Storypoint of Grove City

Based on medical record review, interviews and review of the facility's incident/accident log, the facility failed to document the time, place, date of occurrence, a general description of the incident and the care provided or action taken for incidents of sexual abuse. This had the potential to affect all 73 residents residing in the facility.

Findings Include:

Review of the resident's progress note dated 12/15/24 at 11:28 A.M. revealed the nurse was notified by the Caregiver (CG) #230 of an incident that occurred at 9:00 A.M. CG #230 was walking by a female resident's room and observed Resident #40 laying on top of Resident #39 with her legs spread attempting to remove Resident #39's pants.

Review of the progress note dated 12/15/24 at 2:53 P.M. revealed the nurse was notified by the CG #151 of an incident that occurred at approximately 1:30 P.M. CG #151 observed Resident #40 in the dining room seated next to an Resident #48 touching her chest/breasts.

Review of the progress note on 12/27/24 at 5:27 P.M. revealed CG #230 had to intervene and stop Resident #40 from aggressively touching another female on her arm and breast.

Review of the progress note dated 01/12/25 at 9:36 P.M. revealed Resident #40 was found in a female resident's room with his hands under the blanket attempting to get onto the bed with her.

Review of the resident's progress note dated 01/13/25 at 3:35 P.M. revealed Resident #40 was found in an unknown female resident's room standing over the bed holding his penis.

Review of the resident's progress note dated 01/22/25 at 1:46 P.M. revealed the resident had his hands inappropriately on an unknown male resident as well as unknown female residents.

Review of the progress note dated 01/28/25 at 5:25 P.M. revealed the resident was wondering in and out of female resident's rooms. Resident #275 reported Resident #40 used the bathroom in her room and when he finished, he turned around to face her with is pants and underwear down.

Review of the progress note dated 01/29/25 at 6:35 P.M. revealed the resident was found in Resident #39's room with his pants down sitting on her couch touching his penis. Resident #39 was yelling out for help. The entry documented another incident occurred when Resident #40 was trying to strong arm his way into Resident #49 (a female resident) room.

Review of the progress note dated 02/17/25 at 8:16 A.M. revealed the resident was found in Resident #36' (a female resident) room with his pants off.

On 03/03/25 at 2:30 P.M., an interview with the WD #154 revealed she had not documented the sexual abuse on the facility's incident/accident log.

