**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to protect a resident's right to be free from sexual abuse. The facility did not implement interventions to protect residents (R) from sexual abuse by a resident. Not implementing interventions affected 1 of 2 residents (R1) reviewed for sexual abuse. *On 03/28/24, a Certified Nursing Assistant (CNA) found R2 in R1's room. R2 was shirtless and zipping and buttoning R2's pants while in R1's bed. R1, who is cognitively impaired, stood in the middle of the room with a T-shirt and no pants. The facility did not implement appropriate interventions to prevent a second occurrence of sexual abuse from occurring. *On 04/01/24, a CNA found R2 in R1's room. R1 was in bed on R1's back. R2 was lying with R2's head next to R1's feet. R2's feet were on the floor with R2's legs off the bed and his pants and brief pulled all the way down to R2's feet with his bare buttocks on the bed next to R1's waist, and R2's penis was exposed. The failure implement immediate safety measures to prevent further sexual abuse from occurring created a finding of immediate jeopardy which began on 03/28/24. The State Agency (SA) notified Nursing Home Administrator (NHA) A and Director of Nursing (DON) B of the immediate jeopardy on 04/17/24 at 2:15 p.m. The facility took steps to correct the deficient practice on 04/02/24, after the incident to ensure compliance. Based on this determination, the immediate jeopardy was removed and corrected on 04/02/24. The citation is issued as past non-compliance. Findings include: The facility's Abuse, Neglect, and Exploitation policy dated April 2008, with recent revision date of January 2023, states: It is the policy of this community to take appropriate steps to prevent the occurrence of abuse, neglect, and misappropriation of property. It is also the policy of this community to take appropriate steps to ensure that all alleged violations of federal or state laws that involve mistreatment, neglect, abuse, injuries of unknown source, and misappropriation of resident property (alleged violations) are reported immediately to the administrator of the community. Prevention: d. The residents have a right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship. Resident's cognition will be assessed on admission and with change in condition to determine capacity to consent to a sexual contact. Assessments will be maintained in the medical record and their care plan will be updated to reflect these preferences as a preventative measure against sexual abuse. R1 is a female resident who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, disorientation, and depression. R1's Minimum Data Set (MDS) assessment dated [DATE] identifies a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicates severe cognitive impairment. R1's MDS documents R1 requires set-up with eating, substantial/maximum assistance with showering/bathing, partial/moderate assistance with dressing, supervision/touch assistance with personal hygiene, is independent with bed mobility, sitting to stand positions, chair to bed/bed to chair transfers, toilet transfers, and supervision with walking. R1's medical record documents R1 has an activated Power of Attorney for Health Care (POAHC). R1 has a determination of incapacitation which is signed on 02/23/22 stating R1 is incapacitated, that is Unable to receive and evaluate information effectively or to communicate decisions to such an extent that she/he lacks the capacity to manger her/his health care decisions. R1 has a care plan stating the focus is abuse prevention due to vulnerability. It was initiated on 02/02/24. R1's goals state R1 will have minimized the risk of abuse through the next review date. It was initiated on 02/02/24. The target date is 05/13/24. R1's interventions are to observe, suspect abuse, remove the resident from the aggressor, and relocate to a safe location. Observe and provide a safe environment. Notify the supervisor, DON, NHA, and SW (Social Worker). Date initiated 02/02/24. R2 is a male resident who was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, Alzheimer's disease, and hallucinations. R2's BIMS score is 15 out of 15, indicating intact cognition. R2's MDS dated [DATE] documents that R2 is independent with eating, requires substantial/moderate assistance with showering/bathing, dressing, personal hygiene, tub/shower transfers, partial/moderate assistance with toileting hygiene, bed mobility, walking 50 feet with