Brookdale Pinnacle

Based on review of medical records, review of a police report, review of an abuse investigation, interviews with staff, residents, Sexual Assault Nurse Examiner (SANE) #800 and Police Detective #801, and review of facility policy, the facility failed to ensure Resident #37, #53, #55 and #100, who were cognitively impaired and resided on a memory care unit, were free from sexual abuse by Resident #44 who was also cognitively impaired and had a history of sexually inappropriate behavior. This resulted in Real and Present Danger and the potential for serious physical, mental and/or psychosocial negative outcomes for four residents (#37, #53, #55 and #100) when the facility failed to recognize and respond to Resident #44's increased sexual behavior. Resident #44 was found in Resident #37's bed naked under the covers on 03/09/24. Resident #44 took his pants off and pulled Resident #53 out of bed and then put his hand over her mouth when she was screaming and crying on 03/13/24. Resident #44 was also holding onto Resident #53's arms on 03/13/24. Resident #100 reported to Licensed Practical Nurse (LPN) #53 on 05/16/24 that Resident #44 raped her on the night of 05/15/24. Resident #44 was observed in Resident #55's room with his left-hand covering Resident #55's mouth and his right hand tucked into the front of his sweatpants on 05/18/24. There were no interventions put in place for staff to implement to address Resident #44's behaviors on 03/09/24, 03/13/24, 05/16/24 and 05/18/24 and to prevent further abuse from happening. This affected four (#37, #53, #55 and #100) of four residents reviewed for abuse and placed an additional twelve (#35, #36, #38, #42, #43, #45, #46, #47, #51, #52, #54, and #56) cognitively impaired female residents residing on the memory care unit of the facility, where Resident #44 had unrestricted access, at risk for further potential sexual abuse. The facility census was 57.

On 05/23/24 at 11:20 A.M., Executive Director (ED) #68 and Health and Wellness Director (HWD) #74 were notified Real and Present Danger began on 03/09/24 after Resident #44 was found in Resident #37's bed naked under the covers on 03/09/24. Resident #44 took his pants off and pulled Resident #53 out of bed and then put his hand over her mouth when she was screaming and crying on 03/13/24. On 05/16/24, Resident #100 reported to LPN #53 on 05/16/24 that Resident #44 raped her on the night of 05/15/24. Resident #44 was observed in Resident #55's room with his left-hand covering Resident #55's mouth and his right hand tucked into the front of his sweatpants on 05/18/24. There were no interventions put in place for staff to implement and/or to address Resident #44's behaviors on 03/09/24, 03/13/24, 05/16/24 and 05/18/24 and/or to prevent further abuse from happening.

The Real and Present Danger was abated on 05/29/24 when the facility implemented the following corrective actions:

On 05/20/24, Resident #44 was admitted to a behavioral health hospital.

On 05/23/24, ED #68 filed a police report regarding the incidents that took place on 03/09/24, 03/13/24 and 05/18/24.

On 05/23/24, ED #68, HWD #74, and Registered Nurse (RN) Care Manager #580 or designee completed resident interviews of all female residents residing in the memory care unit. There were no identified abuse concerns from the interviews with the female residents.

On 05/23/24, ED #68, HWD #74, and RN Care Manager #580 or designee completed skin assessments on all female residents residing on the memory care unit. There were no identified abuse concerns from the skin assessments with the female residents.

Beginning 05/23/24, District Director of Clinical Services (DDCS) #583, District Director of Operations (DDO) #802, and District Clinical Specialist (DCS) #581 or designee audited chart notes of all female residents on the memory care unit to help identify additional residents who may have been impacted by the allegation of noncompliance. The audits were completed on 05/28/24 and there were no identified abuse concerns.

On 05/24/24, ED #68 issued an immediate discharge notice to Resident #44.

On 05/24/24, DDCS #583, and Divisional Director of Memory Care (DDMC) #582 or designee will begin reviewing potential admissions for appropriateness.

Beginning 05/24/24, ED #68, and DDO #802 or designee completed interviews with all associates who had provided care in the affected unit as a measure to help identify additional residents who may have been impacted by the allegation of noncompliance. The interviews will be completed by 05/29/24.

