**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident observations and staff interviews the facility failed to ensure Resident #91 was free from nonconsensual sexual contact. In addition the facility failed to ensure Resident #75 was free from verbal abuse. The occurances with Resident #91 and Resident #75 both constituted an Immediate jeopardy (IJ) situation. The state agency (SA) determined the failure to protect Resident #75 from verbal abuse caused Resident #75 fear and anxiety due to verbal abuse from Licensed Practical Nurse (LPN) #28. At the time of the incident Resident #75 was unable to verbalize how this made her feel due to thinking the Facility administration would retaliate against them. Emotional and psychological abuse can have severe short- and long-term effects. This type of abuse can affect both your physical and your mental health. You may experience feelings of fear, confusion, anxiety, shame, guilt, frequent crying, and up to suicide or death. This action not only harmed Resident #75 but placed the remaining 110 residents in an IJ situation because LPN #28 was still employed at the facility and residents voiced fear of her. The facility was first notified of the IJ pertaining to Resident #75 at 2:09 PM, on 05/28/24. The state agency (SA) received the Plan of Correction (POC) at 5:00 PM on 05/29/24. The SA accepted the POC on 05/29/24 at 5:22 PM. The SA observed for the implementation of the POC and the IJ was abated on 06/04/24 at 4:23 PM. In regards to Resident #91 who suffers from end stage dementia and is rarely/to never understood. The staff found Resident #91 and Resident # 61 in bed together on 04/07/24. Through the course of their investigation, they contacted the healthcare decision maker who stated that it was okay and just a way of life and if both wanted to do it to let them have privacy to do it. After this conversation with the family member of Resident #91 the Social Worker stopped her investigation and the facility entered the following intervention on Resident #91's care plan: When resident is displaying sexual behavior and both resident and male resident are willing, Staff to provide privacy for residents, but if behavior is unwanted by either residents, staff to provide redirection. The results of the investigation were that no sexual abuse occurred. Interviews with the Social Worker, Nursing Home Administrator, and the Director of Nursing found none of the three was able to verbalize how Resident #91 was able to consent to sexual contact. They all indicated Resident #91 was seeking out Resident #61 and they felt that was her consent because she sought him out and sat on his bed. The behaviors exhibited by Resident #91 is consistent with her diagnosis of End Stage Dementia and does not constitute consent to sexual contact. The facility's failure to assess Resident #61 for the ability to consent for sexual contact, combined with there thoughts of her consent being constituted by her wandering and setting on Resident #61's bed, and the care plan that indicates the family said if it was okay with both residents to provide them with privacy put Resident #91 in an immediate Jeopardy (IJ) situation. The facility was notified of this IJ at 10:57 am on 05/30/24. The State Agency (SA) accepted the facility's plan of correction (POC) at 4:01 PM on 05/30/24. After review of the implementation of the POC it was determined the IJ was abated at 4:23 PM on 06/04/24. Resident Identifiers: #91 and #75. Facility Census: 111. Findings Include: a) Resident #75 An interview with a Resident who wishes to remain anonymous due to fear of retaliation found they can hear LPN #28 coming and thinks lord please don't let her (staff #28) be in a bad mood. Anonymous resident states LPN #28 has a mean streak and I know my boundaries and stay away or just be quite and continued to say how they get upset and cry with fear of LPN #28. Resident # 75 stated on 05/29/24 at 10:45 AM, LPN #28 still yells a lot to other people and holds herself up to a higher standard. If LPN #28 has to supervise the resident smoke break. She states I hope yall know if someone dies it's your fault because I'm not there to help this statement was made last week. Resident # 75 also states they punish you around here like forgetting to feed you or answer the call light and will not give you a shower. On 05/30/24 at 11:56 AM Resident #21 stated she is concerned for the other residents in the facility. She can hear staff members yelling at them when they don't eat fast enough. On 5/28/24 at 10:00 AM, an interview with the Administrator regarding LPN #28 verbally abusing resident, the Administrator stated, she had been reported and investigated and taken care of. On 5/29/24 at 11:20AM, an interview with Director Of Nursing (DON) found, on a Thursday around May the 22 or 23 she was hiring some new nurses and let LPN #28 set in on the abuse and neglect part of the in service, and LPN #28 is scheduled to watch Abuse and neglect videos starting May31. A review of the facilities reportable on 5/29/24 at 9:00AM revealed Resident # 75 had an argument with Licensed Practical Nurse (LPN) # 28 on 05/08/24 at 11:00 AM. Further review of the facility reportable regarding Resident #75 Showed LPN #28 was verbally cussing at Resident #75 stating, I do my Fucking best to give all my residents the medication that they need a witness states she brought up how she has another resident on morphine and