two turns, is independent with toilet transfers, and wheelchair mobility. R2's care plan states inappropriate comments toward others/staff and residents. R2's goal is to have zero episodes of inappropriate comments per month. Date initiated 05/17/23. Revision date of 11/07/23. Target date of 06/25/24. R2's mood behavior will not interfere with other residents' rights through the next review. The review was initiated on 05/08/23. The revision date was 11/07/23. The target date was 06/25/24. R2's interventions are to allow resident to choose when they want things done, within reason. Date initiated 05/08/23. Check for comfort levels, thirst, hunger, and temperature-offering comfort as able/accepted. Date initiated 05/08/23. R2's abuse risk care plan for actual and/or potential abuse vulnerability. Date initiated 05/08/23. Revision date of 08/10/23. R2's goal is to minimize the risk of abuse through the next review date. The review was initiated on 05/08/23. The revision date was 11/07/23. The target date is 06/25/24. R2's interventions are to observe/suspect abuse, move the resident from the aggressor, and relocate. Date initiated 05/08/23. On 04/16/24, Surveyor reviewed a facility-reported incident, which stated on 03/28/24, a CNA found R2 in R1's room. R2 was shirtless and zipping/buttoning his pants while in R1's bed. R1 was standing in the middle of the room in a t-shirt and no pants. The facility separated R1 and R2 but did not implement any additional interventions. On 04/01/24, R2 was again found in R1's room by a CNA. R1 was in bed on her back. R2 was lying with his head next to R1's feet. R2's feet were on the floor with his legs off the bed, and his pants and brief pulled all the way down to his feet with his bare buttocks on the bed next to R1's waist. R2's penis was exposed. Facility investigation indicates that R1 and R2 were separated. R1 was monitored for distress. Nursing staff conducted assessments on R1 and R2, and no injuries were noted. The facility contacted the ombudsman and provided education to staff on abuse, identification, prevention, and reporting abuse. Staff signatures indicate the facility provided education on 04/02/24. The facility notified R1's and R2's family members and physicians of the incidents. The facility notified the police, and nursing conducted head-to-toe assessments on R1 and R2. The facility initiated 1:1 supervision 24/7 of R2, with the facility working on a discharge plan for R2. The facility interviewed staff and other residents. Facility documentation, dated 03/28/24, states CNA D informed Registered Nurse (RN) G that CNA D had walked into R1's room and R2 was shirtless in R1's bed while R1 was standing in the middle of the room with no pants on. RN G and CNA D spoke with both residents (R1 and R2) and asked each of them about the situation, and both denied anything sexual occurring. Both residents (R1 and R2) were informed their families would be contacted. RN G contacted R1's family, who expressed no interest in further action other than keeping the residents separated to prevent a repeat situation. The facility contacted R2's family, and R2's family were skeptical and upset about the problem. Still, they did not express any interest in taking further action other than keeping the residents apart to prevent a repeat situation. A progress note in R2's medical record states that on 03/28/24 at 10:20 p.m., CNA D informed RN G that R2 referred to R1 by saying, She's the confused one. Social Worker (SW) C's documentation on 04/01/24 at 6:38 p.m., states that the note is a follow-up on the incident on 03/29/24 (the date should be 03/28/24). The facility will continue to investigate to ensure that both parties consent. An ombudsman notification was sent to determine the proper protocol for this situation. On 04/16/24 at 11:55 a.m., Surveyor interviewed CNA D and asked CNA D to walk Surveyor through the incident that occurred on 03/28/24 between R1 and R2. CNA D stated she checked on R2 for evening care, and R2 was not in R2's room. R1 and R2 were seen together in the evening, walking around the facility. CNA D went to R1's room, knocked, and entered; R2 was zipping and buttoning his pants when CNA D walked in and R2 was shirtless in R1's bed. CNA D returned R2 to his room, R2 stated, If I were a little younger and a little faster, it would have happened. R2 said, I suppose you will give her (R1) the third degree. CNA D stated the facility would talk with R1 to see what