**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to ensure residents were free from sexually aggressive behavior (such as making sexually explicit comments and forced observation of masturbation and exposure ) from Resident #59. The lack of action from the facility to address and protect the other residents resulted in an immediate jeopardy situation for more than an isolated number of residents. The facility was notified of the immediate jeopardy on 11/07/23 at 5:01 PM. The plan of correction, as follows, was accepted at 6:57 PM on 11/07/23: -Resident #59 will be placed on 24 hour, one on one supervision effective 5:00 pm on November 7, 2023, to protect all residents. Documentation will be done q (every) 15 minutes as to what the resident is doing, and log will be maintained. (Log attached) -An immediate report will be submitted to OHFLAC, APS, and the Regional Ombudsman on November 7, 2023. -Resident #132 will be moved over to B-Side of facility at his request. This will be done November 7, 2023. -Referral will be made for geriatric psych placement and evaluation and treatment. Upon acceptance at geriatric psych facility, Resident #59 will be admitted . -Resident #59 will not be given a roommate for a minimum of 90 days pending geriatric psych admission, pending their acceptance of resident and their recommendations. -Resident #59 will be seen by (Name of Telepsych) for medication review and recommendations. Resident is already established with (Name of Telepsych company) at Nella's at [NAME] Lake Healthcare. -Resident #59 ' s behaviors will be documented on q shift, for the next 90 days, by licensed nursing staff and will be reviewed at monthly QAPI meetings. The Immediate Jeopardy was abated on 11/08/23 at 10:41 AM. The deficient practice remained a scope and severity of G, for Resident #132 who suffered emotional harm and concern that Resident #59 would return to his room as Resident #59 remained near this resident. Resident identifiers: #59 and #132. Facility census: 79. Findings included: a) Resident #132 Review of the facility's narrative of complaints filed in the last six (6) months on the morning of 11/7/23, provided to the survey team by the Social Worker (SW) #2 found the summary dated 11/04/23: (Typed as written) (Name of Resident #132) reported that his roommate (Resident #59) asked him if he could F*** him in the a**. This resident was immediately moved to another room; he had concerns that he was still in the same hallway near (Resident #59.) Plans are being made to move (Name of Resident) to the other side of the building. Staff confirmed with (Name of Resident) and his mother that (Name of Resident #59) only made inappropriate remarks but never tried to touch (Name of Resident #59.) On 11/07/23 at 12:05 PM, the surveyor asked Resident #132 how he was. The resident stated, I'm madder than hell. When asked why, he stated, My roommate made some derogatory sexual comments to me over the weekend and now I am across the hall from him. I still have to look at him. I want moved as far away from him as I can. I want moved to the other side of the building. He can still see me, and I can still see him. He can come into my room at any time, he can walk right over to my room. The resident said when he told the staff about the incident, he was moved out of his room to a room directly across the hallway from Resident #59. Resident #132 said he called the police and wanted Resident #59 arrested. He said he was told Resident #59 had Dementia and cannot be arrested. Resident #132 said Resident #59 knows exactly what he is doing. He keeps coming to his doorway and staring at me. The resident said he was unable to get out of bed by himself and that once staff got him up in his wheelchair he was mobile. Resident #132 said if Resident #59 would get close enough to him he could hit him. He said he feared what he might do to Resident #59 if he could. Record review found Resident #132 was admitted to the facility on [DATE]. The Resident was placed in a room with Resident #59. Review of Resident #132's medical record found a nurse's note, dated 11/04/23 noting the Resident had made multiple calls to 911 for the alleged incident that occurred with the previous roommate. This nurse spoke with emergency services to let them know the Resident was not in harm. On 11/04/23 at 11:10 AM, the resident's mother wanted information regarding her son's previous hospital visits. The nurse noted his mother was not on the list of family members to have information about the resident. The nurse allowed the resident to grant permission for his mother to have information. There was no indication that the resident lacked capacity at this time. The Medical Record contained a capacity statement noting the resident had capacity to make medical decisions from a previous admission to the facility. Record review found Resident #132 was sent to the local hospital on [DATE], after the resident and his mother insisted, he be sent to the hospital. The resident left for the emergency room in the afternoon and was in the building around 4:30 PM on the same day. On 11/07/23 at 1:31 PM, the Social Worker (SW) #2 was asked if she was aware of the incident. She stated she was and provided witness statements. SW #2 said the incident was not reported to the proper State