**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents were free from physical and verbal abuse for 1 (R1) of 3 residents reviewed for abuse.R1, who is diagnosed with dementia, started displaying aggressive behaviors and being resistive to cares within the first 2 weeks of being admitted to the facility. The facility did not develop or implement a behavior care plan with resident specific interventions to help guide staff in how to care for R1. On 8/11/25, R1 was being cared for by Certified Nursing Assistant (CNA)-C and Registered Nurse (RN)-D. R1 was agitated, aggressive and resistive to cares. CNA-C was working to calm R1. RN-D entered R1's room and was yelling at R1 to let them take care of R1. While R1 was sitting at the edge of R1's bed, RN-D grabbed R1's legs and threw them in R1's bed, making R1 lay down in bed. RN-D then grabbed R1's blanket and used the blanket to hold R1's shoulders down. While holding R1's shoulders down on the bed, RN-D was shaking R1's shoulders and was yelling in R1's face. CNA-C eventually got RN-D to release R1 and leave the room. During an interview, R1 stated that R1 was afraid during this interaction. The facility's failure to keep R1 safe and free from physical and verbal abuse by a facility staff member created a finding of immediate jeopardy that began on 8/11/25. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the immediate jeopardy on 8/27/25 at 2:36 PM. The immediate jeopardy was removed on 8/11/25 and corrected on 8/25/25. Based on this determination, this citation is being cited as past noncompliance.Findings include:The facility policy with a last revision date of 9/2024, titled Freedom from Abuse, Neglect and Exploitation documents: It is the policy of the [name of facility] to take steps to ensure that the residents are protected from abuse. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents will not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident.Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families. Physical abuse includes but is not limited to hitting, slapping, pinching, and kicking.Abuse Policy Requirements: The facility is to monitor staff for burnout, which could lead to the potential maltreatment of residents. Staff and contracted individuals will be taught the signs and symptoms of staff burnout. Staff should report any signs and symptoms of burnout to their supervisor.The facility's population presents the following factors. which could result in mistreatment of residents: The assessment, planning of care and services and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of cognitive deficits, sensory deficits, aggressive behaviors, residents who have behaviors such as. verbal outbursts, residents with communication disorders, those who are nonverbal and those that require heavy care and/or are totally dependent on staff. The facility will ensure a comprehensive dementia management program to prevent resident abuse.The alleged perpetrator will immediately be removed and resident protected. Employees accused of alleged abuse will be immediately removed from resident care areas and will remain removed pending the results of a thorough investigation.R1 was admitted to the facility on [DATE] and has diagnoses that include Dementia, Major depressive disorder, and Primary Osteoarthritis of right shoulder.R1's admission Minimum Data Set (MDS) assessment dated [DATE] documents R1 is moderately cognitively impaired. R1 does not exhibit any behaviors.R1's Dementia Care Area assessment dated [DATE] documents: [R1] has dementia. [R1] may exhibit some confusion due to dementia. [R1] is verbal and able to communicate but struggles in recalling information. Staff may need to help [R1] anticipate needs and provide reminders and cues.R1 has an activated Health Care Power of Attorney.R1's MD orders with a start date of 4/24/25 include:-Sertraline [an Antidepressant medication] Oral Tablet 100 [Milligrams (mg)]. Give 1 tablet by mouth one time a day related to Major Depressive Disorder.-Behaviors-monitor for the following-fearfulness, self-isolation, poor appetite, sad/worried facial expressions. Every shift.-Mood: monitor for depressed mood, statements of sadness, crying, self-isolation, etc. Every shift.R1's cognitive function [related to] dementia care plan initiated on 4/24/25 documents the following interventions: Ask yes/no questions in order to determine [R1's] needs. Communicate with [R1]/family/caregivers regarding her capabilities and needs.R1's depression care plan initiated on 4/24/25 documents the following pertinent intervention: Monitor/record/report to MD [as needed] acute episode feelings or sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/eating habits, change in sleep patterns, diminished ability to concentrate, change in psychomotor skills.Surveyor noted R1 did not have a care plan for challenging behaviors related to R1's dementia diagnosis.Surveyor reviewed R1's behavior notes located in the progress note section of R1's Electronic Medical Record (EMR) and R1's behavior monitoring completed by CNAs in the CNA task section of the EMR. Surveyor noted the following pertinent documentation of R1's behaviors:R1's behavior note dated 5/7/25 at 2:58 PM, documents: [R1] was pushing the CNA and not accepting cares but wanted to go to the bathroom. [R1] did, after explaining that [staff] was there to help and didn't want [R1] to fall, accept assistance.Surveyor noted R1 displayed an aggressive behavior and got physical with the CNA.R1's behavior note dated 5/16/25 at 9:04 PM, documents: [R1] was reported to be aggressive and agitated at or around [9 PM]. The CNA reported that [R1] was standing at the doorway and ambulating within the room without assist. [R1] was holding hangers and at the same time grabbing the CNA by the wrist. [R1] reported to have wanted the CNA to get out . When [writer] went into the room to talk with [R1, R1] reported to [writer] the same statement and wanted me to get out . [Writer] explained to [R1] the rationale behind ensuring [R1's] safety . [writer] asked [R1] if [R1] needed anything and tried to reorient [R1]. This intervention did not work. [R1] appears to not comprehend [writer's] counseling about the risks and benefits of refusing our assistance, and [R1] refuses our help at this time.Surveyor noted R1 displayed an aggressive behavior and got physical with the CNA.Surveyor noted that in May of 2025, R1 had 2 documentations in R1's medical record regarding aggressive behavior, refusals of care, and being physical with staff members. Surveyor reviewed R1's care plan and noted that after R1 displayed these behaviors, a care plan to help guide staff with individualized interventions was not developed or implemented. Surveyor reviewed R1's EMR and noted that the facility did not document that R1's provider was made aware of R1's increased behaviors.On 8/27/25 at 9:29 AM, Surveyor interviewed Social Services Manager (SSM)-F. Surveyor asked about R1's behaviors. SSM-F stated that R1 typically has behaviors at night. SSM-F stated that if R1 starts having behaviors of sundowning that R1 typically will deescalate after staff leave and reapproach the resident. Surveyor asked if a resident displaying behaviors should have a care plan. SSM-F indicated that SSM-F would put a care plan in with significant behavior. SSM-F stated that residents will have a cognitive loss care plan that will give some direction to staff. In addition, SSM-F stated that staff on the memory care unit are well trained and know how to handle residents with dementia. Surveyor asked if R1 should have had a behavior care plan after displaying aggressive and physical behaviors in May. SSM-F stated that is a great question. Surveyor asked if initiating the behavior care plan was missed. SSM-F stated I think so. SSM-F stated that after the incidents in May, interventions should have been added to R1's care plan. Surveyor asked if R1's MD was made aware of R1's behaviors. SSM-F stated that nursing would typically document if the MD was made aware. SSM-F stated that SSM-F would get involved if there was a significant behavior like a resident-to-resident abuse issue.R1's Behavior note dated 7/2/25 at 2:14 PM, documents: [Interdisciplinary Team (IDT)] Behavior management meeting. [R1] is not followed by Psych services. [R1's primary care MD] manages [R1's] medications: . Sertraline 100 [mg] AM. No concerns at this time, [R1] doing well and has family involvement. [Medical Director] would like to review once [R1] has been here for six months to give time to move past adjustment period.On 8/26/25 at 1:54 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked about the meaning of the above note. DON-B stated that the IDT Behavior management team meets regularly to discuss residents who are prescribed psychotropic medications. DON-B stated that R1's MD manages R1's antidepressant medication. R1 is not seen by psych services. The Medical Director of the facility indicated R1 needed more time to be assessed at the facility before a Gradual Dose Reduction of R1's medication was attempted.Surveyor noted that R1's previous aggressive behaviors and refusals of care were not documented as a discussion in the Behavior Management IDT team meeting documentation and a care plan to help guide staff with resident specific interventions was not developed or implemented.R1's alert progress note documented by RN-D on 7/14/25 at 7:07 AM, documents: Demonstrating new behavior. Crying documented which may be due to family leaving following visiting. [R1] displayed no sadness or crying through night. [R1] does not like to be disturbed and will get angry stating What the hell is going on!R1's Behavior note dated 7/17/25 at 5:24 PM documents: [R1] put [R1's] hands on CNA's neck while attempting to transfer. Resident has increased agitation on PM shift. Non-verbal facial expressions appear to be angry.R1's alert progress note documented by RN-D on 7/30/25 at 2:48 AM, documents: Demonstrating new behavior. Threatening behavior noted. [R1] may become angry and swear when disturbed or unwilling to follow instructions. Resistive, threatening behavior previously noted.Surveyor noted R1's aggressive, resistive and physical behaviors continued in July.R1's Quarterly MDS assessment dated [DATE] documents R1 is moderately cognitively impaired. According to the MDS assessment, R1 did not exhibit any behaviors. R1 requires supervision/touching assistance for toilet transfer.R1's Behavior note documented by RN-D on 8/6/25 at 5:19 AM, documents: [R1] observed in bed, approached and offered cares and informed of medication that was due to be administered. [R1] became resistive, combative, swinging arms at staff and refusing all cares demanding staff get out. [R1] found to