Based on observations, medical record review, interviews, review of the facility investigation and review of the facility's Abuse, Neglect or Exploitation policy, the facility failed to ensure cognitively impaired residents who resided on the memory care unit, were free from sexual abuse by a sexually aggressive, cognitively impaired male resident (#40), and the staff resorted to locking all of the resident's doors on the memory care unit in an effort to prevent access to potential victims of Resident #40's sexually aggressive behaviors. Additionally, the facility failed to implement their Abuse, Neglect or Exploitation Policy by not thoroughly investigating when Resident #40 began displaying sexually aggressive behaviors towards Resident #39, Resident #48 and other unidentified female residents residing on the Memory Care Unit (MCU). This resulted in Real and Present Danger and the potential for serious physical and/or psychosocial/emotional harm when facility staff failed to recognize the sexual abuse by Resident #40 and failed to implement interventions to ensure the safety and wellbeing of the female residents on the memory care unit to prevent further sexual abuse from happening when Resident #40 continued to display sexually aggressive behaviors on 12/15/24, 12/27/24, 01/12/25, 01/13/25, 01/22/25, 01/28/25 and 01/29/25 towards female residents. This affected two residents (#39 and #48) of three residents reviewed for abuse and placed an additional sixteen (#29, #30, #31, #32, #34, #35, #36, #37, #38, #41, #42, #43, #44, #46, #47, and #49) female residents, residing on the MCU where Resident #40 resided, at risk for further potential abuse. The facility census was 73. On 03/03/25 at 3:17 P.M., the Executive Director (ED), Wellness Director (WD) #154, Assistant Wellness Director (AWD) #191, Regional Wellness Director (RWD) #265 and the Regional Executive Director (RED) #270 were notified the Real and Present Danger began on 12/15/24 when staff found Resident #40 in Resident #39's room on top of the female resident with her legs spread trying to get her pants off. Again on 12/15/24 Resident #40 was observed by staff sitting next to Resident #48 touching the resident's chest/breasts. On 12/27/24, Resident #40 was observed by staff aggressively touching an unknown female resident's arm and breast. On 01/12/25, Resident #40 was found by staff in Resident #39's room with his hands under the blankets attempting to get in bed with the resident. On 01/13/25, Resident #40 was found in an unknown female resident's room standing by the bed with his pants down holding his penis. On 01/22/25, staff observed Resident #40 inappropriately touching an unknown male resident and a few unknown female residents. On 01/28/25, Resident #40 was wandering in and out of female resident's rooms. On 01/29/25, staff found Resident #40 in Resident #39's room sitting on her couch touching his penis, with Resident #39 yelling out for help. The facility staff resorted to locking female resident room doors to keep Resident #40 away from the female residents. The facility staff observed and was aware of the continued sexually aggressive behaviors displayed by Resident #40 on multiple occasions and failed to implement appropriate interventions and to report and thoroughly investigate the incidents of sexual abuse. The Real and Present Danger was abated on 03/08/25 when the facility implemented the following corrective actions: On 12/15/24, Resident #40 was removed immediately from Resident #39's room by Care Giver (CG) #230 after Resident #40 was found on top of Resident #39. Resident #40's family and physician were contacted by WD #154. Physician orders were obtained for Depakote (used to treat certain psychiatric conditions), and the medication was administered. Resident #39 was evaluated with a psychosocial questionnaire by WD #154 with no negative findings. The family of Resident #39 was notified by WD #154. On 12/15/24, Resident #40 was removed from the dining room after Resident #40 was found touching Resident #48's chest/breasts. Resident #40's family and physician were contacted. Community Staff initiated one-on-one with CG #151 until the sitter service arrived. Outside provider (Assisting Hands) contacted to provide 24/7 one-on-one sitter service indefinitely. Resident #48's power of attorney (POA) was notified. On 12/16/24, Certified Nurse Practitioner (CNP) #235 ordered Cimetidine (medication used to treat ulcers and can be given for sexually inappropriate behaviors) 400 milligrams (mg) twice a day (BID). On 12/29/24, increased confusion was noted. New order per CNP #235 for urinalysis culture and sensitivity (UA C&S) and to increase Melatonin (a medication used to treat sleeplessness). On 01/02/25, Resident #40 was noted not sleeping at night by one-on-one caregiver. New order for Trazadone (antidepressant) 100 mg at hour of sleep (HS), and Depakote 250 mg three times a day (TID) per CNP #235. On 01/09/25, Resident #40 had increased confusion/lethargy. Resident #40's family requested to discontinue sitter due to Resident #40 having decreased mobility. New order was obtained from CNP #235 for Keflex (antibiotic) 500 mg BID for 5 days. On 01/11/25, Resident #40 was in his wheelchair with general agitation noted. On 01/12/25, Resident#40 attempted to get in bed with Resident #39. Resident #40 was promptly removed from Resident #39's room by CG #219. On 01/13/25, Resident #40 was found standing over another resident's bed with his pants down. The caregiver removed the resident from the room immediately. Community one-on-one initiated and called outside provider to resume 24/7 one-on-one indefinitely. WD #154 called Resident #40's daughter to initiate one-on-one with Assisting Hands. Community staff are aware to monitor Resident #40 closely until Assisting Hands are present. On 01/14/25, one-on-one from outside provider Assisting Hands started. On 01/14/25, new order was obtained from CNP #235 for Macrobid (antibiotic used to treat urinary tract infections) 100 mg BID for 5 days. On 01/21/25, new orders received from CNP #240 to discontinue Depakote, start Valproic Acid (used to treat bipolar disorder) 250 mg/5 milliliter (ml), start Ativan (used to treat anxiety) 1 mg every 12 hr as needed (PRN). Discontinue one-on-one per Resident #40's family request due to no documented behaviors. On 01/22/25, Resident #40 noted with increased agitation. New order to start Mind Care Solutions Psychiatry (appointment was scheduled for 02/13/25; however, did not come to facility to see Resident #40 until 02/20/25). On 01/23/25, Licensed Practical Nurse (LPN) #193 documented as needed (PRN) medications were effective currently for Resident #40. On 01/28/25, Resident #40 was noted wandering into other female resident's rooms with one-on-one sitter. On 01/29/25, Resident #40 was found in Resident #39's room sitting on the couch with his pants down. Resident #39 yelled for help. Resident #40 was escorted out of the room per CG #130. PRN medication given per LPN #167. Per Resident #39's POA review of resident camera, no physical touch of Resident #39 occurred. On 01/30/25, new order per CNP #235 to increase ABH gel (used for nausea) from BID PRN to TID PRN. On 02/06/25, new order to admit Resident #40 to hospice services per Physician #245. On 02/14/25, new order for Haldol (used to treat mental disorders) PRN for agitation per Physician #245. On 02/20/25, new order per Mind Care Psychiatric Mental Health Nurse Practitioner (PMHNP) #250 to start Fluoxetine (antidepressant), D/C Ativan, decrease Melatonin, Valproic Acid Level and Depakote Level. On 02/26/25, new order for UA C&S per CNP #235. On 02/28/25, new order for one-on-one 24/7 outside provider (Assisting Hands) initiated indefinitely until Resident #40 discharges to the community. On 03/03/25, skin sweeps completed on all residents by WD #154 and AWD #191. No unexplained or new questionable skin issues were noted. On 03/03/25, resident safety questionnaire interviews to determine if residents feel safe in their environment completed by WD #154 and AWD #191of all memory care residents. Any non-interviewable residents will be observed for any signs and/or symptoms of abuse like new behaviors not attributed to resident's disease