authorities. She said she did not know why but Resident #59 hadn't done anything else. The SW provided a copy of a Complaint, Comment Concern Resolution, dated 11/04/23: The form noted Resident #132 reported his roommate (Resident #59) asked him if he could F*** him in the A**. Resident #132 was immediately moved to another room. When Resident #132 was still concerned because he was only moved across the hall, Resident #132 was moved to the other side of the building. The follow up resolution was: Resident #132 was satisfied with the resolution of moving him to the other side of the building. The form was signed by the administrator, Director of Nursing (DON) and the Social Worker on 11/06/23. Observation on 11/07/23 during the morning, found the Resident had never been moved to the other side of the building. On the morning of 11/07/23 the Resident was observed by the survey team to be directly across the hallway from his old roommate, Resident #59. Statements attached to the complaint included: A statement from a Licensed Practical Nurse (LPN) #36, dated 11/04/23 at 1:52 PM, Revealed the LPN received a telephone call from the Resident's sister stating she wanted to report a sexual assault against her brother. The sister was at the hospital with Resident #132 when the call was made to the facility. The LPN spoke to the sister and the resident who related the same story regarding Resident #59. Resident #132 denied being physically touched by Resident #59. The LPN said she would tell the social worker and the administrator about the situation. A second statement from Nurse Aide (NA) #23 revealed the resident had reported the incident to her and said Resident #59 was whispering things to him in the night saying he wanted to F*** him in the A**. Then his mother came in and they started the process of sending him to the hospital. She stated she reported it the first chance she had because of everything going on. The statement was signed by NA #23 but was not dated. A statement dated 11/4/23 from the activity assistant (AA) #28 documented she was also aware of the situation after the Resident told her what the roommate #59 said. Resident #59 asked if he could F*** him in the A**. At 9:40 AM on 11/08/23, LPN #36 said she became aware of the situation after Resident #132's sister called her on the telephone when the Resident was in the emergency room. She said she called the administrator to let him know. She said she did not report the incident because no one told her to. At 9:44 AM on 11/08/23, NA #23 said she became aware of the situation around breakfast on the morning of 11/04/23 when Resident #132 told her what happened. She said it was a busy morning and she forgot to tell the nurse about it. It was a busy morning, because Resident #132 wanted to go to the hospital because he said he needed to get the fluid drawn off of him. I was trying to get him ready to go out. At 8:06 AM on 11/08/23, Resident #132 said, I feel like I have no rights, they are supposed to listen to me, I know I have rights. b) Resident #59 Record review found the Resident was admitted to the facility on [DATE]. Review of the Resident's most recent Minimum Data Set (MDS) a quarterly, with an Assessment Reference Date (ARD) of 10/29/23 found this resident is ambulatory and transfers are independent, and no staff assistance is required. Review of daily progress notes found no notes were written on 11/04/23 regarding the alleged incident in this Resident's record. No notes of any kind were written about this Resident on 11/04/23. Review of the progress notes for this Resident from 02/01/23 to present found the following documented behaviors: The Resident's responsible party was notified on 02/28/23, by the SW that he was being admitted for a psychiatric stay due to recent inappropriate sexual behaviors. The behaviors leading up to the hospitalization included: 2/2/2023 03:11 General Nurses Note Note Text: Aid reported to nurse that while showering him he asked if she wanted to play with this while holding his penis in his hand. Aid explained to him that that was inappropriate. While aid was helping resident to dry off and get dressed he again while holding his penis asked her if she would play with it. Aid again explained that that was inappropriate and that he needed to stop. A note dated, 02/06/23 at 5:30 PM, General Nurses Note At approximately 5:30 CNA (Certified Nurse Aide) approached undersigned and another nurse and stated that this male resident had exposed himself to a female resident in B side dining room. CNA informed that female was immediately escorted from dining room and taken to her room. A note dated 2/23/2023, 00:09 General Nurses Note Note Text: Resident was seen multiple times by staff member with private areas exposed in the common area in front of a female resident trying to get her touch him inappropriately. Resident was redirected each time. (This incident was reported to the proper State Authorities.) The Resident was sent to the psychiatric facility on 02/28/23 and returned to the facility on [DATE]. Progress notes indicated the Resident's behaviors continued after his return to the facility: 3/28/2023 01:33 General Nurses Note Note Text: Resident was found playing with penis in hallway while female residents were in hallway multiple times during the shift. This nurse has made multiple attempts to keep residents in room. Resident becomes aggressive when room door is shut. Attempted to redirect with snacks/drink and conversation no effect. Resident at this time is sitting at bedside. Call light within reach. 