**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview the facility failed to ensure residents were free from abuse from other residents. Beginning on 04/19/23 Resident #20 began displaying physical, verbal and sexually abusive behaviors towards residents and staff. A review of the record found at least 20 noted incidents of such behavior. The abusive behavior was not consistently reported as required, the physician and responsible party was not consistently notified, the victims were not consistently identified, and interventions were not consistently put into place to prevent the abuse from reoccurring. Resident #20 still currently resides at the facility and has had documented episodes of said behaviors as recent as 07/05/24. The State Agency (SA) determined this put more than a limited number of Residents currently residing in the facility at risk for immediate serious harm and/or death and constitutes an Immediate Jeopardy (IJ) situation. The facility was notified of the IJ at 2:09 PM on 07/30/24. The abatement plan of correction (POC) was submitted and accepted by the state agency at 4:07 PM on 07/30/24. The POC read as follows: F600 Resident #20 was placed on one to one on 07/30/24 at 2 PM All residents of the facility have the potential to be affected. The Director of Nursing (DON)/designee interviewed residents with Brief Interview for Mental Status (BIMS) of 7 (seven) or below if the resident permitted for potential sexual, verbal and physical abuse on 07/30/24 with any corrective action immediately upon discovery. Re-education was provided by the Director of Nursing (DON)/designee to all employees on 07/30/24 to ensure allegations of sexual, verbal, physical abuse are identified, immediate intervention put in place to prevent reoccurrence, immediately reported to the appropriate states agencies and thoroughly investigated. A post-test to validate understanding. Any employees ot available during this time frame will be provided re-education, including post-test upon the beginning of next shift to work. New employees will be provided education, including post-test during orientation by the DON/designee. The Director of Nursing (DON)/designee will monitor progress notes starting on 07/30/24 to ensure that allegations of sexual, verbal, physical abuse have been correctly identified, reported in a timely manner and appropriate intervention put in place to prevent the reoccurrence daily across all shifts for 2 (two) weeks including weekends and holidays, then 3 (three) times a week for 2 weeks then randomly thereafter. Results of monitors will be reported by the Director of Nursing (DON)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee. On 07/31/24 at 4:31 PM after interviews with staff to confirm the receipt of and understanding education and observation of the implementation of the abatement POC, the IJ was abated. The IJ started on 07/30/24 and ended on 07/31/24. Resident identifier: Resident #20, Resident #22, Resident #62. Facility Census: 67 Findings Include: a) Resident #20 On 07/29/24 at approximately 3:15 PM, a review of the facility reported incidents (FRI), it was discovered a FRI had been submitted for Resident #22. During the review of this FRI, it was noted on 07/02/24 at 6:15 PM, Resident #20 was witnessed grabbing Resident #22's breast. Nurse Aide (NA) #62 and NA #40 witnessed the incident, separated and redirected the residents, and immediately reported the incident to Licensed Practical Nurse (LPN) #20. A review of the FRI revealed the following 5 (five) day was submitted as a summary of the incident and read as follows: On July 2, 2024 at approximately 6:15 PM, Resident #20 was witnessed grabbing Resident #22's breast. NA #62 and NA #40 witnessed the incident, separated and redirected the residents, and immediately reported to LPN #20. Resident #22 is a [AGE] year-old female resident who was admitted to (Name of Facility) on September 13, 2017. The resident has diagnoses of dementia, Alzheimer's disease, unspecified psychosis and wandering. Resident #22 is ambulatory, frequently wanders and ambulates about the facility ad lib. The resident does not retain the capacity to make healthcare decisions and her son is the health care surrogate and conservator. Resident #20 is a [AGE] year-old male resident who was admitted to (Name of Facility) September 9, 2022. The resident has diagnoses of dementia and Alzheimer's disease. Resident #20 has a history of sexual behaviors and inappropriately touching other residents, visitors and staff. The resident utilizes a wheelchair and independently locomotion about the facility ad lib. Resident #20 does not retain capacity to make health care decisions and his daughter is Medical Power of Attorney (MPOA). A head-to-toe check was performed on Resident #22 following the incident on 07/02/24 and no injuries or skin issues