be very incontinent and the linens wet. [R1] refused AM medication yelling NO! [R1] encouraged to accept assistance with the walker to the [bathroom] but [R1] blatantly refused, again slapping at staff. [R1] sat at bedside requiring 1:1 supervision.R1's Behavior note documented by RN-D on 8/7/25 at 4:37 AM documents: [R1] assisted to the [bathroom] early in the shift and again at [4:20 AM]. [R1] cooperative and accepting of care. [R1] offered early AM medications at approximately [4:30 AM] and was accepting of the medication offering no resistance. [R1] in better spirits than previous morning when found incontinent and unruly.R1's Behavior note dated 8/8/25 at 7:00 AM documents: [R1] refused. assistance beginning of the shift around [1:30 AM]. [R1] was self-ambulating without the walker going towards the bathroom, was agitated, and [didn't] want anyone in room. [R1]. started yelling at CNA get out of here! and wanted to close the door. Writer attempted to offer assistance, but [R1] continue to yell get out of here! Writer and CNA continued to monitor resident by just standing outside the door as the more you approached [R1], the more [R1] gets agitated. [R1] safely used the toilet and went back to bed. No further behaviors noted; did [sleep] well. Writer gave [R1, R1's] early AM medications and was pleasant and compliant.Surveyor noted R1's behaviors became more consistent in facility staff documentation. Surveyor reviewed R1's care plan and noted that after R1 displayed these behaviors more consistently, a care plan to help guide staff with individualized interventions was not developed or implemented. Surveyor reviewed R1's EMR and noted that the facility did not document that R1's MD was made aware of R1's increased behaviors.R1's Communication with the Physician progress note documented by RN-D on 8/9/25 at 4:18 AM, documents: Situation-[R1] resistive and combative with cares, is waking up frequently to urinate at night and is incontinent more frequently. Background- [R1] routinely accepts cares, is awake twice a night to [use the bathroom], and is mostly continent. Assessment- [R1] yelling at staff to get out, not accepting assistance and putting self in unsafe situations. Recommendation-Rule out urinary tract infection (UTI) with [Urinalysis (UA)/Culture and Sensitivity (C&S)].On 8/26/25 at 3:20 PM, Surveyor interviewed DON-B. Surveyor asked what the communication with Physician progress note workflow entails. DON-B stated that the communication note that RN-D entered on 8/9/25 was documented in R1's medical record. After entered, the note is printed and then faxed to the MD. Facility staff would then wait for a reply with any new orders from the MD office. DON-B indicated that R1's MD does have an on-call service that staff can utilize on the weekend.Surveyor noted that the communication with the Physician progress note documented by RN-D was faxed to the MD on 8/9/25 at 4:18 AM, which was an early Saturday morning.Surveyor reviewed R1's EMR. Surveyor noted that R1's MD did not communicate back to facility on 8/9/25 or 8/10/25. Surveyor noted that facility staff did not document that R1's MD was notified of R1's increased behaviors through the on-call service that was available to staff on weekends. Surveyor noted R1's MD replied to the facility communication about R1's behaviors on 8/11/25 at 1:30 PM, which was a Monday afternoon. Surveyor noted that R1's MD ordered a UA and C&S test to be completed. Surveyor reviewed R1's laboratory results and noted R1's urinalysis results came back negative, indicating that R1 did not have a UTI.On 8/11/25 at 3:17 AM, facility staff submitted an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report to the state agency. The report documents: . On 8/11, [R1] was confused and attempting to get up from bed. [R1] was combative with [CNA-C]. [RN-D] came into room to help assist with [R1]. [CNA-C] reported that [RN-D] was yelling at [R1] to get back into bed and held [R1's] shoulders to attempt to keep [R1] in bed.On 8/26/25 at 12:22 PM, Surveyor interviewed CNA-C, who witnessed the abuse to R1 and reported the abuse to DON-B. Surveyor asked what happened on 8/11/25. CNA-C stated that CNA-C was answering a call light in a different resident's room when RN-D came into the room and yelled that CNA-C needed to go to R1's room and R1's needs should take precedent to what CNA-C was doing. CNA-C completed helping the resident and went to R1's room around midnight. When CNA-C entered R1's room, RN-D was present and yelling at R1 while R1 was on the toilet. R1 was agitated. CNA-C told RN-D that CNA-C would take it from there and RN-D left the room. CNA-C stated that CNA-C tried to assist R1 in changing R1's brief and helping R1 off toilet. R1 continued to be agitated and resistant. CNA-C stated that CNA-C stood behind R1 as R1 started using R1's walker to return to bed. R1 sat on the edge of R1's bed. CNA-C stated that CNA-C stayed behind R1. CNA-C stated that R1 was yelling, agitated and upset. RN-D reentered the room and yelled at R1, You need to let us help. CNA-C indicated that RN-D told R1 to shut up and then told R1 that R1's family pays us to take care of you. R1 started to mock RN-D and RN-D did the same back to R1. CNA-C stated that CNA-C tried to redirect RN-D and told RN-D to step out of the room. CNA-C stated that RN-D then took R1's legs and threw them into R1's bed. CNA-C stated that CNA-C told RN-D to take a minute. CNA-C stated that RN-D snapped and started screaming at R1. RN-D screamed, I'm so sick of these people. RN-D took R1's blanket and put it over R1. R1 then tried to sit up and was swinging R1's arms at staff. RN-D's eyeglasses came off. CNA-C stated that RN-D then used the blanket to restrain R1 and was holding R1's shoulders down. CNA-C stated that RN-D was shaking R1 and yelling in R1's face. CNA-C tried to push RN-D off R1. CNA-C continued to ask RN-D to leave and told RN-D that CNA-C could take it from here. Eventually, RN-D stood up, got off R1 and left the room. CNA-C stated that CNA-C stayed with R1 until another staff member, CNA-E, came to help. CNA-C then went to call management to report what happened. CNA-C stated that CNA-E got R1 to calm down and R1 fell asleep. CNA-C stated that RN-D was known to staff for getting stressed out. CNA-C stated that CNA-C had seen RN-D have temper tantrums where RN-D would swear, jump up and down and yell. CNA-C stated that these tantrums were not directed at residents in the past but would take place in the hallway or nurse's station. CNA-C stated that RN-D would have these outbursts here and there, but nothing directed toward a resident until this occasion.On 8/26/25 at 12:59 PM, Surveyor attempted to conduct a phone interview with CNA-E without success.The facility self-report included a statement from CNA-E. The statement taken by DON-B on 8/11/25 at 2:00 AM, documents: . [CNA-E] was not in the room during this confrontation but was called into the room to help [CNA-C] with resident. When [RN-D] asked [CNA-E] to go help [CNA-C], [RN-D] told [CNA-E] that [R1] had hit [RN-D] and made [RN-D's] glasses come off. [RN-D] told [CNA-E] that [RN-D] put [R1's] legs in the bed then held down [R1's] shoulders to keep [R1] in bed.On 8/26/25 at 12:36 PM, Surveyor attempted to conduct a phone interview with RN-D without success.The facility self-report included a statement from RN-D. The statement taken by DON-B on 8/11/25 at 1:30 AM, documents: . [RN-D] stated that [RN-D] has been having problems with [R1] for 3 or more days regarding behaviors and attempting to walk by self unsafely. When [RN-D] entered the room this night, [CNA-C] was in the room attempting to assist [R1], [RN-D] stated that [R1] sat up when [RN-D] entered and yelled get out! [RN-D] attempted to assist [CNA-C] to put [R1's] legs in the bed and cover [R1] with a blanket. [R1] had already smacked [CNA-C] and [R1] told [RN-D] [R1] would hit [RN-D]. [RN-D] stated that they got [R1] into bed and [RN-D] held [R1's] shoulders down so [R1] would stay in bed. [R1] hit [RN-D] with [R1's] fist in [RN-D's] face and knocked off [RN-D's] glasses. So [RN-D] continued to hold [R1's] shoulders down to keep [R1] safe. [RN-D] stated that [RN-D] did not abuse [R1] but was keeping [R1] safe from getting out of bed on [R1's] own.Surveyor reviewed RN-D's education record. Surveyor noted that RN-D had received the required abuse education, most recently on 1/27/25 and 6/24/25. The facility self-report included a statement from R1. The statement taken by SSM-F on 8/11/25 at 9:15 AM documents: . [SSM-F] asked [R1] about last night. [R1 stated] Do you really want to know the truth? [R1] reported that 2 staff pulled [R1's] pajamas and blankets off [R1]. [SSM-F asked] Why would they do that? [R1 stated], They want to rule me, I guess. [SSM-F asked] Who did this? [R1 stated], An older lady with glasses and gray hair and a younger lady with brown hair . [SSM-F asked] Were you afraid? [R1 stated] Of course.On 8/26/25 at 11:00 AM, Surveyor interviewed R1. Surveyor asked if R1 felt safe at the facility. R1 immediately stated yes. Surveyor asked if R1 has ever been made to feel afraid while at the facility. R1 paused, looked down and stated yes. R1 stated that staff had come in the room and made R1 feel very uncomfortable and afraid. R1 could not remember the names of any staff involved. Surveyor asked if R1 could describe what the staff member looked like that made R1 afraid. R1 stated, little old people with hair.Surveyor noted that on 8/11/25 and on 8/26/25, R1 reported being afraid of a facility staff member.On 8/26/27 at 1:54 PM, Surveyor interviewed DON-B about the early morning of 8/11/25. DON-B stated that DON-B was called by CNA-C around 12:30 AM to inform DON-B of CNA-C's concern. DON-B stated that CNA-C called Nursing Home Administrator first but was unable to reach NHA-A at that time. DON-B came to the facility and got to R1's unit around 1:15 AM. DON-B stated that RN-D was documenting in the EMR in the hallway at RN-D's med cart. DON-B took RN-D off the unit to interview RN-D. DON-B walked RN-D out of the building after the interview. DON-B started investigating right away. DON-B informed NHA-A of the incident and called the police. DON-B assured that R1 was assessed and informed Social Work to follow up with R1. DON-B stated that abuse and resident rights education to staff was started right away.Surveyor noted that RN-D was in the common hallway of R1's unit when DON-B arrived about 45 minutes after the incident occurred.Surveyor reviewed the rest of the facility self-report about the abuse incident and noted the following: CNA-C reported the abuse immediately. RN-D was suspended pending the investigation. R1 had a skin assessment and pain assessment completed and no