happened. CNA D stated that R2 said, She is the forgetful one. R2 also told CNA D that R1 and R2 used to be neighbors. On 04/16/24 at 3:15 p.m., Surveyor interviewed RN G and asked RN G to walk Surveyor through the incident that occurred on 03/28/24 between R1 and R2. RN G was paged regarding the incident. RN G stated CNA D checked on R2 for evening care, but R2 was not in R2's room. RN G stated when RN G got to R1's room, R2 was standing in the middle of the room in a T-shirt and briefs, and R2 was putting on a shirt. RN G stated RN G assisted R2 to the wheelchair and assisted R2 to R2's room. When questioned about the incident, RN G stated R2 kept saying, I can't get an erection; all I can do is try. RN G stated the Medication Technician (MT) H and CNA D stated R1 said a man had crawled into the bed. R1 did not know it was R2 at that moment. RN G stated R1's and R2's families were notified about the incident and told the residents were separated and would be monitored. Families are not concerned, per RN G. On 04/16/24 at 10:38 a.m., Surveyor interviewed DON B and asked about the incident between R1 and R2 on 03/28/24 and why the police were not called and why the facility did not initiate an investigation. DON B stated the facility was looking at the encounter as consensual. DON B stated R1 and R2 are routinely going about the facility together. DON B stated R1 and R2 have a right to a relationship. Surveyor asked if the facility had assessed the residents' ability to consent. DON B said, No. Of note, R1's BIMS is 3, meaning R1 does not have the capacity to consent to a sexual relationship. The facility did not implement interventions to prevent further abuse. The facility did not notify police, did not conduct an investigation, did not notify R1's or R2's physicians timely, and did not conduct an intimacy & sexual history on R1 and R2 relating to the 03/28/24 sexual abuse incident. The facility was aware that R1 has a determination for incapacity. The facility was aware in May of 2023 of R2's inappropriate comments toward others/staff and residents. Surveyor reviewed R1's and R2's medical records for the second incident on 04/01/24. R2's progress note states on 04/01/24 at 9:19 p.m., R2 was found in R1's room for the second time. R1 was in R1's bed on R1's back. R2 was lying with R2's head next to R1's feet. R2 had R2's feet off the floor with R2's legs off the bed with, R2's pants and brief pulled all the way down to the feet and R2's bare buttocks on the bed next to R1's waist, and R2's penis exposed. R1 and R2 stated they needed a few minutes. RN G and CNA F assisted R2 with pulling up R2's pants and assisting R2 to the wheelchair. R1's underwear was found in the bed at R1's feet. Staff assisted R2 back to R2's room and questioned R2 about the situation. R2 stated R2 hadn't been able to get an erection for a long time, and all R2 could do was try. RN G asked what happened in the room and R2 stated they (R1 and R2) were lying there. RN G asked R2 if R2 knew R1 was confused, making the situation complicated, to which R2 replied, I know, she's confused. She keeps asking me how many kids I have and asks me other questions repeatedly. The facility implemented 15-minute checks throughout the night. A behavior progress note, dated 4/1/2024 at 9:35 p.m., states R1 was questioned about the situation, to which R1 replied, I don't know what happened. He (R2) just crawled into bed with me and started kissing me. R1 was observed earlier in the night as going to bed after R2 had already gone to bed, suggesting that R2 had gotten himself out of bed and entered the resident's room. On 04/10/24 at 1:22 p.m., Surveyor interviewed CNA F and asked to walk Surveyor through the incident between R1 and R2 on 04/01/24. CNA F stated when CNA F walked into R1's room, R2 yelled, Get out. R2 was sitting on R1's bed, but R1's legs were off the bed, and R2 was lying partially down by R1's waist with no pants on. CNA F stated that R1 had a nightgown on. CNA F stated CNA F and MT H returned to R1's room after RN G took R2 back to R2's room and asked R1 what happened. R1 stated R1 was sleeping, and R2 came in, got into bed with R1, and started kissing R1. CNA F stated MT H and CNA F were assisting R1 in settling in bed again, but R1's bedding had to be changed because the sheet had a quarter-size blood spot. Surveyor asked if R1 was injured. CNA F stated that CNA F did not know. On 04/16/24 at 3:15 p.m., Surveyor interviewed RN G and asked RN