were observed. The resident did not exhibit any emotional or psychological distress or change in behaviors. Resident #20 was immediately placed under every 15 minute checks for 72 hours following the incident. A urinalysis was collected during the evening of 07/02/24 and was negative for Urinary Tract Infection. Meditelecare Psych was notified of the incident on 07/02/24 and evaluated the resident in house on 07/03/24. A recommendation to increase Celexa to 30 milligrams (mg) by mouth daily. This recommendation was reviewed with Medical Director and orders were completed. All interviewable residents were interviewed. One resident did say Resident #20 touched her leg but was not in a sexual way, no other residents had any concerns. This was reported to all appropriate agencies. The perpetrator was placed on every 15 minute checks. Skin checks were performed on all non-interviewable residents. No signs of abuse were identified. The care plan of both residents were reviewed and updated to reflect changes. On 07/29/24 at 7:41 PM, a record review was conducted for Resident #20 which revealed multiple entries of documentation related to Resident #20's behaviors of verbal, physical and sexual aggression towards facility staff and other residents residing in the facility. The following documentation was noted to be dated for 05/08/23 at 06:44 PM: Resident yelling and was rude to staff and other residents this afternoon. Redirected and resident continued to yell. Further review of Resident #20's medical record revealed escalating behavioral disturbances. The following notes were present in Resident #20's medical record: -- 04/19/23 at 9:09 AM. Resident was in dinning room with other resident talking vulgar to her. Kept telling her he wanted her pussy. Female resident removed from situation and Resident #20 was told he can not talk to other residents that way. Will continue to monitor closely. No physician or POA notification documented. -- 04/22/23 at 2:00 PM. Resident was removed from dining room for threatening to hit another resident. Resident was in hallway in WC and started yelling cuss words, saying I don't give a fuck, I'll knock the hell outta you. When nurse ask resident what was wrong, He replied I don't give a fuck. Resident was ask to stop cussing and to go to his room to cool off for his safety and others. No physician or POA notification documented. --. 07/28/23 at 12:52 PM. Resident refused care this a.m. Resident cussing at staff and residents, calling them names. Resident redirected and situation resolved. No physician or POA notification documented. -- 08/13/23 at 12:07 PM. Resident has been obnoxious to the staff and residents. Resident has hassled a resident multiple times by following, stomping his feet near her, verbally aggravating and asking for a kiss from her. He has badgered staff for coffee, milk and sugar throughout the morning not waiting for staff to meet his request before growing louder and more commanding. No physician or POA notification documented. -- 08/13/23 at 4:18 PM. Resident was observed by this nurse to be making rude and inappropriate hand gestures and sounds as a young, teenage girl visiting in the facility. He continued to talk about this teenager, attempting to get another resident to engage in conversation about what he wanted to do to her, and on and on. This nurse interrupted the conversation, telling the resident to stop the conversation, that it was not appropriate and not accepted. No physician or POA notification documented. -- 08/15/23 at 09:34 PM. Resident has been very rude and disrespectful this eves caught grabbing an other resident breast. When confronted became very angry cursing staff. Then asked CNA to suck his Dick. Then he asked CNA repeatedly if she wanted to party. Resident was educated on this and asked to go to his room. At this time resting quietly. Will continue to monitor closely. No physician or POA notification documented. -- 08/16/23 at 11:49 PM. attempting to go into a female residents room, grabbing at another female resident. Trying to kick and hit this nurse. Cursing and yelling. No physician or POA notification documented. -- 08/16/23 at 3:53 PM. Nursing staff witnessed resident groping another female residents private area and grabbing her butt. The female resident attempted to walk away from resident, but was grabbed by the waist and continuously being groped at her private areas and butt. Nursing staff yelled the residents name to attempt to gain his attention. Resident did let the female resident go, but attempted to scoot in his wheelchair attempting to grab at female resident as she continued to walk away. When nursing staff arrived to the resident, he was assisted in his wheelchair away from the female resident. Nursing staff attempted to redirect resident, but resident yelled Shut the fuck up and go to