concerns were identified. The police were called, and a case number was given to the facility. All facility staff members staffing the unit gave statements. A sample of facility residents was interviewed and asked if they felt safe at the facility, if they had concerns about their care and if they had been abused. No concerns were identified. Staff education was started immediately for physical and verbal abuse. The Summary of factual investigative findings documented: . After completion of investigation, although [RN-D] was attempting to keep [R1] safe, reported abuse was substantiated.R1's challenging behaviors care plan initiated on 8/15/25 documents: [R1] has potential to be physically aggressive [related/to] dementia and poor impulse control as result of impaired cognition. [R1] may hit or strike out at staff or peers during cares. Pertinent interventions initiated on 8/15/25 include: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Assess and address for contributing sensory deficits. Assess and anticipate resident's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. Communication: provide physical and verbal cues to alleviate anxiety: give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmy away, and approach later.Surveyor noted, after over 3 months of challenging behaviors, facility staff entered a behavior care plan guiding staff in how to care for R1 when R1 has challenging behaviors.On 8/27/25 at 10:01 AM, Surveyor informed NHA-A and DON-B of the concern that R1 had dementia and had documented behaviors in May of 2025. A behavior care plan was not initiated to guide staff in caring for R1 and R1's MD was not notified of the behaviors. NHA-A stated that R1's behaviors were more sundowning and R1 lives in the memory care unit. NHA-A stated that NHA-A understands the concern about the care plan but stated that staff on the unit know what to do because of their training. Surveyor continued and shared concern that when R1 had continuing behaviors, facility staff sent a communication note to R1's doctor on 8/9/25 regarding R1's behaviors possibly being a symptom of UTI. The facility did not follow up on 8/9 or 8/10/25 when the MD had not acknowledged the facility staff concerns about R1's behaviors. R1's behavior's continued, which led to a facility staff member, RN-D, yelling at R1 and holding R1's shoulders down which made R1 afraid.The facility's failure to protect a vulnerable resident from physical and verbal abuse created a reasonable likelihood for serious harm, including psychosocial harm, thus leading to a finding of immediate jeopardy. The immediate jeopardy was removed on 8/11/25 when staff were educated on abuse and residents rights.The immediate jeopardy was corrected on 8/25/25 after the facility completed the following:-All staff education on verbal and physical abuse which started on 8/11/25.-All staff education on resident's rights including: Freedom from mistreatment, Freedom from physical restraints, Treatment options (including the right of the resident to refuse care or treatment), Self-determinations (including the right of the resident to make decisions relating to care), and the Right of the Resident to be treated with courtesy and respect which started on 8/11/25.-All staff meeting on 8/18/25 which included additional abuse training, as well as burnout and stress management of staff. Staff not in attendance had the training available online to view on 8/25/25.-Audit started on 8/11/25 included check-ins with 5 residents a day to cover any resident concerns. Audits will continue for 4 weeks.-Audit started on 8/11/25 included check-ins with 5 staff a day to cover abuse, and staff stressors. Audits will continue for 4 weeks.-Grievance audit started on 8/11/25 included facility staff reviewing resident grievances each weekday for 4 weeks. Staff to audit for any area of concern related to abuse or misconduct.-Staff interviewed other residents in the facility on 8/11/25.-Police were notified on 8/11/25.Based on this determination, the citation F600 was cited as past non-compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not provide appropriate treatment and services for 2 (R2 and R7) of 2 resident reviewed with a diagnosis of dementia with behavioral symptoms to allow them to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. R2 was admitted to the facility with a diagnosis of dementia with behaviors. Shortly after admission, R2 started exhibiting behavior symptoms included wandering into female peers' rooms and making sexual comments, propositioning and gesturing to staff and peers. The R2 was seen by psych services to assist with behavior concerns and pharmacological interventions which were not effective. R2's care plan was not person centered and did not address R2's sexual and wandering behaviors exhibited towards others resulting in sexual abuse of 5 female peers. After the abuse, R2's care plan interventions were not reviewed and/or revised when documented interventions were not effective. R7 was admitted to the facility with a diagnosis of dementia with behaviors. In June of 2023 R7 started exhibiting behaviors that included physical altercations with staff and peers, wandering into female peers' rooms and making sexual comments to staff and peers. R7 was seen by psych services to assist with behavior concerns and pharmacological interventions which were not effective. R7's care plan was not person centered and did not address his sexual and wandering behaviors exhibited towards others resulting in sexual abuse of 1 female peer and physical abuse of 3 peers. After the abuse, R7's care plan interventions were not reviewed and/or revised when the documented interventions were not effective. The facility failed to assess and provide services for residents with a diagnosis of dementia allowing them to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The facility did not ensure residents with diagnoses of dementia, who exhibited behaviors directed towards other residents had person centered care plans created that addressed sexual, aggressive, and wandering behaviors. Residents' care plan interventions were not reviewed and/or revised when interventions were not effective, and peers were not protected from unwanted sexual and aggressive behaviors created a finding of immediate jeopardy that began on 6/20/23. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the Immediate Jeopardy on 11/7/23 at 2:53 PM. The immediate jeopardy was removed on 11/14/23, however; the deficient practice continues at a scope/severity level of D as the facility continues to implement its removal plan. This is evidenced by: Surveyor reviewed facility's Mood and Behavior Policy with a revision date of 6/2023. Documented was: BACKGROUND [Facility] promotes and supports a resident centered approach to care. The purpose of this policy is to define and set expectations regarding mood and behavioral health services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, therefore an individualized approach to care is essential . PURPOSE The purpose of the Mood and Behavior Policy and Procedure is to provide a plan of care that is individualized to the residents needs based upon the comprehensive assessment by the interdisciplinary team. This plan of care will include medically related social services to address mood and behavioral health services to attain or maintain the highest practicable well-being. DEFINITIONS Behavior: Behavioral symptoms that may cause distress or are potentially harmful to the resident, or may be distressing or disruptive to facility residents, staff members or the environment. (CMS MDS 3.0 RAI Manual) . Behavioral or Psychological Symptoms of Dementia (BPSD): A term used to describe behavior or other symptoms in individuals with dementia that cannot be attributed to a specific medical or psychiatric cause. The term behaviors is more general and may encompass BPSD or responses by individuals to a situation, the environment or efforts to communicate an unmet need . PROCEDURE . C. Recognition and Management of Dementia a. The facility will assess and determine individualized behavioral care plan interventions for individuals with dementia. b. Behavioral interventions are individualized approaches (including direct care and activities) that are provided as part of a supportive physical and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities. c. [Facility] staff will be encouraged to participate in Virtual Dementia training and other dementia training opportunities upon hire and as desired. 4. Mood and Behavior Tracking a. Mood and Behavior tracking documentation will be completed by front line staff, based upon comprehensive assessment outcomes, to identify any mood and behavior patterns, interventions attempted and outcome of approaches. (see Behavior Documentation Policy - nursing procedure) b. Mood and behavior tracking will be reviewed by the interdisciplinary team on a quarterly basis or more often as needed to determine trends and effectiveness of care plan interventions c. Mood and behavior tracking will be reviewed by the Behavior Management Team to determine trends and effectiveness of care plan interventions . 7. Documentation a. The interdisciplinary team will document assessment findings, care plan approaches/interventions and behavior/mood tracking results in the medical record . a. Admission b. Quarterly c. Monthly per Behavior Management Committee protocols d. As needed 8. Emergent Changes a. If resident displays behaviors or mood changes that are a potential danger to the safety, health or welfare of themselves or others, the interdisciplinary team will assess the resident's current status and in conjunction with the discharge policy, make appropriate intervention or placement decisions. 