Beginning 05/24/24, ED #68, HWD #74, and RN Care Manager #580 or designee will review the 24-hour report each day for the next 90 days to help identify residents that may present a safety risk. This will be completed on 08/23/24.

Beginning 05/24/24, DDCS #583, and DCS #581 or designee will conduct a site visit monthly for the next ninety days that will include an audit of any incident reports from the prior ninety dates, interviews of five associates, and interviews of five memory care residents to help identify any potential at risk residents. This will be completed on 08/23/24.

Beginning 05/28/24, ED #68, and DCS #581 or designee conducted retraining for all clinical associates and leadership on sexuality and intimacy, abuse and neglect, the Ohio Bill of Rights, and associate obligations, creating a culture of behavior and problem solving and reportable events. The training will be completed by 05/29/24 or staff who have not completed the training will not be permitted to provide resident care until training is completed.

Beginning on 06/22/24, ED #68, HWD #74, and RN Care Manager #580 or designee will interview five female residents weekly for sixty days to verify reports of safety and comfort in their home.

Although the Real and Present Danger was abated on 05/29/24, the violation continues as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.

Findings include:

Review of Resident #44's medical record revealed the resident was admitted to the facility on 02/27/24. Diagnoses include other long term drug therapy, frontotemporal dementia, encephalopathy, hypertension, chronic viral hepatitis B with delta agent and depression.

Review of Resident #44's personal service assessment dated 03/13/24 revealed the resident had memory loss and cognitive impairment. Resident #44 had difficulty with orientation to person, place, and time. Resident #44 requires assistance with dressing, grooming, showering, and going to and from the dining room. Resident #44 was independent with toileting.

Review of Resident #44's progress note dated 03/09/24 at 9:53 P.M. revealed the resident was in another resident's (Resident #37) bed naked and with her under her covers. The nurse and three Resident Assistants (RA's) attempted to get the resident from her bed and room. Resident #44 was cursing and kicking. Staff moved the female resident (Resident #37) from her bed to another location.

Review of Resident #44's progress note dated 03/13/24 at 1:27 A.M. revealed the resident was going into other female resident rooms and shaking their shoulders to wake them up out of sleep. Resident #44 was not listening to redirection and Resident #44 pushed on the memory care doors and left to read the visitor book in the lobby of the memory care unit.

Review of Resident #44's progress note dated 03/13/24 at 10:00 P.M. revealed Resident #44 was going into other female resident rooms. When asked to leave the room or when staff tried to redirect Resident #44, the resident became agitated and was swinging his arms. Resident #44 entered a female resident's (Resident #53) room where he took off his pants and pulled her out of bed. The female resident was screaming and crying, and Resident #44 then put his hand over her mouth. Resident #44 was holding onto the female resident by her arms. The RA tried to redirect Resident #44 but was unsuccessful. The RA called the nurse and when the nurse approached the situation, Resident #44 and the female were standing in the hallway fully clothed. The female resident was still screaming, and the nurse tried to redirect the resident but was not successful. The nurse was able to remove Resident #44 from the female's room where he became agitated and aggressive. Resident #44 refused as needed medications. The Power of Attorney (POA) and HWD #74 were made aware.

Review of Resident #44's progress notes from 05/15/24 to 05/17/24 revealed no information related to Resident #100 alleging Resident #44 raped her at the facility on 05/15/24.

Review of Resident #44's progress note dated 05/18/24 at 8:09 P.M. revealed the resident was observed in another resident's (Resident #55) room at approximately 8:00 P.M. with his left hand covering the female resident's mouth. Resident #44 had his right hand tucked into the front of his sweatpants. The caregivers redirected Resident #44, and the resident exited the room immediately.

Review of Resident #44's progress note dated 05/19/24 at 10:00 P.M. revealed the RA told the nurse that Resident #44 punched her in the left side of her face. Resident #44 was inside another resident's room going through her things when she was asking him to get out and he would not leave. Two RA's were trying to redirect Resident #44 out of the other resident's room when Resident #44 punched and grabbed the RA. This was reported to HWD #74 and the POA.

Review of Resident #44's progress note dated 05/20/24 at 9:07 A.M. revealed the nurse attempted to redirect the resident into his room due to him continuously going into multiple resident rooms and causing a disturbance. Resident #44 punched the nurse with his right fist on the left side of her face and stated you expletive term. HWD #74 was notified.