hell. Nursing administrator was notified of the occurrence and did speak with resident with an RN as a witness. On call psych notified and was set up with an apt for tomorrow morning. Order to call PMH on call provider. Spoke with Summer, and she states she will speak with provider and call back. After speaking with PMH provider, order to continue with current medications, keep Psych apt tomorrow and continue to monitor and redirect additional behaviors. -- 08/16/23 at 06:52 PM. Kitchen staff reported to nursing staff that she was in the kitchen wrapping silverware when she heard a female yelling help help when kitchen staff went to see what the issue was, she witnessed resident groping a female resident, touching her breast and private areas. States resident had female resident pinned where she could not get away from him. When the kitchen staff was able to get to the female resident, resident did let her pass by. Administrator notified of occurrence. No physician or POA notification documented. -- 08/17/23 at 11:24 AM. Resident refused a.m. medications. Resident cussing at nurse when trying to administer medications. Resident attempting to touch visitors. No physician or POA notification documented. -- 08/17/23 at 7:26 PM. Resident had behaviors this PM. touching and inappropriate touching of female residents and staff. Dr. (Last name of physician) in new orders. #1 Increase Celexa to 40 milligrams (mg) by mouth every day. POA informed of behaviors and medication changes. -- 08/18/23 at 10:52 AM. eINTERACT Summary for Providers noted Resident #20 was demonstrating physical aggression, verbal aggression and other behavioral symptoms. In addition, it stated, Resident making sexual gestures and vulgar comments to staff and residents. Redirected, unsuccessful. Resident was placed on one on one and behaviors continued. No physician or POA notification documented. -- 08/26/23 at 04:55 PM. Staff found resident at the supply door, blocking exit of female resident, he would not let her get away from him. One on one in place for safety of residents. Resident redirected to another area of building and offered coffee. No physician or POA notification documented. -- 08/26/23 at 07:19 PM. Resident attempting to isolate female resident and not allow them to leave his presence. Staff observed this behavior and intervened on behalf of female resident, providing her with egress. No physician or POA notification documented. --09/13/23 at 09:22 AM. Physical behaviors, directed towards others occurs daily or almost every day. Verbal behaviors, directed towards others occurs daily or almost every day. -- 10/16/23 at 09:06 PM. Escalation of inappropriate behavior, grabbing at staff and other residents, masturbating in front of staff, sexual comments, picking his pants leg up to show his penis. No physician or POA notification documented. -- 02/25/24 at 08:50 PM. Resident chasing women down the hall yelling come back here, hit another resident . cursing at staff. No physician or POA notification documented. -- 05/18/24 at 12:12 PM. Certified Nursing Assistant (CNA) reported to nursing that resident grabbing staff and a resident and making lewd comments. Redirected resident will report to oncoming shift. No physician or POA notification documented. -- 06/02/24 at 10:00 PM. resident chasing women residents, trying to grab them inappropriately and trying to touch staff inappropriately. No physician or POA notification documented. -- 07/05/24 at 08:30 PM. resident continues to make sexual comments to staff and argue with residents. No physician or POA notification documented. In addition to the above mentioned documentation, Resident #20's diagnosis list, orders and care plan was reviewed. On 07/30/24 at approximately 10:00 AM, a review of the investigation conducted by facility staff related to the incident that occurred on 07/02/24 in regards to Resident #22 was conducted which revealed interviews with all licensed nursing staff. In review of the interviews, the question Are you aware of sexual abuse occurring at this facility? was answered No by all licensed nursing staff. No interviews of CNA's were present. These interviews were conducted by RN #33. On 07/30/24 at approximately 11:30 AM, a review of the facility Policy and Procedure entitled, Abuse Prohibition was performed. This policy and procedure was noted to state that the facility will implement an abuse prohibition program through screening of potential hires, training of employees, prevention of occurrences, identification of possible incidents or allegations which need investigation, investigation of incidents and allegation, protection of residents during investigations and reporting of incidents, investigations and Center response to the results of their investigations. In addition the policy and procedure states that the facility will identify, correct