1) R2 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease, and Dementia with Psychotic Disturbances, Disorders of the Nervous System, Bladder Cancer, Prostate Cancer, Anxiety and Depression. R2 has an Activated Power of Attorney (POA). Surveyor reviewed R2's MDS (Minimum Data Set) Assessment with an assessment reference date of 10/17/23. Documented under Cognition was a BIMS (brief interview mental status) score of 14 which indicated cognitively intact. Surveyor reviewed R2's Initial Social Service History assessment from the 4/19/22 admission. Documented was: Mental Health History: No. Psych Hospitalizations: No. Trauma History: No. Surveyor noted this is the only assessment related to R2's psychosocial, trauma or mental health history. Surveyor reviewed R2's Comprehensive Care Plan with an initiation date of 12/30/22. Documented was: Focus: Behaviors: [R2] has a history and potential of asking staff, peers, and others to engage in physical contact with him. He accepts no as an answer. Goal: [R2] will have fewer episodes of questioning staff and peers to engage in contact with him. Interventions: - Anticipate and meet [R2's] needs by re-education of boundaries with peers and staff. - Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately. Allow [R2] to have privacy in his room if he so desires for self-satisfaction. - If reasonable, discuss [R2's] behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. - Intervene as necessary to protect the rights and safety of himself and others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Surveyor reviewed R2's medical record and noted: -Documented on 6/20/23, at 9:07 AM, by Licensed Practical Nurse (LPN)-I was Housekeeper came to this writer stating that [R2] asked her to have sex with him. This writer spoke to resident. Resident stated, If not her, How about you? This writer explained that this is inappropriate and we should not speak this way to others. Interventions not effective. Social Worker made aware. Surveyor notes the facility documentation states the interventions are not effective, but they are not revised. -Documented on 6/20/23, at 9:15 AM, by Social Worker (SW)-D was [R2] has been propositioning the staff this morning. He has asked the cleaner for sex and asked this worker for a gift for the holiday. [R2] will ambulate in the hallway in just his [incontinence] product or if he is dressed he will motion for staff to come in his room. When staff reminded [R2] that he is being inappropriate he stated, Ok, thank you anyway. God Bless. -Documented in R2's Progress Notes on 6/27/23, at 2:45 PM, by LPN-J was Behavior Note: Observed [R2] coming out of [R3's room]. I asked him why he was in that room. He stated he wasn't. I told him I saw him come out of the room and he got quiet . [R3] and her personal care giver stated he did come in her room but quickly exited when he saw her care giver. They stated he does this frequently. I asked them to put her light on when this happens and we can try to discourage this behavior. -Documented on 6/29/23, at 9:05 AM, by Registered Nurse (RN)-F was [Psych Nurse Practitioner (NP)-O] with independent psychiatric consultants e-mailed notification of resident throwing away scheduled Paxil 10mg on 6/28/2023. Also in regards to his inappropriate behavior that was documented on 6/20/2023. Writer informed her that the Night RN fax request to MD (Medical Doctor) to discontinue medications and asked if she had any recommendations. Awaiting a response at this time. -Documented on 7/4/23, at 5:57 AM, by Licensed Practical Nurse (LPN)-R was Behavior Note: [R2] was up all night. Encouraged/reproached to go to bed several times but kept on refusing. Was making a sexual statement/comment to staff and this writer; able to redirect and resident apologized for behavior. -Documented on 7/5/23, at 1:56 PM, by Social Worker (SW)-D was Behavior Management [Interdisciplinary Team (IDT)] discussed. Paxil is being offered to [R2], but he is refusing often. Will continue to offer. Surveyor noted the IDT Behavioral team did not document discussion of R2's continued sexual comments, wandering, redirection needed and overall need for more resident specific interventions due to dementia and progression. -Documented on 7/7/23, at 4:13 AM, by RN-C was COMMUNICATION - with Physician, NP (Nurse Practitioner), PA (Physician Assistant): Situation: Resident declining the paroxetine (paxil)10 mg [orally (PO)] for anxiety disorder scheduled for [12:30 AM] daily. Background: Few meds are included on [electronic chart] since resident declines to take them stating the good Lord will heal me and I don't have anxiety. Recommendations: Discontinue the paroxetine 10 mg PO scheduled for [12:30 AM]. -Documented on 7/12/23, at 2:08 PM, by LPN-J was [R2] opening doors to peer rooms. They are in the bathroom and it was explained to him that their rooms are not for other residents. He stated he didn't know and he was giving them air. I explained there is a filtration system and they can breathe. I asked if we need to keep his door open. He stated no I don't want it open. I asked if he could breathe in his room. He again stated yes. I reminded him that there are peers who have asked him to not come in their rooms. I also reminded him that they have a right to privacy especially when they are in the bathroom. He had to be redirected a couple more times but did get better. -Documented on 7/13/23, at 3:41 AM, by RN-C was [R2] going into several other residents' rooms, waking other residents. Also declines to do [bedtime (HS)] cares and get to bed though appears tired and observed sleeping in room recliner. -Documented on 7/14/23, at 2:29 PM, by LPN-J was COMMUNICATION - with Physician, NP, PA: Situation: Psych NP-O notified via e-mail regarding [R2] declining the paroxetine 10 mg PO for anxiety disorder scheduled for [12:30 AM] daily. And request to discontinue the medication due to refusal? Awaiting response at this time. Surveyor notes RN-C recommended discontinuing R2's paroxetine 10 mg on 7/7/23 however the staff continue to attempt to administer the medication. -Documented on 7/21/23, at 3:24 PM, by LPN-J was CNA was giving [R2] bath and they were discussing how red his legs are and then asked her if she wanted to see his 3rd leg. She told him to stop talking to her like that and helped him out of the tub. -Documented on 7/24/23, at 3:16 PM, by SW-D was [SW-D] observed [R2] propelling himself around the unit. As he was passing by closed resident room doors he could open the door so that it was cracked open. This SW watched him open several empty room doors. This SW approached [R2] as he was opening a door and asked him not to open closed doors. He stated that he was sorry and God Bless. Surveyor reviewed Psych NP-O's visit note from 8/2/23. Documented was NARRATIVE: Staff reports [patient] with regular refusals of paroxetine, charting shows same. [Behavioral] interventions in place. The Psych NP did not address the ineffective interventions or continued sexual behaviors. Documented on 8/2/23, at 5:15 PM, by SW-D was IDT Team- Behavior Management- [R2] is at baseline. He continues to not take his medication regularly. [Psych NP-O] saw him today and requested to discontinue the Paxil. Documented on 8/5/23, at 2:48 AM, by RN-C was [R2] is constantly opening other residents' doors when they are using the restroom. Claims we are gassing the other residents. Acknowledged. Documented on 8/8/23, at 3:03 AM, by LPN-J was Went in to a female peer's room while she was undressed. CNA removed him from her room. Later [R2] was receiving a bath and he said he goes in people's rooms because people are having sex and they needed air. Documented on 9/26/23, at 4:18 PM, by LPN-J was I was assisting [R4] when [R2] was approaching us in his [wheelchair (W/C)]. She stated oh here that man comes. He approached and asked if we wanted to play table tennis. I told him that activities had balloon volley ball. He stated I mean table tennis where you women are the table [R4] asked this writer to get him away from her. I asked him to go one direction and assisted her another direction. Documented on 10/17/23, at 10:49 AM, by LPN-J was Behavior Note: [R2] approached central supply clerk with sexually inappropriate requests. She was shocked by the conversation so [activity staff] assisted with the situation. I was informed of the situation and requested a male employee come to the unit. He did and spent some time with [R2] and immediately when he left [R2] made his way to the day area where a husband was visiting [R6] his wife. [R2] proceeded to make sexually inappropriate comments to her and was fondling himself in front of them. CNA again removed [R2] from the area. I went to the day area and apologized to the couple . Documented on 10/17/23, at12:38 PM, by SW-D was On this date, [R2] has been making inappropriate sexual comments to others. This behavior is cyclical for [R2]. At times, he has delusions about his peers. He is redirectable to his room when he is exhibiting this behavior. [R2] has dementia and uses a wheelchair for mobility. R2 also responds positively to males when he is exhibiting this behavior. Surveyor notes this intervention is not documented on R2's care plan. Documented on 10/17/23, at 2:52 PM, by LPN-J was [R2 was sexually inappropriate and CNA was unable to perform bath. Will offer on another day when residents behaviors allow. Documented on 10/17/23, at 3:54 PM, by SW-D was This SW attempted to follow up with [R2]; however, he was napping. This SW will follow up at a later time. Documented on 10/17/23, at 8:40 PM, by RN-Q was [LPN-G] member of resident found him lying in his bed with a [R1], both were unclothed. Resident was lying in bed awake. Resident stated that it was hot in here and that the two residents were just resting. Resident is alert to self and family members. He was last seen in hallway 10 minutes earlier. Resident has a diagnosis of dementia. [R1] was escorted out of room by nurse and CNA. Resident remains at baseline mental status. Skin assessment completed. All skin is intact, no bruising or signs of trauma. [SW-D], [NHA (Nursing Home Administrator)-A] and [DON (Director of Nursing)-B] were notified of incident. Documented on 10/18/23, at 9:56 AM, by DON-B was Informed psychiatric nurse practitioner of incident with peer last evening. Awaiting response. Documented on 10/18/23, at 10:18 AM, by SW-D was Met with [R2] this morning. He was exhibiting hyper sexual statements about himself and others. [R2's] filter is impaired as a result of his dementia. [R2] has recall of recent incident with peer. R2's judgement is also impaired as a result of his dementia. [R2] did not appear to be in any distress during the interview. R2's Care Plan was revised at this time for Behaviors to include: Focus: .