Review of Resident #44's progress note dated 05/20/24 at 8:00 P.M. revealed Resident #44 was noted with physical aggressive behaviors toward staff. Resident #44 was more agitated when staff attempted to redirect Resident #44 out of other resident rooms. Resident #44 continued to refuse medication. Staff spoke to the physician regarding medication changes and a possible psychiatric stay. Resident #44 was transported to the psychiatric hospital and the POA was notified.

Review of Resident #37's medical record revealed the resident was admitted to the facility on 08/27/18. Diagnoses include major depressive disorder and unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety.

Review of Resident #37's personal service assessment dated 12/28/23 revealed the resident had memory loss and cognitive impairment. Resident #37 had difficulty with orientation to person, place, and time. Resident #37 required assistance with dressing, grooming, toileting, showering, and going to and from the dining room.

Review of Resident #37's progress notes from 01/01/24 to 05/22/24 revealed no information related to Resident #44 being found in Resident #37's bed naked under the covers on 03/09/24.

Review of Resident #53's medical record revealed the resident was admitted to the facility on 04/12/23. Diagnoses include confusional arousals, and vascular dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety.

Review of Resident #53's personal service assessment dated 03/15/24 revealed the resident had memory loss and cognitive impairment. Resident #53 had difficulty with orientation to person, place, and time. Resident #53 required assistance with dressing, grooming, toileting, showering, and going to and from the dining room.

Review of Resident #53's progress notes from 01/01/24 to 05/22/24 revealed no information related to Resident #44 taking his pants off, pulling Resident #53 out of bed and/or putting his hand over Resident #53's mouth when she was screaming and crying on 03/13/24. Resident #53's progress notes also had no information regarding Resident #44 holding onto Resident #53's arms on 03/13/24.

Review of Resident #100's medical record revealed the resident was admitted to the facility on 05/15/24. Diagnoses include major depressive disorder, Alzheimer's disease, essential hypertension, hyperlipidemia, arthritis, atherosclerotic heart disease of native coronary artery without angina pectoris, old myocardial infarction, and chronic pain. Resident #100 discharged from the facility on 05/17/24.

Review of Resident #100's personal service assessment dated 05/15/24 revealed the resident had memory loss and cognitive impairment. Resident #100 had difficulty with orientation to person, place, and time. Resident #100 was independent with dressing, grooming, showering, and toileting. Resident #100 required assistance with going to and from the dining room and community activities.

Review of Resident #100's progress note dated 05/15/24 revealed the resident arrived at the facility at 2:20 P.M. and was admitted. Resident #100 was shown her room and became very sad when she saw her bed and rocking chair. Resident #100 wanted to know how long she was going to be there.

Review of Resident #100's progress note dated 05/17/24 revealed the resident's sister and daughter arrived at the facility very hostile and speaking loudly and negatively to the nurse. They stated that Resident #100 was not returning to the community and demanded her medications and reported Resident #100's other daughter that was the POA relinquished her POA at the hospital stating she was done and could not deal with her. Staff asked if she was the alternative POA listed on the documents, and she stated she was not the alternate POA. Staff explained that they would need to contact the POA directly before releasing any information or medication. Staff called the POA, and she stated it was okay to release the medication and information to them and stated, give them what they want. Resident #100's POA stated she had not relinquished her POA yet and felt it would be better for the facility not to deal with her family. The POA stated she believed that Resident #100 wanted to leave the facility and go home and will state whatever she needed in order for her to do so. Medications were released with current medication orders, and she stated they would be there sometime that weekend to move Resident #100's belongings out of the facility. Resident #100's door was locked per family request.

Review of Resident #100's medical record from 05/15/24 to 05/17/24 revealed there was no documentation related to Resident #100's allegedly being raped by Resident #44 at the facility on 05/15/24.

Review of Resident #55's medical record revealed the resident was admitted to the facility on 06/28/22. Diagnoses include unspecified dementia unspecified severity with behavioral disturbance, heart failure, hyperlipidemia, polycystic ovarian syndrome, cramp and spasm and Vitamin D deficiency.