about to pass away, LPN #28 asked Resident #75 who was more important. Further review of witness statements from six(6) other staff members revealed the arguing between LPN #28 and Resident #75 went on for at least 20 minutes, Personal medical information regarding Resident #75 was revealed in front of everyone around during the time of the incident. LPN #28, wrote in her statement, she could have handled the situation better. The facility did not substantiate this reportable saying the arguing and confrontation was not verbal abuse. LPN #28 was not suspended and is currently working at the facility. The following are the witness statements which were collected by the facility as part of the investigation: Certified Nursing Assistant Student #65 witness statement read: During smoke break @ 8:00 PM on May 7, 2024 I was outside with a few residents, they were smoking. A nurse started screaming at a resident. The resident just asked about her meds, the nurse told her she put them in the trash because she wouldn't take them. The resident said no, i just only wanted to take a couple because i haven't used the bathroom and I need something to make me go. The nurse(LPN#28) said no you take Melatonin, Rots, and some other pill, and told her the only reason she has trouble now is because she was shot and the reason was taken to the hospital because she had a fever of 104. This went on for about 20 mins. This happened not only in front of me but three other staff and seven or eight residents. But that wasn't the only resident she screamed at as there was a man in a wheelchair. Certified Nursing Assistant Student #77 witness statement read: Yesterday May 7, 2024 when we took smokers out around 8 Resident #75 was telling LPN #28 that she needed to stop taking one of her medications because it was making her constipate. LPN #28 then started yelling at Resident #75 telling her they would not have prescribed it to her if. Resident #75 told LPN #28 that the medication was causing her to end up in the hospital . LPN#28 yelled to Resident #75 that it was not the medication causing her to be constipated it was that damn gunshot wound that is making her have all the complications LPN#28 told Resident#75 she does her Fucking best to give all her residents the medication that they need. She brought up how she also had a resident who was on morphine and about to pass and asked Resident#75 who was more important. When we went back in LPN #28 said I getta go get Resident #75 a damn book. Certified Nursing Assistant Student #68 witness statement read: Yesterday, May 7, 2024. The residents were outside on a smoke break at around 8:00 PM While setting outside with them, a nurse (LPN #28) was outside as well. She was first speaking to (Resident #75), which resulted in (LPN #28) screaming at (Resident #75). (Resident #75) has just come in from the hospital as well. (Resident #75) had firstly refused her medication, later at the smoke break, (Resident #75) asked if she could have her medication, saying she had refused it because of her bowel issues. (LPN #28) proceeded to scream at (Resident #75), discussing her required medicine, her being shot and her refusal. She (LPN #28) was very unprofessional with (firstname Resident #75) discussing private things, private situations, and medications in front of all other residents on East Wing who smoke. (First Name)LPN #28 also cussed at (Firstname) Resident #75 while (LPN#28) was screaming. LPN #28 witness statement reads: This nurse(LPN#28) took resident(Resident #75) to smoke and resident(Resident #75) and this nurse and resident got into a shouting match this nurse(LPN#28) was wrong and has apologized to the resident(Resident #75). This nurse(LPN#28) will take care of the resident(Resident #75) as long as resident (Resident #75) is ok with it. Nurse(LPN#28) regrets causing resident (Resident #75) any issues. Trying to discuss medications with resident (Resident #75)resident(Resident #75) and nurse(LPN#28) discussed incident. Resident(Resident #75) and nurse(LPN#28) discussed incident resident incident and we are over it Certified Nursing Assistant Student #66 read: On May 7, 2024, I witnessed a nurse (first name)LPN#28 screaming at a resident named (first name) Resident #75 over medications. We were on our smoke break and (First name) Resident #75 had asked for a list of her medications and their side effects. (first name) LPN#28 freaked out at (Resident #75) and was yelling at her about how she had refused her meds and that she was not Digging them out of the garbage and Was not getting more out of the cart. (first name) LPN#28 also made sure to list out every medication that Resident #75 was on as well as bring up all of her medical issues due to being shot. There were 7 other residents outside at the time. This incident lasted roughly about 20 minutes and was very uncalled for. (first name) LPN#28 also cussed at her during this time ( F-word - D- Word) Resident #75 statement read: We were having a shouting match, but I am over it. I was upset and didn't have anyone to take it out on. I know we didn't handle this very well. I don't feel like I was abused in any way. I'm fine with (first name) LPN# 28 working with me. b) Facility Plan of Correction for Verbal Abuse: Tag F 600 IJ Date: 5/29/2024 Time: 1409 1.) On 5/29/2024 the administrator, Director of Nursing and Human Resources Director terminated employee #28. On 5/29/2024 all staff were informed that all or any form of abuse or neglect toward a resident would result in immediate termination. 