G to walk Surveyor through the incident between R1 and R2 on 04/01/24. RN G stated RN G was in the room next to R1's. CNA F notified RN G R2 was in R1's room. RN G stated when RN G got to R1's room, R1 had no underwear on. R2 was sitting on the side of R1's bed, upper body lying on the bed, R2's pants were around R2's ankles, and R2 was all exposed. RN G stated RN G assisted R2 in getting dressed and helped him get in the wheelchair and back to R2's room. In R2's room, R2 said nothing had happened. RN G stated RN G had asked R2 if R2 knew R1 was confused. RN G stated RN G told R2 due to R1's confusion, R1 couldn't consent. R2 stated R2 knows that. RN G stated that RN G had told R2 that this could not happen again. RN G stated CNA F told RN G when R1 was asked about the incident, R1 said R1 didn't know and He just came in and started kissing her. R1 didn't know who he was. On 04/16/24 at 3:35 p.m., Surveyor interviewed MT H and asked MT H to walk through the incident between R1 and R2 on 04/01/24. MT H stated CNA F came to get MT H to go into R1's room to find out what happened. R1 was dressed in pajamas. When R1 was asked what happened, R1 said he came into the room and started kissing me. MT H stated R1 was asked multiple times about the incident and R1 replied with the same answer. A social service progress note dated on 4/2/2024 at 4:23 p.m. states SW C was notified on 04/02/24 of the 04/01/24 incident between R1 and R2. SW C documents that both residents (R1 and R2) were questioned, and R2 stated that R1 wanted R2 to come to R1's room and wanted sex. SW C's documentation states when R1 was questioned, R1 didn't remember a man in R1's room or know who R2 is. SW C's documentation states when asked if R1 wanted R2 in R1's bed, R1 said, No. SW C's documentation states this incident was reported to the state, and a call was placed to the police department to report the incident. Police came to the facility and agreed that R1 could not give explicit consent on this advance from R2. Police spoke with R2 and told R2 clearly that R2 is not to go in R1's room again or touch R1 due to R1's inability to make a clear consensual decision regarding sex. SW C's documentation states R2 stated R2 felt bad because R1 wanted more, and R2 hasn't been able to have sex due to prostate issues and is unable to have an erection. (R2's medical record does not state any diagnoses related to the prostate.) SW C's documentation states the facility called the ombudsman earlier to ensure it was proceeding correctly and did not infringe on resident rights. The skin and progress note in R1's medical record dated 4/2/2024 at 6:06 p.m states a head-to-toe skin assessment was performed on R1. R1's right forearm had an approximately 1-inch long-healed scratch from the previous injury when R1 scratched self with R1's nails. No other skin issues were noted. The progress note contains no detailed information on assessing the genital area of R1 to assess for indicators of sexual abuse. R1's medical record progess note dated 04/02/24 at 8:21 p.m. states the primary physician was notified of the 04/01/24 incident between R1 and a male resident. The physician wants to be notified if any issues arise, such as agitation, distress, or unusual behavior. The facility did not notify the physician timely. R2's skin and wound progress note dated 04/02/24 at 6:10 p.m. states R2 underwent a head-to-toe skin assessment. R2 has a small open area on the inner left buttock with a small amount of blood drainage. The abscess on the testicles appears to be gone. Multiple bruised areas on the right hand and right forearm from R2 hitting hand/arm on banister when wheeling down the hallways in a wheelchair. No other skin issues were noted. The facility did not conduct intimacy & sexual history assessments on R1 and R2 until 04/02/24. The results differ between R1 and R2. Results read as follows: Comfortable giving or receiving affection such as a touch, a hug, or a kiss? R1 Yes R2 Yes Are you accustomed to sleeping alone in bed? R1 Yes R2 Yes Are you currently involved in a relationship? R1 No R2 I thought maybe. Before living here, how did you show your companion that you cared? R1 He has been gone a long time. R2 I haven't had one since my wife. Before living here, what was your comfort level with sexual contact? R1 Why are you asking me this. R2 No problems Are you seeking a relationship with someone in the facility? R1 No R2 Not anymore Do you have any concerns regarding