Review of Resident #55's personal service assessment dated 04/12/24 revealed the resident had memory loss and cognitive impairment. Resident #55 had difficulty with orientation to person, place, and time. Resident #55 required assistance with dressing, grooming, toileting, and going to and from the dining room. Resident #55 did not require assistance with showering.

Review of Resident #55's progress notes from 01/01/24 to 05/22/24 revealed no information related to Resident #44 being observed in Resident #55's room with his left-hand covering Resident #55's mouth and his right hand tucked into the front of his sweatpants on 05/18/24.

Review of the redacted police report dated 05/17/24 revealed the incident occurred on 05/15/24 from 9:30 P.M. to 05/16/24 at 8:30 A.M. HWD #74 contacted the police to report a resident (Resident #100) there alleged another resident (Resident #44) raped her. HWD #74 stated LPN #53 was with the resident when she said, the man in the red shirt raped me. HWD #74 stated the suspect was a resident who also resided in the memory care unit. HWD #74 and Memory Care Program Director (MCPD) #75 spoke with the resident since she began staying at the facility to see how she was doing. HWD #74 and MCPD #75 stated that the resident made several comments about not wanting to be at the facility. HWD #74 and MCPD #75 wrote witness statements saying the resident told them the other resident had been in her room, but the resident did not make the allegation of rape to them. The officer spoke to the resident about the allegation and the resident stated she went to bed about 9:30 P.M. on 05/15/24 and during the night she found the other resident lying with her. The resident said she told the other resident to get the hell out but he would not leave. When asked what the other resident did to her, she stated he raped her by penetrating her. The resident was transported to the hospital by private ambulance for treatment and examination. The detective responded to the facility and spoke with HWD #74 and MCPD #75. There was no scene to process and no further leads, evidence, or witnesses.

On 05/22/24 Resident #100's hospital medical records were requested but were not received during the survey.

Review of the facility's investigation dated 05/17/24 revealed HWD #74 checked on Resident #100 as she was a new resident, and it was her first night at the facility on 05/16/24 at 7:40 A.M. HWD #74 asked how her night was, and Resident #100 stated it was not good. HWD #74 asked what happened and Resident #100 stated a man came into her room two times and the first time he ate her cookies and the next time she woke up and he was laying in her bed. HWD #74 stated she told him to get the hell out. HWD #74 asked if he hurt her, but Resident #100 stated no, and she just told him to get the hell out. Resident #100 reported she was raped by another resident on 05/16/24 at 9:00 P.M. HWD #74 was notified, and an investigation was started. Police were notified and Resident #100 was sent to the hospital for examination. Resident #100 was then interviewed with HWD #74 and MCPD #75 after the allegation was reported on 05/17/24 at 9:30 A.M. HWD #74 stated HWD #74 and MCPD #75 wanted to talk to Resident #100 about what she told the nurse last night and Resident #100 replied I was raped. HWD #74 told her she would have to be sent out for a medical evaluation and the police would have to come. MCPD #75 asked if he took her clothes off and Resident #100 stated that she only slept in a T-shirt and underwear. The police then came and interviewed the resident.

Review of the facility's investigation dated 05/17/24 revealed LPN #53 was interviewed on 05/16/24 at 9:00 P.M. LPN #53 stated that it was reported to her that Resident #100 stated she was raped. LPN #53 notified HWD #74 and helped Resident #100 back to her room and got her in her bed. LPN #53 explained there was a lock on her door so no one would be able to get in if they did not have a key.

Review of the facility's investigation dated 05/17/24 revealed RA #49 was interviewed on 05/16/24 at 10:30 P.M. RA #49 stated Resident #100 came to the main area in the memory care unit on 05/15/24 and stated there was a man in her room and she asked if she could remove him. RA #49 went to Resident #100's room and noticed that Resident #44 was in her room going through her things. RA #49 asked Resident #44 to leave and he did.

Interview with ED #68 on 05/22/24 at 9:59 A.M. revealed she was out of the facility on leave at the time Resident #100 alleged Resident #44 raped her at the facility on 05/15/24 and she did not have any details regarding the incident.