[R2] is vocal about his sexual preferences; however, he is unable to act on these as a result of a medical condition. He may or may not attempt to masturbate. Exelon patch ordered for dementia with behaviors on 10/18/23 . Interventions: - Assist [R2] to develop more appropriate methods of coping with sexual desires. Encourage [R2] to express feelings appropriately while defining boundaries. Allow [R2] to have privacy in his room if he so desires for self-satisfaction. - Intervene as necessary to protect the rights and safety of himself and others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Cue, reorient and supervise as needed. Redirect from others. Assist to his room. Engage and encourage activities of interest to redirect his train of thought. When inappropriate, remind that these behaviors are unwanted. Surveyor noted this was the first revision of R2's care plan even with the continued behaviors that were exhibited which the facility documented were due to dementia. Documented on 10/18/23, at 1:02 PM, by RN-F was Message received from [NP-O] in regards to resident's behaviors. New order received for Exelon patch 4.6mg, change daily dx: dementia. [POA] called with message left to call writer back for consent to start medication. Documented on 10/18/23, at 2:50 PM, by LPN-I was [R2] passing through hallway and stopped at another peer's room of opposite sex sitting on bed in her night gown. Resident was staring, smiling and waving at peer. One on one and re-direction given. Assisted resident from doorway of peer's room. Engaged in staff conversation. Interventions effective. Resting quietly in room at this time. Documented on 10/19/23, at 7:44 AM, by LPN-I was Night CNA reports that a male CNA was sitting with resident and [R2] told him I'm not gay but I will give it a try, I'll suck your dick. He was fondling himself at the time. CNA corrected him and took him back to his room. This solicitation happened several times per CNA. Documented on 10/19/23, at 12:22 PM, by LPN-J was [R2] approached both female residents [R4] and [R5] asking them for sexual favors. CNA redirected him and he asked her for sexual favors. Documented on 10/19/23, at 2:02 PM, by LPN-S was [R2] came out of his room and was sitting in his wheelchair at his bedroom door looking down the hallway. As soon as a staff member came by, he asked staff to bring the women at the end of the hallway to his room. Staff member told resident no and she doesn't want to and that her family doesn't want her in his room. He went back into his room and shut the door. Documented on 10/19/23, at 9:35 AM by RN-Q was [R2] up in wheelchair on PM shift saying inappropriate comments to staff and peers. Staff is continuing to redirect as needed. Documented on 10/20/23, at 10:32 AM, by LPN-I was Behavior Note: This writer was in [R2's] room obtaining residents vital signs. Resident stated, I was wondering if you had time to come back and visit later? This writer told resident I am very busy and have a lot of work to do. You can call me if you need help. Resident then stated, I was looking for some action in the bed. Would you join me? This writer explained to resident that is inappropriate and we cannot talk to people this way. Resident replied, Oh, okay. Sorry then, God Bless. Goodbye then. Resident then left his room and headed toward the East dining room. This writer noted resident sitting next to peer of opposite sex leaning in and whispering. This writer re-directed resident to his unit [NAME] to eat breakfast. Intervention effective for short period of time. Hospice CNA reported to this writer that resident was sitting up close to another peer of opposite sex [R4]. Resident was leaning forward whispering and rubbing peer thigh. Re-direction given. Both residents separated. Resident went down to and activity and later brought off unit by RN Nurse Manager. Intervention effective at this time. Documented on 10/21/23, at 7:19 AM, by LPN-J was Behavior Note: [R2] came out of his room several times this AM completely naked, He was redirected to his room. When I asked why he was doing that he stated I'm looking for someone to kiss. I reminded him he is not allowed to come out of his room naked, and that no one on the unit is looking for someone to kiss. He asked why he is being treated different from everyone else. I told him no one is allowed to roam the halls naked. Documented on 10/21/23, at 3:09 PM, by LPN-J was Behavior Note: [R2] did eventually put his clothes on and come out of his room. He was propelling about the unit when I came down the hall just after lunch. [R4] waved me over. She stated I don't want that man in the w/c coming over and talking to me like that. I asked like what? She stated Like you shouldn't be talking to a lady. She then stated My boyfriend is starting to get mad and I don't want that. I could see her boyfriend [R7] was clearly agitated and I asked him if he was ok. He stated yes. He is expression was clearly tense. I told her I would keep an eye out. When I asked [R2] what happened he stated I don't think that guy liked me talking to his girlfriend. I asked [R2] if something happened he said no. I asked what he said, he blew me a kiss and just said bye bye, God bless. Documented on 10/22/23, at 3:06 PM, by LPN-J was Behavior Note: [R5] in the sunroom where she usually sits. [R2] was in the sunroom. Housekeeper came to me stating the [R2] was being sexually inappropriate. I went to observe what was transpiring. [R2] was assisted back to his room. [R5] stated she was kinda scared of [R2] because of how he was talking to her. She did not say what he said. I reassured her and stayed in the area. Documented on 10/24/23, at 2:45 AM, by LPN-T was [R2] was naked in hallway making sexual comments, reported by [night shift (NOC)] CNA. Taken back to his room, and rediverted him. Got him back on track. Documented on 10/24/23, at 3:02 AM, by LPN-T was [R2] is not easy to redirect. But, needs cloths on to be in hallway. Was seen on side of his bed getting himself off. Doing room checks. Documented on 10/24/23, at 9:49 AM by LPN-J was R2 was observed coming out of [R1's] room. This resident was not in the room at the time. Documented on 10/24/23 at 3:01 PM, by LPN-J was [R2] asked if the boy was coming to visit him. The [activities staff] stated no boys were here. He stated He's actually a man and he's going to do man things for me. She repeated there are no men here today. He asked Is there a girl? The aid said no and he didn't ask any more questions. Documented on 10/26/23, at 1:49 PM, by LPN-J was CNA reports resident had to be redirected from [R1's] room [ROOM NUMBER] times. He was trying to persuade her to go back to his room. She became upset. Documented on 10/28/23, at 8:01 PM, by LPN-I was [R2] attempted to push [R1] into his room this evening. CNA intervened and separated both residents. One on one and re-direction given. Intervention effective. Surveyor noted the intervention of 1:1 supervision was not added to R2's care plan. On 11/6/23 at 9:16 AM Surveyor interviewed SW-D. Surveyor asked SW-D what was identified as the assessed cause of R2's behaviors. SW-D stated dementia. Surveyor asked besides redirection, removal from area and telling him he is inappropriate, what interventions are in place to stop R2 from sexually abusing another resident. SW-D stated separate the residents, he is redirectable. Surveyor asked why after months of incidents have the interventions not been revised, new interventions were not put in place and/or monitoring was not increased. SW-D was unsure. On 11/2/23, at 12:55 PM, Surveyor interview LPN-J. Surveyor asked about R2's behaviors. LPN-J stated he opens peers' doors and tries to go in, even when they are in the bathroom. LPN-J stated we attempt to redirect him, talk to him but he is paranoid and wants the doors open. LPN-J stated peers get upset with him. Surveyor asked if increased monitoring of R2 has occurred. LPN-J stated only once but only for a shift. LPN-J stated sometimes he will be wandering on the unit and he will see staff watching him and go into his room because he knows he is being watched. Surveyor asked if she believed the facility is doing everything they can for R2's behaviors. LPN-J stated absolutely not. Surveyor asked if a one to one supervision would possibly stop the sexual comments to other residents. LPN-J stated probably. Surveyor asked if a one to one supervision would possibly stop R2 from touching other residents. LPN-J stated yes. Surveyor asked if the facility had tried to move R2 to another unit. LPN-I stated the facility has not tried to move R2 to another unit even though they have moved others. Surveyor asked about residents with dementia in the building. Surveyor asked if the facility has a system to revise interventions that do not work. LPN-J stated kind of. LPN-J stated the problem was that we need to have a back-up. For example, we are trying an Exelon patch on R2, but if it does not work there is no back up plan. LPN-J stated there should be a future plan if it fails. On 11/6/23, at 7:47 AM, Surveyor interviewed RN-C. Surveyor asked if prior to the 10/17/23 incident with R1 and R2 did she have any training at the facility for preventing sexual abuse with residents that have dementia. RN-C stated no, but this training was really good. On 11/6/23 at 10:05 AM Surveyor interviewed (NHA)-A and (DON)-B. Surveyor asked why the facility did not provide increased monitoring of R2 and why the ineffective interventions were not revised on his care plan. (NHA)-A stated, We are at a loss of what to do with [R2]. On 11/7/23, after Surveyor discussed concerns of R2's documented continued sexual abuse towards peers without revised interventions and/or increased supervision with the facility, the facility implemented 15 minute checks for R2. 2)R7 was admitted [DATE] with diagnoses that include Alzheimer's Disease, Depression, Dementia with Agitation, Hypertension and Anxiety. Surveyor reviewed R7's Minimum Data Set (MDS) Annual Assessment with an assessment reference date of 9/6/23. Documented under Cognition was a BIMS score of 03 which indicated severely impaired. Surveyor reviewed R7's Initial Social Service History assessment from 9/8/22 admission. Documented was: Mental Health History: in recovery - alcoholism. Psych Hospitalizations: None. Trauma History: Unknown. Surveyor noted this is the only assessment related to any psychosocial, trauma or mental health history. Surveyor reviewed R7's MD Orders. Documented with a start date of 10/26/22 was BEHAVIORS - MONITOR FOR THE FOLLOWING: Angry outbursts, irritability, or frustration; every shift Y if NONE observed; NO if one/some observed. A Comprehensive Care Plan was put in place for R7 on 11/7/22 and revised on 12/12/22, Documented was: Focus: Challenging Behaviors: [R7] has potential to be physically aggressive resulting in Anger, Dementia, and Poor impulse control as result of impaired cognition. He may hit or strike out at staff or peers especially when being redirected. He is being followed by Psychiatry. Goal: [R7] will demonstrate effective coping skills through the review date. Intervention: - Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. - Assess and address for contributing sensory deficits - Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. - Give the resident as many choices as possible about care and activities. - Offer busy box or oriented tasks during down time. Surveyor reviewed R7's medical record and documented was: Documented on 6/15/23, at 10:35 PM by Registered Nurse (RN)-Q was [R7] chased CNA after CNA instructed resident not to go in another resident's room. Resident then redirected to sit down and watch TV