your interactions with this person R1 No R2 I didn't realize she has a bad memory Any history of abuse? R1 No R2 No Any history of sexually transmitted infections? R1 No R2 No On 04/02/24 at 8:21 p.m., R1's medical record progress note states the primary physician was notified of the 04/01/24 incident between R1 and a male resident. The physician wants to be notified if any issues arise, such as agitation, distress, or unusual behavior. The facility did not notify the physician timely. The facility contacted R2's physician assistant (PA) on 04/02/24 at 8:32 p.m. regarding the incident between R2 and a female resident on 04/01/24. The note states R2 will be seen by the primary physician on 04/03/24. The facility did not notify the physician timely. The primary physician saw R2 on 04/03/24 and ordered Sertraline 50mg by mouth tablet to be started at HS (hour of sleep) on 04/05/24. On 04/04/24 at 8:07 a.m., the facility notified R1's primary provider to discuss an action plan to have R1 evaluated for trauma impact. The physician was informed R1 has not had any physical or emotional signs of trauma. The physician agrees with the current plan and will monitor for trauma and update as needed. On 04/16/24, Surveyor observed R2 in R2's room watching TV, conversing with staff, and eating meals. Surveyor observed R1 during the survey eating meals in the dining room and attending activities in the dining room. On 04/16/24 at 11:28 a.m., Surveyor interviewed Ombudsman (OM) E via telephone and asked if the facility contacted OM E regarding two incidents between R1 and R2. OM E stated the facility did contact OM E. OM E stated OM E told the facility R1 and R2 have a right to a relationship. OM E stated SW C was informed about assessing residents for ability to consent and no ability to consent. OM E stated the form for the assessment was emailed to SW C. OM E stated OM E would be at the facility on 04/23/24 for a meeting to inform everyone about resident rights, having a relationship, consent, and safety. On 04/16/24 at 4:05 p.m., Surveyor interviewed SW C about the incidents between R1 and R2. SW C stated SW C was notified, and OM E was contacted to ensure the facility handled the situation appropriately. Surveyor asked if R1 and R2 were assessed for the ability to consent. SW C stated no assessment was completed until 04/02/24. SW C stated SW C received the form from OM E. Surveyor asked if the family of R1 was asked about a physical exam/rape kit following the incident. SW C stated R1's family didn't want anything done. SW C stated both families stated R1 and R2 have known each other for 40 years. SW C stated R2 had not pursued anyone until R1 was admitted to the facility. On 04/16/24 at 10:38 a.m., Surveyor interviewed DON B about the incident between R1 and R2 on 04/01/24. DON B stated R2 was in R1's room fully exposed on the bed and R1 did not have any underwear on. DON B stated R1 and R2 were separated. R2 was placed on every 15-minute checks at first, then supervision was changed to 1:1 24 hours a day, seven days a week. DON B stated the facility is looking into alternative placement for R2. On 04/16/24 at 1:15 p.m., Surveyor interviewed R1 and asked about the incident between R1 and R2. R1 did not know what Surveyor was talking about. R1 could not recall anything. Surveyor asked if R1 knew R2. Surveyor stated R2's name and R1 said R1 knew R2 and they were friends. Surveyor asked if R1 feels safe in the facility and R1 stated R1 felt safe. Surveyor asked about abuse. R1 denied any abuse. On 04/16/24 at 1:37 p.m., Surveyor interviewed R2 and asked about the incident between R2 and R1. R2 stated he was sitting with R1 and other residents in the dining room after activities and R1 got up and started wandering around. R2 stated he figured R1 was looking for R1's room. R2 stated he had taken R1 to R1's room. R2 stated R1 invited R2 into the room. R2 stated he has known R1 for many years. R1 and R2 have been friends, and their kids went to school together per R2. R2 stated R1 kept asking him where R2's wife was. R2 stated R1 wanted R2. R1 started undressing and trying to undress R2. R2 stated he and R1 were in bed together when staff came to the room. R2 stated he didn't want to hurt R1. R2 stated he lost his head. R2 stated he is not proud of self. R2 stated R2's kids are not proud of R2 either. On 04/17/24 at 12:16 p.m., Surveyor spoke with R1's family member (FM) J. Surveyor asked if the facility notified the family about