and intervene in situations in which abuse, neglect, and/or misappropriation of resident property is more likely to occur. Furthermore this policy and procedure states that all suspected abuse must be reported to the physician and the resident's family. The policy and procedure also states that the facility who has identified a resident who has in any was threatened or attacked another will be removed from the setting or situation and investigation will be completed. That immediately upon [NAME] information concerning a report of suspected or alleged abuse, mistreatment or neglect, the Administrator or designee will perform the following: 1. Report the allegation involving abuse (physical, verbal, sexual, mental) not later than 2 (two) hours after the allegation is made. 2. Report allegations to the appropriately state and local authority(s) involving neglect, exploitation or mistreatment (including injuries of unknown source), suspected criminal activity, and misappropriation of resident property, not later that 2 (two) hours after the allegation is made. 3. Initiate an investigation within 24 hours of allegation of abuse. 4. The Center will protect residents from further harm during the investigation. On 07/30/24 at 12:38 PM, an interview was conducted with RN #28 who acknowledged she was aware of Resident #20's verbal, physical and sexual behaviors, stating that Resident #20 self propels in his wheelchair and that it is absolutely best to keep eyes on him. On 07/30/24 at approximately 12:45 PM, an interview was conducted with RN #30 who acknowledged she was aware of Resident #20's verbal, physical and sexual behaviors. On 07/30/24 at approximately 01:10 PM, an interview was conducted with RN #32 who stated that she attends the facility morning clinical meeting and acknowledged she was aware of Resident #20's behaviors because it had been discussed. On 07/30/24 at approximately 01:20 PM, an interview was conducted with Resident #62. At this time, Resident #62 stated that she is afraid of Resident #20. Resident #62 reported that Resident #20 had a reputation of touching women. Resident #62 stated she had reported Resident #20 had entered her room one night and touched her leg and tried to get into bed with her. Resident #62 further stated that when she asked Resident #20 to leave he refused, Resident #62 stated she then called the nurse who came and got Resident #20. Resident #62 reported that she has witnessed Resident #20 touching other residents in the breast and groin area. On 07/30/24 at 01:33 PM, an interview was conducted with RN #33, who was documented as having performed the investigation into the incident involving Resident #20 and Resident #22 When this Surveyor questioned RN #33. This Surveyor asked why the interviews she conducted stated no licensed nursing staff were aware of sexual abuse occurring in the facility when 2 (two) RN's interviewed today stated they were. RN #33 responded, I can't answer why they would each tell us something different. This Surveyor then asked RN #33 if she questioned CNA's and other facility staff related to witnessing abuse by Resident#20 due to CNA's reporting the incident. RN #33 responded I didn't interview CNA's or other staff to see if they witnessed abuse by Resident #20. At this time, RN #33 verbalized she had been in her current position for approximately 1.5 years and that she, among other RN's, were responsible for reading the facility progress notes prior to morning clinical meeting and she is unaware of the above documented allegations of abuse by Resident #20. The corporate Clinical Lead Nurse was present for this interview. Immediately upon discovering the above mentioned occurrences of abuse placed Resident #20 on one to one observation. On 07/30/24 at 2:39 PM, an interview with the facility corporate Clinical Lead Nurse was conducted, in which she acknowledged the following: 1. The facility was unable to identify the resident's in the above mentioned progress notes. 2. No investigations had been performed related to these incidents. 3. No follow-up assessments had been conducted to assess for the psychosocial well-fare of these residents. 4. These incidents had not been reported or investigated by the facility as indicated in the facility Policy and Procedure entitled Abuse Prohibition. 5. Resident #20 frequently refused medication for his behavioral disturbances. 6. The facility policy and procedure entitled, Abuse Prohibition had not been implemented in this occurrences. 7. The facility failed to notify the physician and POA for all occurrences. 8. The facility failed to keep the residents safe from verbal, physical and sexual abuse. 8. These incidents and the verbal, sexual and physical abuse had not been taken to Quality Improvement Committee (QIC). No further information was provided prior to the end of the survey.