3/30/2023 02:05 General Nurses Note Note Text: resident was in his room standing in front of door holding his penis in his hand, CNA asked him to shut door if he was going to do that. Resident redirected. 5/5/2023 05:31 General Nurses Note Note Text: while CNA'S doing rounds noted resident standing in doorway with his pants pulled down, holding his penis in his hands looking into the ladies that live across the hall's room. Redirected resident, he became slightly upset but pulled his pants up and laid down on his bed. 6/13/2023 02:00 General Nurses Note Note Text: CNA doing rounds, saw this resident in room [ROOM NUMBER]. hiding between the bed and sink asked resident what he was doing. He stated 'she waved her hand for me to come over there.' Explained to resident that was a males room and he is sleeping. Assisted resident back to his room. Explained to him if he needed anything to ring his call bell. 7/26/2023 02:51 General Nurses Note Note Text: resident up sitting in dining room when Resident #21 went by him he took his penis out of his pants and was trying to show it to her. Resident was educated to how inappropriate that was and assisted back to his room. 7/27/2023 02:38 General Nurses Note Note Text: Resident ambulating throughout facility grabbing at groin. Resident was redirected to room. Resident sitting on side of bed. Denies any pain or discomfort at this time. 7/31/2023 03:45 General Nurses Note Note Text: This nurse was walking down hallway when passed residents room when he was playing with self in doorway with door open. Attempted to close door when resident became agitated grabbing at door. This nurse redirected resident to laying down in bed. Call light within reach. Review of the care plan found the following: The resident has a behavior problem r/t (Related to) sexually inappropriate behaviors, exposing self to others. Date Initiated: 02/06/2023. Revision on: 02/28/2023 No changes noted, continue goals. Date Initiated: 04/27/2023 The goal associated with the problem: Behaviors have lessened since last review. Continuing goals. Date Initiated: 07/28/2023. Revision on: 11/01/2023 Target Date: 01/28/2024 The resident will have fewer episodes of sexually inappropriate behaviors weekly by review date. Date Initiated: 02/06/2023 Revision on: 11/01/2023 Target Date: 01/28/2024 No behaviors noted. Continue goals. Date Initiated: 11/01/2023 Interventions included: Anticipate and meet the resident's needs. Date Initiated: 02/06/23 Revision on: 02/06/23 Attempt to redirect resident when behaviors occur. Date Initiated: 02/06/23 If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Date Initiated: 02/06/23 Revision on: 02/06/23 Monitor behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Date Initiated: 02/06/23. Revision on: 02/06/23 Notify Social Worker as needed. Date Initiated: 02/06/2023. Psych eval and inpatient if needed. Date Initiated: 02/24/2023. At 3:38 PM on 11/07/23, the administrator and the Director of Nursing reviewed the care plan and were asked: How does the facility monitor the Resident's behaviors and how is the cause of the behaviors determined as indicated in the care plan? In addition, the administrator and DON were asked: Who are the other residents involved in the nursing notes in Resident #59's chart? Were incident reports completed? Were any of the incidents reported to the proper State authorities? How are the other residents being protected from Resident #59's behaviors? The DON said the Resident saw a tele-med psychiatrist. Review of the tele-med psychiatrist notes with the DON, found the resident had a visit on 03/30/23 and the psychiatrist noted, .Resident has had no further behaviors . Yet behaviors were recorded on 03/28/23, when the resident was found playing with his penis in the hallway while female residents were present. The attempts at redirection were unsuccessful. The next tele- med visit was on 06/08/23 again the psychiatrist documented no behaviors. The resident did have behaviors on 05/05/23. On 08/25/23, the psychiatrist documented the resident had no behaviors, yet behaviors were documented on 07/26/23, 07/27/23 and 07/31/23. The DON had no answer as to why the psychiatrist did not know about the behaviors. The DON was asked if the facility should be responsible for telling the psychiatrist about the Resident's behaviors? She said yes but could not explain how the psychiatrist did not know about the behaviors. On 11/08/23 10:09 AM, the DON identified Resident #21 from Resident #59's 07/26/23 progress note. A review of Resident #21's progress notes found no notes were written in her medical record regarding the incident on 07/26/23. At the close of the survey no further information was provided regarding how Resident #59's behaviors affected other residents. No information was provided to indicate the facility provided daily monitoring of Resident #59 before the alleged incident on 11/04/23. No information was provided to verify the facility reported the alleged incidents involving other residents after the 02/23/23 reporting.