process or any physical signs of abuse. No concerns for safety voiced or observed. On 03/03/25, education started to all staff on Nurses Incident Report, Abuse, Resident Rights, Resident Redirection/Behaviors, and Dementia. Education to be completed by the ED and WD #154/designee by 03/08/25. On 03/03/25, additional mandatory staff education, service plans updated, guidance on how staff are to respond when residents are engaging in sexual activity, residents' rights to refuse sexual activity, notification to POA, Physician, and WD #154, informed consent, incident reporting, documentation on behaviors, occurrences, agitation, physical and sexual behaviors per the ED and WD #154. On 03/03/25, initiated communication form for nurses to utilize for behavior follow up. The form was developed by RWD #265 and ongoing follow-up audits with WD #154 or designee will occur daily Monday through Friday indefinitely. On 03/03/25, Mind Care Psychiatric services education to nurses for referral process and ongoing follow up appointment communication. To be completed by WD #154 or designee with ongoing monitoring to be done by WD #154 or designee weekly indefinitely. On 03/03/25, individual nurse staff education for involved nurses for completing incident reports per company standards completed by WD #154 or designee. On 03/03/25, individual staff education to wellness management for completing sexual incident investigations with appropriate physical and psychosocial evaluations, notifications, and interventions for resident safety completed by RWD #265 (Individuals educated: WD #154, AWD #191, and the ED). On 03/03/25, education on Point Click Care (electronic medical record system) progress category and education with wellness management on running the 24 hour/72 hour report per company standard completed by RWD #265 (Individuals educated: WD #154, AWD #191, and the ED). On 03/03/25, an additional section was added to the existing stand-up form to address and communicate resident documented incidents to be discussed every morning by WD #154 or designee. On 03/03/25, a collaborative services meeting with detail and discussion on resident behaviors weekly with all functional leaders (WD #154, the ED, Settings Director #152, Executive Chef #161, Housekeeping Supervisor #172, and Life Enrichment Director #162) in attendance. Form to be completed by WD #154 or designee. Ongoing follow up for completion by the ED. On 03/03/25, Stop and Watch tool implemented with education provided to all wellness staff for caregivers to communicate resident behaviors. Education to be completed by WD #154 or designee with ongoing follow up by WD #154, AWD #191, or designee. The Stop and Watch tool will be on the agenda for the next six months of employee meetings and discussed in all new orientations. On 03/03/25, Certified Dementia Practitioner (CDP) #255 was consulted to conduct ongoing dementia/behavior training series. On 03/06/25, Dementia/Behavior training, and Stop and Watch tool training was completed by the ED and WD #154 to all staff. On 03/06/25, Abuse, Neglect, and Misappropriation training that started on 03/03/25 was completed with all staff. On 03/06/25, education to all nursing staff on Mind Care Referral Process with Change in Behavior/Condition was started and completed by 03/08/25. Although the Real and Present Danger was abated on 03/08/25, 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 the medical record for Resident #40 revealed an initial admission date of 10/23/24 with the diagnoses including but not limited to dementia, hyperlipidemia, metabolic encephalopathy, glaucoma, hypertension, arteriosclerotic heart disease, chronic obstructive pulmonary disease (COPD), diverticulitis of large intestine, cystitis and overactive bladder. Review of the resident's Siegel's Liquid Scale of Mental Status (SLUMS) dated 10/28/24 revealed a score of nine indicating a pronounced cognitive deficit that could be indicative of dementia. Review of Resident #40's progress note dated 10/30/24 at 6:44 P.M. revealed the resident's Power of Attorney (POA) called the facility and reported the resident was displaying hypersexual behaviors throughout the night with his wife (Resident #4). The POA requested the facility to have the resident evaluated and prescribed medication along with a sleep aide. Review of the resident's progress note dated 10/31/24 at 12:10 P.M. revealed the Certified Nurse Practitioner (CNP) was contacted about the family's concerns and new orders were received for Buspar (a medication used to treat anxiety) 5 milligrams (mg) by mouth three times a day and Melatonin 10 mg by mouth daily at bedtime. Further review revealed no medications or interventions were implemented to treat the residents' hypersexual behaviors. Review of the resident's progress note dated 12/12/24 at 5:09 P.M. revealed the resident was moved to the MCU at 2:45 P.M. Review of the residents' significant change wellness evaluation dated 12/12/24 revealed the resident had mild cognitive impairment. The assessment indicated the resident communicated clearly, understands others, and expressed wants and needs. Review of the resident's progress note dated 12/12/24 at 6:05 P.M. revealed a new order was obtained for Depakote 125 mg by mouth three times a day as needed for agitation. Review of the resident's Global Deterioration Scale (a tool commonly used to assess the stages of cognitive decline in individuals experiencing dementia) dated 12/13/24 revealed the resident was a stage three indicating the resident had a mild cognitive deficit characterized by increased forgetfulness, some difficulty concentrating, may have trouble finding the right words, may start to get lost when traveling to unfamiliar locations, coworkers may start to notice a change in performance, may have some trouble retaining information when reading a book and lack of concentration may be evident upon clinical testing. Review of the resident's progress note dated 12/13/24 at 6:11 P.M. revealed the nurse observed the resident engaging in physical contact with an unknown female resident by caressing their leg in the common area. The resident was redirected to his room and educated on personal space and boundaries appropriate to the resident's level of understanding. The staff was to continue to monitor for inappropriate behavior. Review of the resident's progress note dated 12/15/24 at 11:28 A.M. revealed the resident's nurse was notified by the Caregiver (CG) #230 of an incident that occurred at 9:00 A.M. The CG (#230) was walking by a female resident's room and observed Resident #40 laying on top of Resident #39 with her legs spread attempting to remove Resident #39's pants. The residents were immediately separated and Resident #39's door was closed and locked. Resident #40 was redirected to the common area and given Depakote 125 mg by mouth. Review of the progress note dated 12/15/24 at 2:53 P.M. revealed the nurse was notified by the CG #230 of an incident that occurred at approximately 1:30 P.M. The CG (#230) observed Resident #40 in the dining room seated next to an unknown female resident touching her chest/breasts. Resident #40 was redirected to watch a football game with staff and other residents. The resident was administered the as needed medication Depakote 125 mg. Review of medical record revealed on 12/16/24 the medication Cimetidine 400 mg by mouth twice daily was ordered for sexual behaviors. Review of the progress note on 12/16/24 at 7:23 P.M. revealed the resident approached Resident #48 and touched her shoulder. The private one-on-one sitter was able to redirect Resident #40 away from the female resident. Review of the progress note on 12/17/24 at 3:36 P.M. revealed the resident was walking around trying to sit with different female residents. The private one-on-one sitter was able to redirect the resident. Resident #40 asked the private one-on-one sitter how to get other female residents back to his room so he could take off their clothes. Review of the progress note on 12/27/24 at 5:27 P.M. revealed CG #230 had to intervene and stop Resident #40 from aggressively touching another female on her arm and breast. The entry documented the resident was told the behavior was inappropriate and not to do it