R1's two incidents with a male resident. FM J stated the facility notified the family immediately. Surveyor asked if the facility offered to have R1 examined after the incidents. FM J stated the family didn't want anything done. FM J stated R1 doesn't remember from one minute to the next. FM J stated that R1 was happy-go-lucky and that the family believes R1 had not been injured. Surveyor asked if the facility was doing what the family expected. FM J stated the facility is fine. The facility is doing what it needs to do to keep the two residents apart. On 04/16/24 at 12:42 p.m., Surveyor interviewed R2's FM I and asked if the facility notified the family about R2's two incidents with a female resident. FM I stated the facility notified the family. Surveyor asked if the facility was doing what the family expected. FM I stated the facility is doing its best to prevent further incidents. FM I stated these two residents have known each other for many years. FM I states no further concerns at this time. There is no evidence that R1 had the ability to consent to a sexual relationship due to her cognitive impairment. Sexual contact with a person who has not consented to such contact or who is unable to consent is considered sexual assault in Wisconsin. According to the article written by a member of the [NAME] University Law School, Grandparent Molesting: Sexual Abuse of Elderly Nursing Home Residents and its Prevention, Emotional signs and symptoms [of sexual assault in a nursing home] include denial, humiliation, flashbacks, intense fear, guilt, anxiety, depression, feelings of hopelessness and helplessness, phobias, and rage. These conditions are symptomatic of post-traumatic stress disorder or rape trauma syndrome. Because victims of sexual abuse are likely to be cognitively impaired, practitioners must consider additional effects of abuse. Often, cognitively impaired individuals are unable to describe the assault event, the fears, or the feelings of helplessness. Providing these victims with necessary services makes it more challenging because they cannot express their needs. In addition, victims suffering from dementia, including Alzheimer's disease, often display post-rape emotional distress, including disorganized or agitated behaviors, sleep disturbance, and extreme avoidance of certain staff members. Research shows that sexual abuse may increase the victim's mortality. Injuries, but more significantly stress, from the assault may exacerbate other health conditions of the victim, such as hypertension and diabetes. http://scholarship.law.[NAME].edu/cgi/viewcontent.cgi?article=1066&context=elders The facility's failure to keep residents free from sexual abuse created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on 03/28/24. On 04/02/24, the facility identified the deficient practice that occurred when R2 sexually abused R1. The facility took steps to correct the deficient practice and ensure compliance on 04/02/24. Based on this determination, the immediate jeopardy was removed on 04/02/24 and corrected on 04/02/24 when the facility implemented the following: 1. Placed R2 on 1:1 supervision 24 hours a day, seven days a week. 2. Moved R2 to another room across from the nurse's station, further from R1. 3. Educated staff on abuse, identification, prevention, and reporting abuse. 4. Physician review of medications for R2. 5. Obtained Neuro psych referral for R2. 6. R1's care plan updated follows: R1's care plan states that the focus is trauma-informed care. R1 has the potential for complications related to experienced trauma due to diagnosis of dementia and to possible non-consensual sexual encounter with a male resident on 04/01/24. Date initiated 04/02/24. R1's goals state R1 will be free of serious negative outcomes related to personal trauma. Date initiated 04/02/24. Target date of 05/13/24. R1's interventions are to encourage residents to talk about the past and to make goals and decisions about care. By listening, R1 establishes a trusting relationship with the resident. R1 maintains a calm, non-threatening manner while working with the resident. 7. R2's care plan update as follows: Has a history of sexual behavior toward a female resident on 04/01/24. The plan of care is to be one-on-one with the resident 24/7, with staff taking turns, and start a plan of discharge. Date initiated 04/02/24. Intervention: Allow resident to wander within the unit, along with one-on-one with staff. Date initiated 04/02/24.