2.) Because this has the potential to affect all residents, on 5/29/2024 all residents were interviewed by administrative staff to ensure that they felt safe and had never endured any type of abuse or neglect any residents unable to be interviewed were assessed for any visible signs of abuse or neglect during their stay at [NAME] Healthcare Services of [NAME] with any corrective action immediately upon discovery. 3.) The Director of Nursing and Social Worker has begun in-servicing ALL staff on 5/29/2024 about facility abuse and neglect zero tolerance policy and procedure and failure to comply resulting in immediate termination. All staff will be in serviced as of 5/29/2024 prior to their next shift, and virtually if need be. 4.) The Administrator will ensure adherence to the Abuse and Neglect Policy and Procedure, ensure that any employee who commits any act of abuse or neglect will be terminated immediately. The Social Worker will complete the log attached for all reports of abuse and neglect and turn the log in to the Administrator each time a complaint is made so the Administrator can handle corrective action of the staff immediately. To ensure continued compliance, the monitoring log will be re-evaluated. c) Resident #91 A review of a Facility Reported Incident which was received by the state agency on 04/07/24 found the following: Type of Incident was a resident to resident incident. The type of abuse was specified as Sexual. The incident form indicated the the staff became aware of the abuse at 9:00 AM on 04/07/24. Resident #91 was listed as the alleged victim. The perpetrator was listed as Resident #61. The reportable listed four (4) staff members as witnesses to the incident. The staff were identified as QA #66, Licensed Practical Nurse (LPN) #105. Restorative Aide #102, and Prior Employee # 1 (Position unknown), The incident report indicated the residents were witnessed in lying in bed in a sexual position. The place was indicated it was Resident #61' bed. A review of the facility's five day follow up report found the following information: .2. steps taken to investigate the allegation: Provide a detailed summary of ALL steps taken to investigate the allegation. Summary of Interviews with the alleged victim and/or the victims responsible party, if applicable. Indicate any visual cues from the resident of psychosocial distress. (The facility's response) No suspicion of abuse or neglect. Resident to Resident No Harm. Summary of Interviews with witnesses including but not limited to, what the individual observed or knowledge of the alleged incident or injury: (Facility Response) None. Summary of Interviews with the alleged perpetrators identifying whether they are staff, resident, visitor, contractor, etc. (facility response) None. Summary of Interviews with other residents who may have had contact with the alleged perpetrators: (Facility Response): None. Summary of Interviews with staff responsible for oversight and supervision of the location where the alleged victim resides (Facility Response) Residents were separated, and educated about sexual contact with other residents. Summary of the interviews with staff responsible for oversight and supervision of the alleged perpetrator if the perpetrators staff or a resident: (Facility Response) see above. Provide Summary information from the investigation related to the incident from the residents clinical record as relevant portions of the RAI, the residents care plan, nurses' notes. social service note, lab reports, x-ray reports, physician or other practitioner reports, or reports from other disciplines that are related to the incident. If a resident to resident altercation occurred provide any relevant details that may have caused the alleged perpetrators behavior, such as habits, routines, medications, diagnosis, how long he/she may have lived at the building, or BIMS score. (facility response): none. If available within the five working day timeframe provide summary of information of other documents obtained, such as hospital/medical progress notes/orders and discharge summaries, law enforcement reports and death reports if applicable. (facility Response) None. 3. Conclusion Provide a brief description of the conclusion of the investigation and indicate if findings were: (For incidents reported as injuries of unknown source indicate if the injury resulted from abuse or neglect, based on evidence from the investigation) Verified: The allegation was verified by evidence collected during the investigation. Indicate how the allegation was verified by evidence collected during the investigation and describe the evidence. (Facility Response) No abuse or neglect. Not Verified: The allegation was refuted by evidence collected during the investigation. Indicate and describe why the allegation was unable to be verified during the investigation. (Facility Response ) No Abuse or neglect Inconclusive: The allegation could not be verified or refuted because there was insufficient information to determine whether or not the allegation had occurred. If this incident was identified as inconclusive, indicate and describe how this was determined. (Facility Response) No abuse or neglect. 