again. Review of the progress note dated 01/07/25 at 6:35 P.M. revealed the resident was wandering into other resident's rooms and was difficult to redirect by private one-on-one sitter. Review of the progress note dated 01/12/25 at 9:36 P.M. revealed the resident was found in a female resident's room with his hands under the blanket attempting to get onto the bed with her. The resident was redirected back to his own room. Review of the resident's progress note dated 01/13/25 at 3:35 P.M. revealed the resident was found in an unknown female resident's room standing over the bed holding his penis. The entry documented CG #230 caught the resident before anything could happen. Review of the resident's progress note dated 01/22/25 at 1:46 P.M. revealed the resident had his hands inappropriately on an unknown male resident as well as an unknown female resident. The entry documented the facility staff moved the other residents away from Resident #40 and you cannot leave him out of your sight. Review of the resident's progress note dated 01/22/25 at 9:32 P.M. revealed all other resident room doors must be continually locked. The progress notes documented multiple unknown residents verbalized fear of the resident and worry that he will try to touch them or hurt them. The progress note indicated the resident remained very sexual towards staff and other residents. The nurse documented, staff desperately attempting to keep an eye on resident at all times, but there are times when all staff are very busy, and resident is unattended. This presents safety concerns for all involved. The nurse documented Resident #40 violating another unknown resident by putting his hands down her pants. The nurse documented the facility management and family were aware of the continued behaviors and the private one-on-one sitter was discontinued. Review of the progress note dated 01/27/25 at 7:42 P.M. revealed Resident #40 continued to have sexually inappropriate behaviors and documented, Resident has tried to get fresh with a couple of the ladies. Review of the progress note dated 01/28/25 at 5:25 P.M. revealed the resident was wandering in and out of female resident's rooms. Resident #275 reported Resident #40 used the bathroom in her room and when he finished, he turned around to face her with his pants and underwear down. Review of the progress note dated 01/29/25 at 6:35 P.M. revealed the resident was found in Resident #39's room with his pants down sitting on her couch touching his penis. The female resident was yelling out for help. The entry documented another incident occurred when Resident #40 was trying to strong arm his way into Resident #49's (a female resident) room. Review of the progress note dated 01/30/25 at 11:23 A.M. revealed an unknown family member stated, That man (Resident #40) keeps walking into other rooms and my mom's room. My mom does not feel safe. Review of the progress note dated 02/17/25 at 8:16 A.M. revealed the resident was found in Resident #36's (a female resident) room with his pants off. On 02/28/25 at 9:23 A.M., interview with CG #170 revealed they have a problem with Resident #40 going in female resident rooms, touching them inappropriately, kissing the female residents and taking his clothing off. CG #170 revealed the resident did reside on the Assisted Living (AL) with his wife (Resident #4) until he was sexually abusing his wife, so his daughter moved him to the MCU. On 02/28/25 at 10:56 A.M., an interview with LPN #112 revealed Resident #40 has inappropriate sexual behaviors with staff and female residents. She said they try to keep an eye on him but caring for all the residents, there are times he is left alone. She said some days are worse than others. LPN #112 revealed facility management and the residents' family are aware of the continued sexual behaviors. On 02/28/25 from 12:00 P.M. to 12:50 P.M., observation of Resident #40 during the lunch meal in the dining room revealed the resident was ambulating about the dining room touching both male and female residents with staff redirecting the resident to sit in a chair. Further observation revealed no one-on-one sitter present with the resident. On 02/28/25 at one-on-one0 P.M., an interview with Hospice Registered Nurse (HRN) #227 revealed she was aware of the resident's hypersexual behaviors and assisted the facility in managing the resident's behavior medications. HRN #227 revealed the resident was sexually inappropriate with both staff and residents. HRN #227 revealed his as needed Haldol was changed to scheduled on 02/27/25 due to the resident forcefully placed a Hospice LPN's hand in his groin. HRN #227 revealed the resident will ask facility staff as well as hospice staff to get in bed with him for sex. On 02/28/25 at 1:38 P.M., observation of Resident #40 revealed the resident entered Resident #47's (a female resident) room. Further observation revealed CG #179 walked up to the surveyor and asked if Resident #40 was in Resident #47's room. CG #179 entered the room and redirected the resident out of the room. On 02/28/25 at 3:00 P.M., an interview with WD #154 revealed the acts were not sexual abuse because there was no penetration. She revealed the facility was not required to report sexual abuse from resident to resident to the state agency. She revealed the facility had implemented and tried multiple interventions for the resident's hypersexual behaviors. She revealed they did medication adjustments, education, redirection and a one-on-one sitter now at the facility's cost. Review of a letter provided by the facility from the one-on-one sitter company dated 02/28/25 revealed the company provided 24-hour one-on-one sitter for Resident #40 from 12/15/24 at 8:00 P.M. to 8:00 A.M. on 01/10/25 at which time the family chose to discontinue the service. The letter indicated the care services were resumed on 01/14/25 at 8:00 A.M. to 8:00 P.M. daily through 01/21/25 at which time the care services were discontinued. On 02/28/25 at 3:53 P.M., interview with the Care Management Director from the one-on-one sitter company revealed the last day the company had a one-on-one private duty care giver was on 01/21/25 at the family's expense. On 03/03/25 at 11:26 A.M. an interview with Resident #40's POA revealed the resident displayed hypersexual behavior following a cerebrovascular accident (CVA). The POA revealed her parents slept in separate rooms with Resident #4's door locked at night due to the hypersexual behaviors. The POA alerted the facility of the behaviors as soon as Resident #4 reported the groping and handsyBased on observations, medical record review, interviews, review of the facility investigation and review of the facility's Abuse, Neglect or Exploitation policy, the facility failed to ensure cognitively impaired residents who resided on the memory care unit, were free from sexual abuse by a sexually aggressive, cognitively impaired male resident (#40), and the staff resorted to locking all of the resident's doors on the memory care unit in an effort to prevent access to potential victims of Resident #40's sexually aggressive behaviors. Additionally, the facility failed to implement their Abuse, Neglect or Exploitation Policy by not thoroughly investigating when Resident #40 began displaying sexually aggressive behaviors towards Resident #39, Resident #48 and other unidentified female residents residing on the Memory Care Unit (MCU). This resulted in Real and Present Danger and the potential for serious physical and/or psychosocial/emotional harm when facility staff failed to recognize the sexual abuse by Resident #40 and failed to implement interventions to ensure the safety and wellbeing of the female residents on the memory care unit to prevent further sexual abuse from happening when Resident #40 continued to display sexually aggressive behaviors on 12/15/24, 12/27/24, 01/12/25, 01/13/25, 01/22/25, 01/28/25 and 01/29/25 towards female residents. This affected two residents (#39 and #48) of three residents reviewed for abuse and placed an additional sixteen (#29, #30, #31, #32, #34, #35, #36, #37, #38, #41, #42, #43, #44, #46, #47, and #49) female residents, residing on the MCU where Resident #40 resided, at risk for further potential abuse. The facility census was 73.