Interview with MCPD #75 on 05/22/24 at 10:09 A.M. revealed Resident #100 moved into the facility on 05/15/24. MCPD #75 stated she met with Resident #100's POA early in the morning on 05/16/24 and Resident #100's POA stated Resident #100 was upset with her because she did not want to be at the facility. MCPD #75 stated she went down to Resident #100's room and the resident's POA stayed outside the room, and she asked the resident how her night was because the resident's POA wanted her to diffuse the situation before she visited. MCPD #75 stated that Resident #100 stated there was a man (Resident #44) in her room overnight and she told him to get the hell out. MCPD #75 reported Resident #100 told her that the resident was walking around and eating her snacks. MCPD #75 stated that Resident #100 then asked about her POA and her POA came in the room. MCPD #75 reported Resident #100 did not tell her about the rape allegation when she spoke with her the morning of 05/16/24 and she also did not tell her POA who visited on 05/16/24 or HWD #74 who also visited on 05/16/24. MCPD #75 stated Resident #100 later told the night shift nurse while she was seated in the common area You see that guy over there? He raped me. MCPD #75 stated that Resident #100 was referring to Resident #44 as the guy who raped her. MCPD #75 stated Resident #44 was a Caucasian male and there were no cameras on the unit.

Telephone interview on 05/22/24 at 11:10 A.M. with SANE #800 revealed she examined Resident #100 at the hospital on 05/17/24. SANE #800 reported Resident #100 told her that a black man that was younger than her raped her. SANE #800 stated that Resident #100 had no obvious tearing but did have a small abrasion to the labia which could have been caused by wiping. SANE #800 reported the majority of sexual assault victims did not have signs of trauma. SANE #800 stated Resident #100 originally declined a rape kit but then changed her mind and one was completed. SANE #800 reported the rape kit could take six months to one year to be processed.

Observation of the facility on 05/22/24 at 11:14 A.M. revealed Resident #53 was ambulating independently and wandering the hallway on the memory care unit. Resident #53 was clean and dressed appropriately.

Attempts to interview Resident #53 on 05/22/24 at 11:14 A.M. revealed the resident was not able to provide any information due to cognition.

Interview with HWD #74 on 05/22/24 at 11:25 A.M. revealed Resident #100 moved into the facility on 05/15/24. HWD #74 stated she came in early on 05/16/24 and she went to Resident #100's room around 7:40 A.M. because staff reported Resident #100 did not have a good night and she did not go to breakfast. HWD #74 stated Resident #100 told her that there was a resident (Resident #44) in her room eating her snacks and then tried to sleep in her bed. HWD #74 stated she told him to get the hell out and he did not get out at first but eventually did get out. HWD #74 stated she told Resident #100 that a lock was ordered for her door and would be placed on her door that day. HWD #74 reported Resident #100 did not have a lock on her door on the night of 05/15/24. HWD #74 stated Resident #100 wanted to know when she was going to be able to go home and she continually asked about leaving throughout the day. HWD #74 reported Resident #100's daughter came to visit on 05/16/24 at around 8:00 A.M. HWD #74 stated Resident #100 told LPN #53 You see that guy over there in the red shirt. He raped me last night on 05/16/24. HWD #74 reported she was informed of the allegation on 05/16/24 and she called Resident #100's POA and informed her. HWD #74 stated the facility offered to send Resident #100 out to the hospital on 05/16/24 but she refused, and Resident #100 was sent out to the hospital by private ambulance on 05/17/24 at 10:30 A.M. HWD #74 stated she also notified the police of Resident #100's rape allegation on 05/17/24 at 9:20 A.M. HWD #74 stated she spoke with Resident #100's POA on 05/17/24 and Resident #100's POA felt that Resident #100's family members had put things in her head. HWD #74 also reported she interviewed Resident #100 on 05/17/24 and she reported she only slept in a T-shirt and underwear and Resident #44 raped her. HWD #74 stated Resident #44 was not placed on one-on-one checks after the allegation was made on 05/16/24 but Resident #44 mostly stayed in his room. HWD #74 reported Resident #44 was later sent out to the psychiatric hospital on 05/20/24 for hitting staff members.

Telephone interview with LPN #53 on 05/22/24 at 11:55 A.M. revealed Resident #100 told her Do you see that man over there in the red shirt? He raped me last night on 05/16/24 at approximately 10:00 P.M. LPN #53 reported Resident #100 told her that Resident #44 took his clothes off and then took her clothes off and raped her. LPN #53 stated she asked Resident #100 if she wanted to go to the hospital and she declined but she stated she wanted to talk to the police department. LPN #53 stated she reported the allegation to HWD #74.

