview statement was not provided to this surveyor with the 2-page investigation the Administrator presented on [DATE] at 9:30 AM. Resident #1's statement, which was typewritten questions dated [DATE] with no time or signature of who completed the question and answers, was given to this surveyor on [DATE] at 10:00 AM. During a telephone interview on [DATE] at 11:17 AM, the Psych Nurse Practitioner (NP) stated, .I see in my note [[DATE]] that I documented inappropriate behavior but I don't know what the behaviors were.[Named Resident #6] was on my regular caseload due to history of agitation, delusions, Schizophrenia, and grandiosity behaviors.I did not see [Named Resident #1] on my regular caseload. During a telephone interview on [DATE] at 11:55 AM, LPN L stated, he [Named Resident #6] climbed into bed with roommate [Named Resident #1] . During a telephone interview on [DATE] at 12:21 PM, LPN A stated, .I was called by a tech [CNA C].the CNA was in shock.she kept saying come, come.I ran to her.I saw [Resident #6] on top of him [Resident #1] humping him, he [Resident #6] was naked from waist down, I turned the light on, I was saying get off of him.he was fighting us.he elbowed me.all the nurses in the building came to help me.it took [LPN B, me and CNA C] to get him [Resident #6] off [Resident #1].he [Resident #6] had an erection.[Resident #1] had the covers pulled off of him but he had on a diaper .he was just lying there not doing anything .[Named Resident #1] was a wanderer and [Named CNA C] keeps a close eye on him to make sure he is still in the bed .we checked to see if [Resident #1] had any fluids on him and make sure his skin looked ok [Resident #6] put his pants back on .we called the Director of Nursing [DON] but she wasn't able to come out because her tires were messed up and she called the Administrator .this happened about midnight .we moved [Resident #1] to another room .I told the Administrator [Resident #6] yelled at me because I turned the light on and I didn't want him attacking someone else, are we not going to call the police and she [Administrator] said I am going to make some calls then she came back and said she will take care of it tomorrow .we all wrote statements and she [Administrator] collected all the papers .something else should have been done . LPN A stated, .I called [Resident #1]'s wife, I let her know the roommate was a little rough with her husband and gave her the new room number for her husband .I thought [Named DOSS] would discuss what happened with her .I called the other nurse [LPN B] from the other side of the building to help that night .I came back to the building the next morning and [Named Resident #6] was still in the building .I was really upset .I told [Named DOSS] aren't you the Abuse Coordinator, why is [Named Resident #6] still in the building and he said well the whole thing was exaggerated, I said ‘no, no' what kind of investigation did you do you didn't call none of us, I been home all day, get him out of here .finally he came back to me and said they [Named Psychiatric Facility #1] are going to pick him up .I felt like I [had] done what I was supposed to do . During a telephone interview on [DATE] at 12:45 PM, CNA K stated, .I was working that night .it happened around 12:10 [AM], a little after midnight .[Named CNA C] was yelling get the nurse, she couldn't leave the room .screaming hurry, hurry .I yelled for the nurse and went down to the room .[Named Resident #6] was on top of him [Resident #1] naked .he was doing it, he had an erection .it took all of us to finally get him off of him [Resident #1], he [Resident #6] was fighting us .he punched [Named LPN A] .he said I was having sex you never seen two people on top of each other .we asked the Administrator about filling out statements and she said she didn't need our statements .we will deal with that tomorrow . During an interview on [DATE] at 3:00 PM, CNA H stated, .[Named Resident #6] touched another [Named Resident #1] in a sexual way .the staff walked in and [Named Resident #6] was on top of him naked moaning and groaning .it was all the way sexual abuse and physical .[Named Resident #1] was blind .they were roommates .he [Resident #1] couldn't tell you what was going on in the moment . During a telephone interview on [DATE] at 8:18 AM, LPN B stated, .I was in a resident room, and I heard a CNA scream we need you .I go down to the room [Resident #1 and Resident #6's room] I see [Named CNA C] and [Named LPN A], [Named Resident #1] was on his back, clothed . [Named Resident #6] was naked from waist down straddling him thrusting, you could see it in his butt muscles, he had an erection .we were trying to get him off of him and he [Named Resident #6] saying turn off the lights, it took all 3 of us .fighting us .he was a big guy .he [Named Resident #1] was just lying there with eyes closed, hands across his chest, probably praying it would go away .