On 03/03/25 at 3:17 P.M., the Executive Director (ED), Wellness Director (WD) #154, Assistant Wellness Director (AWD) #191, Regional Wellness Director (RWD) #265 and the Regional Executive Director (RED) #270 were notified the Real and Present Danger began on 12/15/24 when staff found Resident #40 in Resident #39's room on top of the female resident with her legs spread trying to get her pants off. Again on 12/15/24 Resident #40 was observed by staff sitting next to Resident #48 touching the resident's chest/breasts. On 12/27/24, Resident #40 was observed by staff aggressively touching an unknown female resident's arm and breast. On 01/12/25, Resident #40 was found by staff in Resident #39's room with his hands under the blankets attempting to get in bed with the resident. On 01/13/25, Resident #40 was found in an unknown female resident's room standing by the bed with his pants down holding his penis. On 01/22/25, staff observed Resident #40 inappropriately touching an unknown male resident and a few unknown female residents. On 01/28/25, Resident #40 was wandering in and out of female resident's rooms. On 01/29/25, staff found Resident #40 in Resident #39's room sitting on her couch touching his penis, with Resident #39 yelling out for help. The facility staff resorted to locking female resident room doors to keep Resident #40 away from the female residents. The facility staff observed and was aware of the continued sexually aggressive behaviors displayed by Resident #40 on multiple occasions and failed to implement appropriate interventions and to report and thoroughly investigate the incidents of sexual abuse.