without difficulty. Documented on 6/16/23, at 7:16 AM, by RN-C was Writer found [R7] in another resident's room. Writer asked that resident leave the room. Resident became aggressive and attempted to strike care staff. Acknowledged. Documented on 6/20/23, at 3:03 PM, by LPN-I was [R7] is wandering into other peer rooms and trying to push other residents while in their w/c. When re-directed by staff resident becomes agitated with a harsh stare and fists clenched following staff around. One on one and re-directed. offered activity or distraction. Interventions effective for short periods of time. Behavior passed on to oncoming nursing staff. Surveyor notes one on one supervision intervention was noted added to R7's care plan. Documented on 6/27/23, at 2:51 PM, by LPN-J was It was reported by the NOC (night shift) CNA that [R7] was in the TV room early this AM before day shift arrived. He had his penis in his hand and asked her what he should do with it. She told him to put it in his pants. Not much later she walked by his room, and he was humping his pillow. He did urinate on his bedding, so she changed his bedding and assisted him with changing his clothing. He has been more difficult to redirect lately per staff and has at times raised his fist at them. See yesterday's note regarding him confusing another female peer for his daughter and [activity staff] helped him to face time with [daughter] to calm him. Surveyor notes the interventions of providing R7 with privacy in his room or Face Timing with his daughter were not added to R7's care plan. Surveyor reviewed Psych NP-O's visit note from 7/5/23. Documented was NARRATIVE: Aggressive [behaviors] towards staff last week by grabbing and bending staff's hand. Independent. No recent acute illness. Surveyor notes R7's care plan was not updated at this time to reflect any new non-pharmacological interventions. R7 was started on 10 mg of escitalopram (Lexapro) for aggression. Documented on 7/9/23, at 9:20 PM, by LPN-S was Writer[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent 5 (R3, R4, R6, R1, and R5) of 6 residents reviewed for abuse to be free from sexual abuse from R2. The facility failed to prevent 3 (R4, R1, and R8) of 6 residents reviewed to be free from sexual or physical abuse from R7. R2 had an identified history of inappropriate sexual behaviors with peers and staff. The facility did not have effective interventions in place to prevent sexual abuse of peers. When sexual abuse of peers did occur, the interventions were not revised, new interventions were not put in place, and monitoring was not increased; R2 continued to sexually abuse his peers. R2 attempted to enter R3's room multiple times uninvited (6/27/23, 8/8/23.) On 8/8/23, R2 entered R3's room while she was undressed. The facility did not assess R3 for any psychosocial harm or mental anguish after the sexual abuse. R4 was approached by R2 on 9/26/23, 10/19/23, 10/20/23 or 10/21/23, and was told sexual comments or propositions and was touched inappropriately on 10/20/23. The facility did not assess R4 for any psychosocial harm or mental anguish after the sexual abuse. R2 made sexually inappropriate comments and gestures in the common area where R6's spouse and R6 were sitting on 10/17/23. The facility did not assess R6 for any psychosocial harm or mental anguish after the sexual abuse. R2 was found naked in bed with R1 (who is severely cognitively impaired) and who was also naked on 10/17/23. R2 continued to try to enter R1's room or push R1 in her wheelchair into his room on 10/24/23, 10/26/23, and 10/28/23. The facility did not assess R1 for any psychosocial harm or mental anguish after the sexual abuse. R5 was approached by R2 on 10/19/23 and 10/22/23 and was told sexual comments or propositions. The facility did not assess R5 for any psychosocial harm or mental anguish after the sexual abuse. R7 had an identified history of inappropriate sexual and physical behaviors. The facility did not have effective interventions in place to prevent sexual and physical abuse. When abuse did occur, the interventions were not revised, monitoring was not increased, and R7 continued to abuse residents sexually and physically. R4 was physically abused in resident-to-resident altercations by R7 on 7/28/23 when he hurt her legs pushing her in her wheelchair and on 9/10/23 when he hurt her shoulders squeezing her. R4 was sexually abused by R7 exposing himself on 9/7/23 and 9/23/23 and watching over her while she slept on 9/10/23. There were no Psychosocial Assessments, pain, skin, or other assessments for R4 to assess for any mental anguish or physical injuries from any physical or sexual abuse. R1 was kicked in the shin's multiple times by R7 on 9/21/23. There were no Psychosocial Assessments for R1 to assess for any mental anguish from the physical abuse. The facility's failure to take immediate action to ensure residents are safe from sexual and physical abuse from R2 and R7 including effective care planned interventions and increased monitoring after incidents of abuse to prevent further incidents of abuse from occurring, and the failure to provide follow up assessments for their psychosocial well-being after incidents of abuse for R3, R4, R6, R1, R5, and R8, created a finding of immediate jeopardy that began on 8/8/23. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the Immediate Jeopardy on 11/7/23 at 2:53 PM. The immediate jeopardy was removed on 11/14/23, however, the deficient practice continues at a scope/severity level of E (potential for harm/pattern) as the facility continues to monitor the effectiveness of their removal plan. Findings include: Surveyor reviewed the facility's Freedom form Abuse, Neglect & Exploitation policy with a revision date of 10/2022. Documented was: DEFINITIONS OF ABUSE AND NEGLECT Abuse and neglect exist in many forms and to varying degrees. a. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also include the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instance of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . ii. Sexual abuse is non-consensual sexual contact of any type with a resident including harassment, inappropriate touching, and assault. Staff will evaluate the resident's capacity to consent to sexual contact. iii. Physical abuse includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment . F. PROTECTION COMPONENTS ABUSE POLICY REQUIREMENTS: It is the policy of this facility that the resident(s) will be protected from the alleged offender(s). PROCEDURE: Immediately upon receiving a report of alleged abuse, the Administrator and or Director of Nursing/designee will coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and well-being for the vulnerable individual are of utmost priority. Safety, security and support of the resident and other residents with the potential to be affected will be provided. The facility will take necessary steps to protect residents from possible subsequent incidents of misconduct or injury. This should include as appropriate: a. Procedures must be in place to provide the resident with a safe, protected environment during the investigation: i. The alleged perpetrator will immediately be removed and resident protected. Employees accused of alleged abuse will be immediately removed from resident care areas and will remain removed pending the results of a thorough investigation. (Decision of the extent of immediate disciplinary action will be made by the Administrator or designee). ii. If a family member or resident representative is possibly contributing to the potential abuse and the resident could be at risk, the facility will evaluate the situation and identify options to put into place for resident protection. iii. If the alleged perpetrator is a facility resident, the staff member will immediately remove the perpetrator from the situation and another staff member will stay with the alleged perpetrator and wait for further instruction from administration, if possible. If the situation is an emergent danger to the other residents or staff, dial 911 for immediate assistance. iv. Examine, assess and interview the resident and other residents potentially affected immediately to determine any injury and identify any immediate clinical interventions necessary. Notify the resident's physician. v. Social Services or designee should keep in frequent contact with the resident and/or resident representative. vi. If the resident could be at risk in the same environment, evaluate the situation and consider options including a room change. vii. Notification of law enforcement and/or State Agency, Crisis Response, Poison Control, etc. as indicated. viii. A medical, evidentiary, or sexual assault exam should be completed as soon as possible, as appropriate . Resident 2: R2 was admitted [DATE] with diagnoses that include Disorders of the Nervous System, Bladder Cancer, Prostate Cancer, Anxiety and Depression, Alzheimer's Disease, and Dementia with Psychotic Disturbances. Surveyor reviewed R2's MDS (Minimum Data Set) Assessment with an assessment reference date of 10/17/23. Documented under Cognition was a BIMS (Brief Interview Mental Status) score of 14 which indicated cognitively intact. Surveyor reviewed R2's MD Orders. Documented with a start date of 7/22/22 was, Monitor Behaviors: Paranoid statements, mood, dreams, sexually inappropriate behaviors etc. Document in progress note. Every shift. Surveyor reviewed R2's Sexual Contact Consent Assessment with an assessment date of 10/18/22. Documented was, 1. Would you like to conduct the sexual contact assessment? 2. No . The rest the assessment was blank. Surveyor reviewed R2's Comprehensive Care Plan with an initiation date of 12/30/22. Documented was: Focus: Behaviors: [R2] has a history and potential of asking staff, peers, and others to engage in physical contact with him. He accepts no as an answer. Goal: [R2] will have fewer episodes of questioning staff and peers to engage in contact with him. Interventions: - Anticipate and meet [R2's] needs by re-education of boundaries with peers and staff. - Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately. Allow [R2] to have privacy in his room if he so desires for self satisfaction. - If reasonable, discuss [R2's] behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. - Intervene as necessary to protect the rights and safety of himself and others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Surveyor reviewed R2's Sexual Contact Consent Assessment with an assessment date of 1/27/23. Documented was, 1. Would you like to conduct the sexual contact assessment? 