[Named CNA K] called the DON she couldn't come but the Administrator came .I know [Named LPN A] called [Resident #1]'s wife and she [LPN A] called [Named Medical Director #1] .I thought [Named LPN A] done a note but she said the note disappeared .it was sexual abuse .I wrote a statement, I remember because it was a full page .the Administrator said we will figure this out in the morning .I never seen [Named DOSS] that night .I was never called about the incident .the police was not called . During a telephone interview on [DATE] at 10:08 AM, CNA C stated, .I witnessed it .I went down to check on [Named Resident #1] because he would wander sometimes .[Named Resident #6] was on top of him naked, I yelled to get someone down here .he [Resident #6] was humping the other man [Resident #1] .I felt so sorry for that man .the curtain was pulled between the beds .I just couldn't believe what I seen .I kept telling him get off of him, he was fighting us .very combative .the nurses helped me .[Named Resident #1] was just lying there .the nurses called the Administrator .the police wasn't called .we moved [Named Resident #1] .[Named Resident #6] didn't get sent out until the next day . During a telephone interview on [DATE] at 2:50 PM, the Intake Representative from Psychiatric Facility #2 was asked the reason Facility #1 needed an inpatient psychiatric stay for Resident #6. The Intake Representative stated, .[DOSS] made a referral related to exit seeking and increase confusion .description was left blank . On [DATE] at 3:04 PM, the Intake Representative from Psychiatric Facility #2 called this surveyor back and stated, .I found in the nursing assessment where he told the nurse, he was having sex, and someone broke in on him . During an interview on [DATE] at 12:42 PM, DOSS stated, .[Named Resident #6] got in bed with [Named Resident #1], nothing sexual .[Named Resident #6] had his clothes on .I am not sure statements were taken from [Named LPN A] .the residents were separated .immediate room change .the Administrator got the statements .I am the Abuse Coordinator .Administrator and I work on investigations together .the Administrator let me know about the incident, I made a referral to psychiatric units because he [Resident #6] was packing his clothes, wandering toward the exit doors, fixated on winning [the] lottery . DOSS was asked to review the census report, and he confirmed [Named Resident #1] changed rooms on [DATE] at 8:21 AM. DOSS was asked when the incident occurred between Resident #1 and Resident #6. He stated, .earlier part of the evening [[DATE]] . DOSS stated, .I don't know the exact time .I don't recall when the Administrator called me .behaviors documentation should be in progress notes .I don't review behavior notes .the concern was his [Resident #6]'s increase in behaviors .I told the staff I can't just drop him off, I contacted two different agencies . DOSS was asked what was put in place to protect the other residents in the facility from Resident #6. DOSS stated, .he was in a room alone .he could walk .staff was alerted to do rounds, he wasn't placed on 1 on 1 supervision .I wasn't involved in getting statements from staff . DOSS was asked to review the care plan and confirmed the sexual inappropriate behaviors [for Resident #6] were added on [DATE]. DOSS stated, .I cannot recall what his sexual inappropriate behaviors were .care plans usually added by nursing. He [Resident #6] was in a private room until he was deceased . DOSS was asked how he would feel about another person getting into bed with him. DOSS stated, .definitely uncomfortable .I didn't interview [Named Resident #1], he was interviewable, but he would say nonsensical words. He had dementia . DOSS was asked as the Abuse Coordinator what would he want to make sure happened with (Named Resident #1). DOSS stated, .make sure his psychosocial needs were met . The DOSS confirmed no progress note was completed about the incident or why [Named Resident #1] changed rooms. DOSS acknowledged the investigation should include statements from the staff who witnessed the incident, should be reported to the state in 2 hours, and a follow up investigation due on the 5th day. During an interview on [DATE] at 1:56 PM, the MDS Coordinator was asked when and why inappropriate sexual behaviors were added to Resident #6's care plan. The MDS Coordinator acknowledged inappropriate sexual behaviors was added to [Named Resident #6]'s care plan on [DATE] but was unsure if this was reported during a morning meeting or the psych provider reported these behaviors. During a telephone interview on [DATE] at 7:35 PM, LPN D was asked if she was aware of the incident between Resident #1 and Resident #6. LPN D stated, .I was working on the other side of the building and a CNA came running said [Named LPN A] needed help .I thought a code or something had happened .[Named CNA C] looked shocked .the staff was trying to get [Named Resident #6] off of his roommate, he was on top of him .he [Resident #6] was walking around the room naked after they got him off his roommate, I stayed right there with him.he was laughing and putting on his basketball shorts .[Named CNA C] was torn up about it .the staff got [Named Resident #1] up and brought him to the nurses station .