The Real and Present Danger was abated on 03/08/25 when the facility implemented the following corrective actions:

On 12/15/24, Resident #40 was removed immediately from Resident #39's room by Care Giver (CG) #230 after Resident #40 was found on top of Resident #39. Resident #40's family and physician were contacted by WD #154. Physician orders were obtained for Depakote (used to treat certain psychiatric conditions), and the medication was administered. Resident #39 was evaluated with a psychosocial questionnaire by WD #154 with no negative findings. The family of Resident #39 was notified by WD #154.

On 12/15/24, Resident #40 was removed from the dining room after Resident #40 was found touching Resident #48's chest/breasts. Resident #40's family and physician were contacted. Community Staff initiated one-on-one with CG #151 until the sitter service arrived. Outside provider (Assisting Hands) contacted to provide 24/7 one-on-one sitter service indefinitely. Resident #48's power of attorney (POA) was notified.

On 12/16/24, Certified Nurse Practitioner (CNP) #235 ordered Cimetidine (medication used to treat ulcers and can be given for sexually inappropriate behaviors) 400 milligrams (mg) twice a day (BID).

On 12/29/24, increased confusion was noted. New order per CNP #235 for urinalysis culture and sensitivity (UA C&S) and to increase Melatonin (a medication used to treat sleeplessness).

On 01/02/25, Resident #40 was noted not sleeping at night by one-on-one caregiver. New order for Trazadone (antidepressant) 100 mg at hour of sleep (HS), and Depakote 250 mg three times a day (TID) per CNP #235.

On 01/09/25, Resident #40 had increased confusion/lethargy. Resident #40's family requested to discontinue sitter due to Resident #40 having decreased mobility. New order was obtained from CNP #235 for Keflex (antibiotic) 500 mg BID for 5 days.

On 01/11/25, Resident #40 was in his wheelchair with general agitation noted.

On 01/12/25, Resident#40 attempted to get in bed with Resident #39. Resident #40 was promptly removed from Resident #39's room by CG #219.

On 01/13/25, Resident #40 was found standing over another resident's bed with his pants down. The caregiver removed the resident from the room immediately. Community one-on-one initiated and called outside provider to resume 24/7 one-on-one indefinitely. WD #154 called Resident #40's daughter to initiate one-on-one with Assisting Hands. Community staff are aware to monitor Resident #40 closely until Assisting Hands are present.

On 01/14/25, one-on-one from outside provider Assisting Hands started.

On 01/14/25, new order was obtained from CNP #235 for Macrobid (antibiotic used to treat urinary tract infections) 100 mg BID for 5 days.

On 01/21/25, new orders received from CNP #240 to discontinue Depakote, start Valproic Acid (used to treat bipolar disorder) 250 mg/5 milliliter (ml), start Ativan (used to treat anxiety) 1 mg every 12 hr as needed (PRN). Discontinue one-on-one per Resident #40's family request due to no documented behaviors.

On 01/22/25, Resident #40 noted with increased agitation. New order to start Mind Care Solutions Psychiatry (appointment was scheduled for 02/13/25; however, did not come to facility to see Resident #40 until 02/20/25).

On 01/23/25, Licensed Practical Nurse (LPN) #193 documented as needed (PRN) medications were effective currently for Resident #40.

On 01/28/25, Resident #40 was noted wandering into other female resident's rooms with one-on-one sitter.

On 01/29/25, Resident #40 was found in Resident #39's room sitting on the couch with his pants down. Resident #39 yelled for help. Resident #40 was escorted out of the room per CG #130. PRN medication given per LPN #167. Per Resident #39's POA review of resident camera, no physical touch of Resident #39 occurred.

On 01/30/25, new order per CNP #235 to increase ABH gel (used for nausea) from BID PRN to TID PRN.

On 02/06/25, new order to admit Resident #40 to hospice services per Physician #245.

On 02/14/25, new order for Haldol (used to treat mental disorders) PRN for agitation per Physician #245.

On 02/20/25, new order per Mind Care Psychiatric Mental Health Nurse Practitioner (PMHNP) #250 to start Fluoxetine (antidepressant), D/C Ativan, decrease Melatonin, Valproic Acid Level and Depakote Level.

On 02/26/25, new order for UA C&S per CNP #235.

On 02/28/25, new order for one-on-one 24/7 outside provider (Assisting Hands) initiated indefinitely until Resident #40 discharges to the community.

On 03/03/25, skin sweeps completed on all residents by WD #154 and AWD #191. No unexplained or new questionable skin issues were noted.

On 03/03/25, resident safety questionnaire interviews to determine if residents feel safe in their environment completed by WD #154 and AWD #191of all memory care residents. Any non-interviewable residents will be observed for any signs and/or symptoms of abuse like new behaviors not attributed to resident's disease process or any physical signs of abuse. No concerns for safety voiced or observed.

On 03/03/25, education started to all staff on Nurses Incident Report, Abuse, Resident Rights, Resident Redirection/Behaviors, and Dementia. Education to be completed by the ED and WD #154/designee by 03/08/25.

On 03/03/25, additional mandatory staff education, service plans updated, guidance on how staff are to respond when residents are engaging in sexual activity, residents' rights to refuse sexual activity, notification to POA, Physician, and WD #154, informed consent, incident reporting, documentation on behaviors, occurrences, agitation, physical and sexual behaviors per the ED and WD #154.

On 03/03/25, initiated communication form for nurses to utilize for behavior follow up. The form was developed by RWD #265 and ongoing follow-up audits with WD #154 or designee will occur daily Monday through Friday indefinitely.

On 03/03/25, Mind Care Psychiatric services education to nurses for referral process and ongoing follow up appointment communication. To be completed by WD #154 or designee with ongoing monitoring to be done by WD #154 or designee weekly indefinitely.