Telephone interview with RA #49 on 05/22/24 at 12:02 P.M. revealed she was sitting in the common area on night shift on 05/15/24 and Resident #100 came out of her room and stated a man was in her room. Resident #100 told RA #49 that she tried to get the man to leave but he would not leave. RA #49 stated she went to Resident #100's room and found Resident #44 was in her room going through her stuff. RA #49 stated that she told Resident #44 that it was not his room and he told her to expletive off and drew his fist at RA #49. RA #49 stated he was able to get Resident #44 out of Resident #100's room, but RA #49 did not ask if Resident #100 was hurt. RA #49 stated Resident #100 was wearing a robe and night gown and did not appear in distress.

Telephone interview with Police Detective #801 on 05/22/24 at 12:35 P.M. revealed he was investigating Resident #100's allegation that she was raped by Resident #44. Police Detective #801 stated Resident #100's rape kit was sent off, but it would take months to get back. Police Detective #801 stated Resident #100 had a lot of family conflict.

Telephone interview with LPN #29 on 05/22/24 at 4:09 P.M. revealed she was called to Resident #53's room on 03/13/24 by a RA. LPN #29 stated that Resident #44 was standing behind Resident #53 with his pants down and his hand covering her mouth when LPN #29 arrived at the room. LPN #29 reported Resident #44 was telling Resident #53 to be quiet and shut up. LPN #29 stated she got between the residents and Resident #44 pulled his own pants up. LPN #29 reported she felt the incident was sexually motivated and that she had heard that Resident #44 had a history of sexual behaviors such as being found asleep naked in female resident beds or taking female residents out of their bed. LPN #29 stated she reported the incident to HWD #74.

Telephone interview with RA #260 on 05/22/24 at 4:17 P.M. revealed she was changing a resident in another room on 05/18/24 when she heard yelling. RA #260 stated she found Resident #55 in her bed trying to yell. RA #260 reported Resident #44 had his left hand over Resident #55's mouth and had his right hand in his pants grabbing at his penis. RA #260 stated Resident #44 told Resident #55 I'm coming back repeatedly. RA #260 reported she felt the incident was sexually motivated and she reported it to HWD #74 and the nurse on duty. RA #260 stated Resident #44 was not on one-on-one, or any type of checks and she was not aware of the rape allegation made by Resident #100 on 05/16/24.

Interview with Resident #45 on 05/22/24 at 4:39 P.M. revealed Resident #44 used to bang on her door all night and try to get in, but she kept her door locked. Resident #45 stated he would sit on the edge of her bed when he came in the room, and everyone was afraid of him. Resident #45 stated she was afraid of Resident #44 and staff had told her that Resident #44 may return to the facility.

Observation of the facility on 05/23/24 at 9:05 A.M. revealed Resident #37 was sitting at the dining room table. Resident #37 was clean and dressed appropriately.

An attempt to interview Resident #37 on 05/23/24 at 9:05 A.M. revealed the resident was not able to provide any information due to being cognitively impaired.

Observation of the facility on 05/23/24 at 9:07 A.M. revealed Resident #55 was sitting at the dining room table. Resident #55 was clean and dressed appropriately.

An attempt to interview Resident #55 on 05/23/24 at 9:07 A.M. revealed the resident was not able to provide any information due being cognitively impaired.

Interview with HWD #74 on 05/23/24 at 11:05 A.M. verified she was informed of Resident #44's sexual behavior towards other residents on 03/09/24, 03/13/24 and 05/18/24 but no formal investigation was completed. HWD #74 stated Resident #44 was placed on increased checks but stated they did not do them at a specific time frame, and she was not able to provide dates, times, or any documentation on when the checks were completed. HWD #74 verified the police were not contacted or notified of the incidents on 03/09/24, 03/13/24 or 05/18/24. The facility confirmed there were twelve (#35, #36, #38, #42, #43, #45, #46, #47, #51, #52, #54, and #56) additional cognitively impaired female residents residing on the memory care unit of the facility, where Resident #44 had unrestricted access and who were at risk for potential sexual abuse.

Review of the facility's policy titled, Abuse, Neglect and Exploitation