[Named LPN A] made phone calls to the Administrator .I am not sure why the Abuse Coordinator didn't come out .I was never asked to write out a statement .the Administrator said ‘we will take care of it in the morning' .[Named LPN A] was upset because [Resident #6] was still on her hall .she went to the [DOSS] about it and he said the situation was exaggerated .she told him I will call the police if you don't do something .[Named Resident #6] was definitely on top of him naked and moving, took 3 people to get him off the other resident . During an interview on [DATE] at 4:00 PM, the DON reviewed the progress notes for Resident #1 and Resident #6 and acknowledged there was no incident documentation. The DON was asked if she would expect the nurse to chart a resident-to-resident altercation. The DON stated, .not always in progress notes, usually in behavior care assist [an area of electronic charting where nursing can chart behaviors] .my expectation would be documentation in the behavior care assist, CNAs and nursing can chart there .The DON acknowledged no behaviors were documented in Resident #1 and Resident #6's behavior care assist notes. During a telephone interview on [DATE] at 6:50 PM, Registered Nurse (RN) U stated, .I forwarded the times to you [Surveyor] I received a call from the facility when [Named Resident #6] was found on top of [Resident #1] and when I called the Administrator .I got the call at 12:16 AM on early morning of [DATE], and I called the Administrator right after that . The call log revealed the call to [RN U] at 12:16 AM and immediately after a call to the Administrator. During an interview on [DATE] at 1:30 PM, an anonymous Staff Member #3 stated, .I came in the next morning [[DATE]] I got report that morning from [Named CNA C] she reported [Named Resident #6] had his pants down when she found him .she was very shaken up about it . During an interview on [DATE] at 3:30 PM, the Administrator stated, .I don't know that we talked about it [Incident between Resident #1 and Resident #6] in QAPI [Quality Assurance Performance Improvement]. The Administrator was asked if behaviors were discussed with monthly QAPI meetings. She stated, .behaviors discussed in morning meetings, if they [referring to management] had knowledge of the event .One on one is not always the correct thing to do with abuse . 4.Review of the medical record revealed Resident #9 admitted to the facility on [DATE], with diagnoses which included Hypertensive Heart Disease, Heart Failure, History of falling, and Osteoarthritis. Review of the Annual MDS assessment dated [DATE], revealed Resident #9 had a BIMS score of 15, which indicated intact cognitive abilities. Review of a letter from Visitor P to Resident #9 post marked [DATE], revealed After the phone call from [Named Family Member F] I felt really bad and hurt about myself for making you feel uncomfortable with my visits .I asked God to forgive me for the things I said and done. I know I done wrong .I can't undo the past, but I ask and hope you will forgive me also . Review of the Police Incident Report Form dated [DATE] at 10:22 AM, revealed .Address of Incident: [Facility #1].Offense Number One.Sexual Battery.Offender #1.[Named Visitor P].Victim.[Named Resident #9].On.XXX[DATE] at 1017 [10:17 AM] hours, I was dispatched to [Named Facility #1].in regards to Sexual Assault between a patient and a visitor.[Named Administrator] , who advised she has a resident, [Named Resident #9] who reported being sexually assaulted.[Named Resident #9] stated it had been happening for at least the last month and a half.[Named Administrator] stated that [Named Resident #9] has had a visitor, a family friend, [Named Visitor P] visit every Monday, Wednesday, and Friday. During the times [Named Visitor P] visits, [Named Administrator] stated she was told by [Named Resident #9] that [Named Visitor P] made numerous attempts to kiss her on the mouth, touching her on the thigh and touching her breast.[Named Resident #9] is alert and oriented and is in good mental health.[Named Family Member O] advised she had a conversation with [Named Resident #9] on [DATE] at [Facility #1].[Named Resident #9] told her that she was being touched inappropriately and that [Named Visitor P] leaned in for a kiss and grabbed her breast.touched inappropriately every Monday, Wednesday, and Friday.the incident occurs at bingo also.she used to be comfortable with her living arrangement but is not anymore due to [Named Visitor P]. She is in fear that he will still find his way into [Facility #1].[Named Resident #9] stated she never provided consent to being touched inappropriately.[Named Family Member O].stated that she made contact with [Named Lieutenant #1].he spoke with [Named Visitor P] and.admitted to touching and sexually assaulting [Named Resident #9].He admitted that this past Friday he was with her at [Facility #1] and that they were playing bingo. He stated that he was holding one side of the card and she was holding the other side. He stated that he leaned over so she could mark the box