On 03/03/25, individual nurse staff education for involved nurses for completing incident reports per company standards completed by WD #154 or designee.

On 03/03/25, individual staff education to wellness management for completing sexual incident investigations with appropriate physical and psychosocial evaluations, notifications, and interventions for resident safety completed by RWD #265 (Individuals educated: WD #154, AWD #191, and the ED).

On 03/03/25, education on Point Click Care (electronic medical record system) progress category and education with wellness management on running the 24 hour/72 hour report per company standard completed by RWD #265 (Individuals educated: WD #154, AWD #191, and the ED).

On 03/03/25, an additional section was added to the existing stand-up form to address and communicate resident documented incidents to be discussed every morning by WD #154 or designee.

On 03/03/25, a collaborative services meeting with detail and discussion on resident behaviors weekly with all functional leaders (WD #154, the ED, Settings Director #152, Executive Chef #161, Housekeeping Supervisor #172, and Life Enrichment Director #162) in attendance. Form to be completed by WD #154 or designee. Ongoing follow up for completion by the ED.

On 03/03/25, Stop and Watch tool implemented with education provided to all wellness staff for caregivers to communicate resident behaviors. Education to be completed by WD #154 or designee with ongoing follow up by WD #154, AWD #191, or designee. The Stop and Watch tool will be on the agenda for the next six months of employee meetings and discussed in all new orientations.

On 03/03/25, Certified Dementia Practitioner (CDP) #255 was consulted to conduct ongoing dementia/behavior training series.

On 03/06/25, Dementia/Behavior training, and Stop and Watch tool training was completed by the ED and WD #154 to all staff.

On 03/06/25, Abuse, Neglect, and Misappropriation training that started on 03/03/25 was completed with all staff.

On 03/06/25, education to all nursing staff on Mind Care Referral Process with Change in Behavior/Condition was started and completed by 03/08/25.

Although the Real and Present Danger was abated on 03/08/25, 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 the medical record for Resident #40 revealed an initial admission date of 10/23/24 with the diagnoses including but not limited to dementia, hyperlipidemia, metabolic encephalopathy, glaucoma, hypertension, arteriosclerotic heart disease, chronic obstructive pulmonary disease (COPD), diverticulitis of large intestine, cystitis and overactive bladder.

Review of the resident's Siegel's Liquid Scale of Mental Status (SLUMS) dated 10/28/24 revealed a score of nine indicating a pronounced cognitive deficit that could be indicative of dementia.

Review of Resident #40's progress note dated 10/30/24 at 6:44 P.M. revealed the resident's Power of Attorney (POA) called the facility and reported the resident was displaying hypersexual behaviors throughout the night with his wife (Resident #4). The POA requested the facility to have the resident evaluated and prescribed medication along with a sleep aide.

Review of the resident's progress note dated 10/31/24 at 12:10 P.M. revealed the Certified Nurse Practitioner (CNP) was contacted about the family's concerns and new orders were received for Buspar (a medication used to treat anxiety) 5 milligrams (mg) by mouth three times a day and Melatonin 10 mg by mouth daily at bedtime. Further review revealed no medications or interventions were implemented to treat the residents' hypersexual behaviors.

Review of the resident's progress note dated 12/12/24 at 5:09 P.M. revealed the resident was moved to the MCU at 2:45 P.M.

Review of the residents' significant change wellness evaluation dated 12/12/24 revealed the resident had mild cognitive impairment. The assessment indicated the resident communicated clearly, understands others, and expressed wants and needs.

Review of the resident's progress note dated 12/12/24 at 6:05 P.M. revealed a new order was obtained for Depakote 125 mg by mouth three times a day as needed for agitation.

Review of the resident's Global Deterioration Scale (a tool commonly used to assess the stages of cognitive decline in individuals experiencing dementia) dated 12/13/24 revealed the resident was a stage three indicating the resident had a mild cognitive deficit characterized by increased forgetfulness, some difficulty concentrating, may have trouble finding the right words, may start to get lost when traveling to unfamiliar locations, coworkers may start to notice a change in performance, may have some trouble retaining information when reading a book and lack of concentration may be evident upon clinical testing.

Review of the resident's progress note dated 12/13/24 at 6:11 P.M. revealed the nurse observed the resident engaging in physical contact with an unknown female resident by caressing their leg in the common area. The resident was redirected to his room and educated on personal space and boundaries appropriate to the resident's level of understanding. The staff was to continue to monitor for inappropriate behavior.

Review of the resident's progress note dated 12/15/24 at 11:28 A.M. revealed the resident's nurse was notified by the Caregiver (CG) #230 of an incident that occurred at 9:00 A.M. The CG (#230) was walking by a female resident's room and observed Resident #40 laying on top of Resident #39 with her legs spread attempting to remove Resident #39's pants. The residents were immediately separated and Resident #39's door was closed and locked. Resident #40 was redirected to the common area and given Depakote 125 mg by mouth.

Review of the progress note dated 12/15/24 at 2:53 P.M. revealed the nurse was notified by the CG #230 of an incident that occurred at approximately 1:30 P.M. The CG (#230) observed Resident #40 in the dining room seated next to an unknown female resident touching her chest/breasts. Resident #40 was redirected to watch a football game with staff and other residents. The resident was administered the as needed medication Depakote 125 mg.