2. No . Assessment of capacity for sexual contact: [R2] is verbal and engages in meaningful conversation. He can make his needs known and makes daily choices. He is able to form friendships with her peers. [R2] is able to consent at this time . Surveyor noted this is contradictory to the care plan and MD order that R2 asks peers to engage in physical contact with him and to monitor R2 for sexually inappropriate behaviors. 1. R3 was admitted [DATE] with diagnoses that include Metabolic Encephalopathy, Dementia, Psychosis and Mood Disturbance, Anxiety, Depression, and Hemiplegia following Cerebral Infarction. Surveyor reviewed R3's Sexual Contact Consent Assessment with an assessment date of 3/3/23. Documented was, 1. Would you like to conduct the sexual contact assessment? 2. No . Assessment of capacity for sexual contact: [R3] is verbal and engages in conversation. She can make her needs known and makes daily choices. She is able to form friendships with her peers. [R3] is able to consent at this time. Surveyor reviewed R3's MDS Quarterly Assessment with an assessment reference date of 5/25/23. Documented under Cognition was a BIMS score of 13 which indicated cognitively intact. Documented in R2's Progress Notes on 6/27/23 at 2:45 PM by Licensed Practical Nurse (LPN)-J was, Behavior Note: Observed [R2] coming out of [R3's room]. I asked him why he was in that room. He stated he wasn't. I told him I saw him come out of the room and he got quiet . [R3] and her personal care giver stated he [R2] did come in her room but quickly exited when he saw her care giver. They stated he does this frequently. I asked them to put her light on when this happens, and we can try to discourage this behavior. Documented in R2's Progress Notes on 8/8/23 at 3:03 PM by LPN-J was, Behavior Note: Went into a resident room [R3] while she was undressed. [Certified Nursing Assistant] removed [R2] from her room. Later he was receiving a bath and he said he goes in people's rooms because people are having sex and they needed air. Surveyor reviewed R3's Electronic Medical Record. There were no Progress Notes from 6/27/23 or 8/8/23 for R3. There were no Psychosocial Assessments or other assessments for R3 to assess for any mental anguish for R3. Surveyor reviewed R2's Electronic Medical Record. There were no Care Plan updates, interventions, or increased monitoring put in place for R2 to prevent further sexual abuse. Documented in R3's Progress Notes on 8/21/23 at 1:30 PM was, [R3] transferred to [Other Unit]. She is alert and smiling while discussing the move . Her private care giver is here today as well and is assisting her. On 11/6/23 at 9:16 AM, Surveyor interviewed Social Worker (SW)-D. Surveyor asked why R3 moved to a different unit. SW-D indicated that R3 was transferred to another unit due to R2 continuing to approach her and coming into her room. On 11/2/23 at 12:55 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-I. Surveyor asked if the facility had tried to move R2 to another unit. LPN-I stated that the facility has not tried to move R2 to another unit even though they have moved others. 2. R4 was admitted [DATE] with diagnoses that include Alzheimer's Disease, Dementia, Major Depressive Disorder, Anxiety, Chronic Pain, Repeated Falls, Depression, and Diabetes Mellitus 2. Surveyor reviewed R4's Sexual Contact Consent Assessment with an assessment date of 11/16/22. Documented was, 1. Would you like to conduct the sexual contact assessment? 2. Yes . [R4] is able to consent to sexual contact. [R4] has a guardian in place. Surveyor noted that R4 could consent to sexual contact but based on documentation, R4 did not consent to any sexual contact by R2. Documented in R4's Comprehensive Care Plan R4 with a most recent revision date of 5/31/23 was: Focus: Mood/Psychosocial Well Being: [R4] has potential for depression as a result of Dementia. She may become more confused or forgetful. She is diagnosed with cognitive impairment and is prescribed psychotropic medication Effexor. On 12-6-22 started Depakote. At times I can have aggression with cares, have verbal aggression towards others, wandering, yelling, refusing to get up, hitting out, throwing objects, biting. I am being followed by Psychiatry. Goal: [R4] will remain free of [signs and symptoms (s/sx)] of distress, symptoms of depression, anxiety, or sad mood by/through review date. To feel safe and secure. Interventions: [R4] enjoys engaging in a mutual friendship with a male peer. This friendship improves the quality of [R4's] life. She enjoys chatting, handholding, showing affection, and kissing this peer with the approval of her legal guardian. Surveyor noted that R7 was now noted as R4's boyfriend at the facility. Surveyor reviewed R4's MDS Quarterly Assessment with an assessment reference date of 8/15/23. Documented under Cognition was a BIMS score of 05 which indicated severely impaired cognition. Documented in R2's Progress Notes on 9/26/23 at 4:18 PM by LPN-J was, Behavior Note: I was assisting [R4] when [R2] was approaching us in his [wheelchair (W/C)]. She stated, oh here that man comes. He approached and asked if we wanted to play table tennis. I told him that activities had balloon volleyball. He stated, I mean table tennis where you women are the table. [R4] asked this writer to get him away from her. I asked him to go one direction and assisted her another direction. Documented in R2's Progress Notes on 10/19/23 at 12:22 PM by LPN-J was, Behavior Note: [R2] approached both female residents [R4] and [R5] asking them for sexual favors. CNA (Certified Nursing Assistant) redirected him and he asked her for sexual favors. Documented in R2's Progress Notes on 10/20/23 at 10:32 AM by LPN-I was, Behavior Note: This writer was in [R2's] room obtaining residents vital signs. Resident stated, I was wondering if you had time to come back and visit later? This writer told resident I am very busy and have a lot of work to do. You can call me if you need help. Resident then stated, I was looking for some action in the bed. Would you join me? This writer explained to resident that is inappropriate and we cannot talk to people this way. Resident replied, Oh, okay. Sorry then, God Bless. Goodbye then. Resident then left his room and headed toward the East dining room. This writer noted resident sitting next to peer of opposite sex leaning in and whispering. This writer re-directed resident to his unit [NAME] to eat breakfast. Intervention effective for short period of time. Hospice CNA reported to this writer that resident was sitting up close to anther peer of opposite sex [R4.] Resident was leaning forward whispering and rubbing peer thigh. Re-direction given. Both residents separated. Resident went down to an activity and later brought off unit by RN (Registered Nurse) Nurse Manager. Intervention effective at this time. Documented in R2's Progress Notes on 10/21/23 at 7:19 AM by LPN-J was, Behavior Note: [R2] came out of his room several times this AM completely naked; He was redirected to his room. When I asked why he was doing that he stated, I'm looking for someone to kiss. I reminded him he is not allowed to come out of his room naked, and that no one on the unit is looking for someone to kiss. He asked why he is being treated different from everyone else. I told him no one is allowed to roam the halls naked. Documented in R2's Progress Notes on 10/21/23 at 3:09 PM by LPN-J was, Behavior Note: [R2] did eventually put his clothes on and come out of his room. He was propelling about the unit when I came down the hall just after lunch. [R4] waved me over. She stated, I don't want that man in the w/c coming over and talking to me like that. I asked, Like what? She stated, Like you shouldn't be talking to a lady. She then stated, My boyfriend is starting to get mad and I don't want that. I could see her boyfriend [R7] was clearly agitated and I asked him if he was ok. He stated yes. His expression was clearly tense. I told her I would keep an eye out. When I asked [R2] what happened he stated, I don't think that guy liked me talking to his girlfriend. I asked [R2] if something happened, he said No. I asked what he said, he blew me a kiss and just said bye bye, God bless. Surveyor reviewed R4's Electronic Medical Record. There were no Progress Notes pertaining to R4's encounters with R2 as were referenced in R2's medical record for the dates of 9/26/23, 10/19/23, 10/20/23, or 10/21/23 for R4. There were no Psychosocial Assessments or follow up with R4 to assess for any mental anguish for R4. Surveyor reviewed R2's Electronic Medical Record. There were no Care Plan updates, interventions, or increased monitoring put in place for R2 to prevent further sexual abuse. On 11/6/23 at 10:30 AM, Surveyor interviewed LPN (Licensed Practical Nurse)-I. Surveyor asked about R2's sexual comments. LPN-I stated that R2 was verbally sexually inappropriate with staff and residents. Surveyor asked what interventions were in place to prevent R2 from sexually abusing residents. LPN-I stated she would redirect R2 back to his area, change the subject, and/or offer distractions like puzzles. Surveyor asked about the incident on 10/21/23. LPN-I stated that when R2 was seen rubbing R4's thigh, LPN-I separated them, told R2 that he couldn't do that and reported the incident to RN-F and ADON (Assistant Director of Nursing)-M. LPN-I stated she separated him because he has a history of threatening behaviors. On 11/2/23 at 12:55 PM, Surveyor interviewed LPN-J. Surveyor asked about R2's behaviors. LPN-J stated he opens peers' doors and tries to go in, even when they are in the bathroom. LPN-J stated, we attempt to redirect him, talk to him, but he is paranoid and wants the doors open. LPN-J stated peers get upset with him. Surveyor asked if increased monitoring has happened? LPN-J stated only once but only for a shift. LPN-J stated sometimes he will be wandering on the unit, and he will see staff watching him and go into his room because he knows he is being watched. 3. R6 was admitted [DATE] with diagnoses that include Alzheimer's Disease, Dementia with other Behavioral Disturbance, Depression, and Hypertension. Surveyor reviewed R6's Sexual Contact Consent Assessment with an assessment date of 5/2/23. Documented was 1. Would you like to conduct the sexual contact assessment? 