4. Corrective action taken: Provide in detail a summary of all corrective action taken. Describe any actions taken as a result of the investigation or allegation. (Facility Response) Residents were separated and educated about sexual contact with other residents. Describe the plan for oversight of the implementation of the corrective action, if the allegation is verified (Facility Response) Staff will provide oversight and monitor the residents for further contact. As a result of of a verified finding of abuse such as physical, sexual, or mental abuse, identify counseling or other intervention planned and implemented to assist the resident (Facility Response) None . An interview with the Social Worker on 05/29/24 regarding the incident that took place on 04/07/24 found she did not take statements from any of the staff because they had contacted the healthcare decision maker, and she basically said it was okay as long as the resident wanted to do it. She stated, she went to his room and sought him out. The social worker continued to state, She wanders in and out of rooms every day, but she always seems to go to his room. She then stated, she must like him. When asked if Resident #91 was able to give consent to sexual contact she said, Well she wanders into his room and gets in his bed so I guess that means she wants it. She stated, It was not abuse or neglect because the healthcare decision make said as long as both people want it then to let it happen. An interview with the Director of Nursing on the afternoon of 05/29/24 revealed she had called the residents healthcare decision maker and the healthcare decision maker stated that it was just a way of life and if they were both okay with it then to just give them privacy. The DON indicated this is the reason they did not consider this sexual abuse. When asked if Resident #91 was able to give sexual consent the DON indicated the resident seeks out Resident #61 and that is what they are basing her consent on. The DON acknowledged the resident has dementia so she stated there are days she will smile, and the resident will sometimes respond to her name. When the DON was asked if Resident #91 was able to find Resident #61's room consistently even though she at times does not even know her own name. She stated, Yes I ' m sorry but she can. An interview with LPN #135 on 05/29/24 at 12:47 PM, confirmed she had witnessed the residents in bed together on 04/07/24. She stated, Resident #91 was in the male resident's room and they were laying on the bed beside each and were interlocked in a sexual position. She stated that she separated them and called the NH and SW. When asked how Resident #91 was acting she stated she had no emotion on her face which is normal due to her dementia. She stated Restorative aide #102 and QA #66 was the nurse aides that told her about the incident. A review of Resident #91's medical record found a Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/18/24 and 03/15/24 both of which indicate the resident is rarely to never understood. The residents diagnosis include: Unspecified dementia, Unspecified severity, with other behavioral disturbance. Resident #91's careplan contained the following focus statement: The resident has increased sexual inhibitions / behavior r/t -Has been striping (SIC) in front of males -Getting into bed with male residents -Touching males in private areas -Allowing male resident to to touch her -Family is aware and stated they wanted the facility to do what is best for both residents, if both resident are willing, to provide privacy for residents, but if behavior is unwanted by either resident, to provide redirection. -uses the medication Tagamet to reduce libido. The interventions included: When resident is displaying sexual behavior and both resident and male resident are willing, Staff to provide privacy for residents, but if behavior is unwanted by either residents, staff to provide redirection. This intervention was added to Resident #91's care plan on 04/12/24 which was five (5) days after the incident on 04/07/24. On 05/30/24 at 8:52 a phone interview with Resident #92's healthcare decision maker found the facility had called and she stated, My brother and I talked about it and told them to just let happen, because how are they going to stop it. When asked if this was her mother's lifestyle prior to her dementia she stated, when she turned 50, she divorced my dad and turned this way. I know she is probably the aggressor. She stated, I do not think it is bothering her in any way. According to the state operations manual (SOM) page 76 the following pertains to an appointed decision maker: While a legal representative may have been empowered to make some decisions for a resident, it does not necessarily mean that the representative is empowered to make all decisions for the resident. The individual arrangements for legal representation will have to be reviewed to determine the scope of authority of the representative on behalf of the resident. A review of the resident's record found the residents daughter was appointed as Durable Power of Attorney on 03/18/14 and this appointment gave her daughter the right to make all financial decisions and medical decisions if Resident #91 was deemed incapacitated to do so. The medical record contained, and incapacity statement dated 08/11/23 which the resident's physician stated the resident does not have capacity to make healthcare decisions due to end stage dementia. According to the SOM page 77 the following pertains to sexual consent: The legal standards and criteria for sexual consent vary across states ([NAME], 2007; [NAME] et al., 1999). The most widely accepted criteria, which are consistent with those applied to consent to treatment, are: (1) knowledge of relevant information, including risks and benefits; (2) understanding or rational reasoning that reveals a decision that is consistent with the individual's values (competence); and (3) voluntariness (a stated choice without coercion). An interview with the Nursing Home Administrator (NHA) at 10:15 PM on 05/30/24, found she thought it was the residents right to have sexual contact if they wanted to. She stated, We felt, (Name of Resident #91) seeks out this resident and climbs in bed with him and gets mad when we try to redirect her. She further stated, Her daughter told us she use to like black men. She then stated, Maybe she walks by his room and sees he is black and wants to be with him. She then stated, the nurse aide who showers him said he never gets hard (a slang term used to indicate an erection), so I know they have never had sex. The SOM on pages 75 to 76 says this in regards to Sexual Abuse: Sexual abuse is non-consensual sexual contact of any type with a resident, as defined at 42 CFR §483.5. Sexual abuse includes, but is not limited to: o Unwanted intimate touching of any kind especially of breasts or perineal area; o All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; o Forced observation of masturbation and/or pornography; and o Taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them (e.g. posting on social media). This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident. Generally, sexual contact is nonconsensual if the resident either: o Appears to want the contact to occur, but lacks the cognitive ability to consent; or o Does not want the contact to occur. Other examples of nonconsensual sexual contact may include, but are not limited to, situations where a resident is sedated, is temporarily unconscious, or is in a coma. Any investigation of an allegation of resident sexual abuse must start with a determination of whether the sexual activity was consensual on the part of the resident. A resident ' s apparent consent to engage in sexual activity is not valid if it is obtained from a resident lacking the capacity to consent, or consent is obtained through intimidation, coercion or fear, whether it is expressed by the resident or suspected by staff. Any forced, coerced or extorted sexual activity with a resident, regardless of the existence of a pre-existing or current sexual relationship, is considered to be sexual abuse. A facility is required to conduct an investigation and protect a resident from non-consensual sexual relations anytime the facility has reason to suspect that the resident does not wish to engage in sexual activity or may not have the capacity to consent. Prior to surveyor intervention the facility failed to evaluate Resident #91 and Resident #61 for the ability to consent to sexual contact. As part of the Plan of Correction the facility evaluated all residents for the ability to consent to sexual contact. A review of Resident #91's and Resident #61's assessment found both lacked the capacity to consent to sexual contact. An interview with the Chief Operating Officer (COO) and the Quality Assurance director at 3:00 PM on 06/03/24 found the facility felt no sexual abuse had occurred. The COO stated we never provided them with privacy eventhough it was in the care plan. He asserted he felt this should not even be a citation. When asked why his DON, NHA, and Social Worker all indicated in their interviews that Resident #91 sought out Resident #61 and that indicated she wanted him and wanted to have sexual contact with him. The COO stated, I think they are just scared for their jobs and was looking at it as a resident rights issue and was trying to say what they thought they needed to say. d) Plan of Correction Tag F 600 IJ Date: 5/30/2024 1.) On 5/30/2024 the administrator assigned 1:1 staffing at all times for resident #91 to ensure she is free from non-consensual sexual acts. On 5/30/2024 all staff were informed that all residents are to be kept free from non-consensual sexual harm despite their mental capacities. 2.) Because this has the potential to affect all residents, on 5/30/2024 all residents were interviewed by administrative staff to ensure that they had never been subject to non-consensual acts of sexual nature during their stay at [NAME] Healthcare Services of [NAME] with any corrective action immediately upon discovery. 3.) The Director of Nursing and Social Worker has begun in-servicing ALL staff on 5/30/2024 about facility ' s policy and procedure about resident engaging in sexual acts and what is prohibited. All staff will be in-serviced as of 5/30/2024 prior to their next shift, and virtually if need be. 4.) The Administrator will ensure adherence to the Resident Sexual Acts Policy and Procedure, ensure that staff intervene prior to any non-consensual sexual acts occur between residents. All resident ' s within the building will be evaluated for their capabilities to consent to sexual acts on 5/30/2024. A monitoring log will be completed to ensure that all residents are evaluated for their capabilities to consent to sexual acts upon admission, at any cognitive change, and/or quarterly thereafter. To ensure continued compliance, the monitoring log will be re-evaluated at the Quarterly and Quality Assurance meeting.