2. Yes . Assessment of capacity for sexual contact: [R6] is unable to consent for sexual contact. [R6] has a husband which is her [Power of Attorney (POA)]. Surveyor reviewed R6's MDS Quarterly Assessment with an assessment reference date of 8/7/23. Documented under Cognition was a Staff Assessment for Mental Status assessment of Cognitive skills for daily decision making severely impaired - never/rarely made decisions. Documented in R2's Progress Notes on 10/17/23 at 10:49 AM by LPN-J was, Behavior Note: [R2] approached central supply clerk with sexually inappropriate requests. She was shocked by the conversation so [activity staff] assisted with the situation. I was informed of the situation and requested a male employee come to the unit. He did and spent some time with [R2] and immediately when he left [R2] made his way to the day area where a husband was visiting [R6] his wife. [R2] proceeded to make sexually inappropriate comments to her and was fondling himself in front of them. CNA again removed [R2] from the area. I went to the day area and apologized to the couple . Documented in R6's Progress Notes on 10/17/23 at 12:15 PM by Admissions Coordinator-K was, Writer received voicemail from [R6's spouse] requesting call back. Contacted him, and he shared that another resident [R2] had made sexually inappropriate comments in the common area where [R6's spouse] and [R6] were sitting. He stated [R2] said statements including, I'm cold and I need someone to warm me up, touched his groin area, and was making bizarre hand gestures. He reports his spouse did not appear to understand what [R2] was saying, and that [R2] did not touch her. He reports that the staff came very quickly and did a great job redirecting [R2] and bringing him away from him and [R6]. No concerns for her noted at this time, but stated he was encouraged by staff to give writer a report of incident. Writer encouraged him to maintain communication with any further incidents or needs. He verbalized understanding and agreement. [NHA-A], [SW-D] updated and both already aware. Surveyor reviewed R6's Electronic Medical Record. There were no Progress Notes in R6's medical record pertaining to the 10/17/23 notes found in R2's medical record. There were no Psychosocial Assessments or other assessments for R6 to assess for any mental anguish for R6. Surveyor reviewed R2's Electronic Medical Record. There were no Care Plan updates, interventions, or increased monitoring put in place for R2 to prevent further sexual abuse. On 11/6/23 at 2:40 PM, Surveyor interviewed R6's Husband-V. Surveyor asked about the incident with R2. Husband-V stated that he recalls the incident with R2. Husband said that R2 was over his shoulder. Husband-V stated R6 looked up and R2 was giving R6 the middle finger and gesturing to his crotch. Surveyor asked if R6 had any negative outcome from the even that he can tell. Husband-V stated, No, she can't remember. 4. R1 was admitted [DATE] with diagnoses that include Congestive Heart Failure, Alzheimer's Disease, Delusions, Dementia, Repeated Falls, and Anxiety. Surveyor reviewed R1's MDS Annual Assessment with an assessment reference date of 8/17/23. Documented under Cognition was a Staff Assessment for Mental Status assessment of Cognitive skills for daily decision making: severely impaired - never/rarely made decisions. Documented in R2's Progress Notes on 10/17/23 at 8:40 PM by RN-Q was, [LPN-G] family member of resident found him lying in his bed with a [R1], both were unclothed. Resident was lying in bed awake. Resident stated that it was hot in here and that the two residents were just resting. Resident is alert to self and family members. He was last seen in hallway 10 minutes earlier. Resident has a diagnosis of dementia. [R1] was escorted out of room by nurse and CNA. Resident remains at baseline mental status. Skin assessment completed. All skin is intact, no bruising or signs of trauma. [SW-D], [NHA-A] and [DON-B] were notified of incident. Surveyor noted that on this date R2 had been sexually inappropriate with R6, staff, and other unidentified peers and staff noting facility was aware of heightened sexual advances on this date. After the incident a Sexual Contact Consent Assessment was completed on 10/19/23. Documented was, 1. Would you like to complete this assessment? Yes . Assessment of capacity for sexual contact: This SW spoke with POA Agent about his authority and wishes for [R1's] involvement with others. He wishes for his mom to have a companion if she wants one. He does not want her alone with a male peer in bedrooms or private areas as a result of her advanced dementia and inability to give consent for an intimate relationship. After the incident R1's Comprehensive Care Plan was revised on 10/18/23. Documented under the Mood and Behavior care plan was: Focus: [R1] may seek male companionship for comfort. Buspar discontinued on 10/4/2023. Interventions: - Engage [R1] in activities. When observed going towards room with male peer, encourage her to stay in common area with male companion. Documented in R1's Progress Notes on 10/18/23 at 10:31 AM by SW-D was, Social Services Note: This SW met with [R1] before breakfast. She was able to state that she is fine. [R1] was quiet; however, this is common for her. She was not able to state any recall of an incident with a peer. She did not appear in any distress. Surveyor noted SW-D did not assess R1 as a reasonable person taking into consideration her diagnoses of Alzheimer's and Dementia. There was no comprehensive psychosocial assessment. Follow-up notes to monitor behaviors and harm were charted twice daily on 10/18/23, 10/19/23, and 10/20/23. Documented in R1's Progress Notes on 10/21/23 at 7:51 AM by LPN-J was, Behavior Note: [R1] was sleeping in her chair and began yelling out, no, no stop it in English. There was no follow-up assessing what or who R1 was yelling about. This is the final follow-up note for R1 after the incident with R2 on 10/17/23. Documented in R2's Progress Notes on 10/24/23 at 9:49 AM by LPN-J was, R2 was observed coming out of [R1's] room. This resident was not in the room at the time. Documented in R2's Progress Notes on 10/26/23 at 1:49 PM by LPN-J was, CNA reports resident had to be redirected from [R1's] room [ROOM NUMBER] times. He was trying to persuade her to go back to his room. She became upset. There was no further charting about R1 becoming upset. Documented in R2's Progress Notes on 10/28/23 at 8:01 PM by RN-I was, [R2] attempted to push [R1] into his [R2's] room this evening. CNA intervened and separated both residents. One on one and re-direction given. Intervention effective. Surveyor noted this was the eighth documented attempt of R2 trying to persuade R1 to come back to his room in 2 days. R2's Comprehensive Care Plan does not address R2 trying to persuade R1 to come to his room. R1's Care Plan states she was looking for a companion which is not in any documentation. Surveyor reviewed R1's Electronic Medical Record. There were no other Psychosocial Assessments or other assessments for R1 to assess for any mental anguish for R1. Surveyor reviewed R2's Electronic Medical Record. There was no increased monitoring put in place for R2 to prevent further sexual abuse. On 11/2/23 at 3:28 PM, Surveyor interviewed RN-Q. Surveyor asked what happened on 10/17/23 with R1 and R2. RN-Q stated she was told to go into R2's room by R2's daughter who is also an employee here (LPN-G). RN-Q saw R2 and R1 laying on the bed with no covers. R2 had his arm around the top of R1's head. R2 and R1 were naked and asleep. RN-Q stated that she and a CNA woke R1 up and got her dressed and took her out to the hall to sit with CNA. R2 got dressed and stayed in his room. RN-Q informed SW-H, NHA-A, and DON-B. When asked if RN-Q had heard R2 making sexual comments or had seen him touch any peers, RN-Q stated, I didn't hear it myself but he has said things to the [CNAs]. Surveyor asked what interventions were in place for R2 when he has sexual behaviors? RN-Q stated redirection, separate residents, and tell R2 that it is inappropriate. (RN)-Q stated that he would cooperate when redirected. On 11/6/23 at 9:16 AM, Surveyor interviewed SW-D. Surveyor asked what interventions were in place for R2's sexual behaviors? (SW)-D stated that staff would redirect R2 and tell R2 that he was being sexually inappropriate. Staff would talk to R2, offer activities, take him outside or out of the environment, or have family visit. When asked if these interventions were successful, SW-D stated that they worked 90% of the time. When asked again if R2's interventions were effective, SW-D said, No. Surveyor asked why R2 was not on one-to-one monitoring for the continued sexual abuse of peers. SW-D stated that is not feasible due to staffing and his paranoia. Surveyor asked why it was not at least tried? SW-D was unsure. On 11/2/23 at 12:55 PM, Surveyor interviewed LPN-J. Surveyor asked if the prior sexual comments from R2 would have been predictive of the situation with R1 on 10/17/23. LPN-J stated no, not with R1, but with other females. LPN-J stated R2 gets fixated on certain females and then will not leave them alone. LPN-J stated she hopes R2 does not continue and fixate on R1 because she will get mad. 5. R5 was admitted [DATE] with diagnoses that include Alzheimer's Disease, Heart Failure, and Metabolic Encephalopathy. Surveyor reviewed R5's Sexual Contact Consent Assessment with an assessment date of 1/27/23. Documented was, 1. Would you like to conduct the sexual contact assessment? 2. No . Assessment of capacity for sexual contact: [R5] is verbal and engages in meaningful conversation. She can make her needs known and makes daily choices. She is able to form friendships with her peers. [R5] is able to consent at this time. Surveyor reviewed R5's MDS Quarterly Assessment with an assessment reference date of 8/16/23. Documented under Cognition was a BIMS score of 05 which indicated severely impaired cognition. Documented in R2's Progress Notes on 10/19/23 at 12:22 PM by LPN-J was, Behavior Note: [R2] approached both female residents [R4] and [R5] asking them for sexual favors. CNA redirected him and he asked her for sexual favors. Documented in R2's Progress Notes on 10/22/23 at 3:06 PM by LPN-J was, Behavior Note: [R5] in the sunroom where she usually sits. [R2] was in the sunroom. Housekeeper came to me stating that [R2] was being sexually inappropriate. I went to observe what was transpiring. [R2] was assisted back to his room. [R5] stated she was kinda scared of [R2] because of how he was talking to her. She did not say what he said. I reassured her and stayed in the area. Documented in R5's chart on 10/23/23 at 9:38 AM by SW-H was, This worker met with [R5] regarding her statement from Sunday. [R5] had no recollection of any interactions with a male peer or ever feeling scared. [R5] stated that she has always felt safe at [facility] and she has no concerns for her safety or care that she is receiving here. Surveyor noted SW-H did not assess R5 taking into consideration her diagnoses of Alzheimer's and Dementia. There was no comprehensive psychosocial assessment. There were no follow-up assessments after this about R5 being scared. There were no Psychosocial Assessments or other assessments for R5 to assess for any mental anguish for R5. There were no c[TRUNCATED]