Review of medical record revealed on 12/16/24 the medication Cimetidine 400 mg by mouth twice daily was ordered for sexual behaviors.

Review of the progress note on 12/16/24 at 7:23 P.M. revealed the resident approached Resident #48 and touched her shoulder. The private one-on-one sitter was able to redirect Resident #40 away from the female resident.

Review of the progress note on 12/17/24 at 3:36 P.M. revealed the resident was walking around trying to sit with different female residents. The private one-on-one sitter was able to redirect the resident. Resident #40 asked the private one-on-one sitter how to get other female residents back to his room so he could take off their clothes.

Review of the progress note on 12/27/24 at 5:27 P.M. revealed CG #230 had to intervene and stop Resident #40 from aggressively touching another female on her arm and breast. The entry documented the resident was told the behavior was inappropriate and not to do it again.

Review of the progress note dated 01/07/25 at 6:35 P.M. revealed the resident was wandering into other resident's rooms and was difficult to redirect by private one-on-one sitter.

Review of the progress note dated 01/12/25 at 9:36 P.M. revealed the resident was found in a female resident's room with his hands under the blanket attempting to get onto the bed with her. The resident was redirected back to his own room.

Review of the resident's progress note dated 01/13/25 at 3:35 P.M. revealed the resident was found in an unknown female resident's room standing over the bed holding his penis. The entry documented CG #230 caught the resident before anything could happen.

Review of the resident's progress note dated 01/22/25 at 1:46 P.M. revealed the resident had his hands inappropriately on an unknown male resident as well as an unknown female resident. The entry documented the facility staff moved the other residents away from Resident #40 and you cannot leave him out of your sight.

Review of the resident's progress note dated 01/22/25 at 9:32 P.M. revealed all other resident room doors must be continually locked. The progress notes documented multiple unknown residents verbalized fear of the resident and worry that he will try to touch them or hurt them. The progress note indicated the resident remained very sexual towards staff and other residents. The nurse documented, staff desperately attempting to keep an eye on resident at all times, but there are times when all staff are very busy, and resident is unattended. This presents safety concerns for all involved. The nurse documented Resident #40 violating another unknown resident by putting his hands down her pants. The nurse documented the facility management and family were aware of the continued behaviors and the private one-on-one sitter was discontinued.

Review of the progress note dated 01/27/25 at 7:42 P.M. revealed Resident #40 continued to have sexually inappropriate behaviors and documented, Resident has tried to get fresh with a couple of the ladies.

Review of the progress note dated 01/28/25 at 5:25 P.M. revealed the resident was wandering in and out of female resident's rooms. Resident #275 reported Resident #40 used the bathroom in her room and when he finished, he turned around to face her with his pants and underwear down.

Review of the progress note dated 01/29/25 at 6:35 P.M. revealed the resident was found in Resident #39's room with his pants down sitting on her couch touching his penis. The female resident was yelling out for help. The entry documented another incident occurred when Resident #40 was trying to strong arm his way into Resident #49's (a female resident) room.

Review of the progress note dated 01/30/25 at 11:23 A.M. revealed an unknown family member stated, That man (Resident #40) keeps walking into other rooms and my mom's room. My mom does not feel safe.

Review of the progress note dated 02/17/25 at 8:16 A.M. revealed the resident was found in Resident #36's (a female resident) room with his pants off.

On 02/28/25 at 9:23 A.M., interview with CG #170 revealed they have a problem with Resident #40 going in female resident rooms, touching them inappropriately, kissing the female residents and taking his clothing off. CG #170 revealed the resident did reside on the Assisted Living (AL) with his wife (Resident #4) until he was sexually abusing his wife, so his daughter moved him to the MCU.

On 02/28/25 at 10:56 A.M., an interview with LPN #112 revealed Resident #40 has inappropriate sexual behaviors with staff and female residents. She said they try to keep an eye on him but caring for all the residents, there are times he is left alone. She said some days are worse than others. LPN #112 revealed facility management and the residents' family are aware of the continued sexual behaviors.

On 02/28/25 from 12:00 P.M. to 12:50 P.M., observation of Resident #40 during the lunch meal in the dining room revealed the resident was ambulating about the dining room touching both male and female residents with staff redirecting the resident to sit in a chair. Further observation revealed no one-on-one sitter present with the resident.

On 02/28/25 at one-on-one0 P.M., an interview with Hospice Registered Nurse (HRN) #227 revealed she was aware of the resident's hypersexual behaviors and assisted the facility in managing the resident's behavior medications. HRN #227 revealed the resident was sexually inappropriate with both staff and residents. HRN #227 revealed his as needed Haldol was changed to scheduled on 02/27/25 due to the resident forcefully placed a Hospice LPN's hand in his groin. HRN #227 revealed the resident will ask facility staff as well as hospice staff to get in bed with him for sex.

On 02/28/25 at 1:38 P.M., observation of Resident #40 revealed the resident entered Resident #47's (a female resident) room. Further observation revealed CG #179 walked up to the surveyor and asked if Resident #40 was in Resident #47's room. CG #179 entered the room and redirected the resident out of the room.

On 02/28/25 at 3:00 P.M., an interview with WD #154 revealed the acts were not sexual abuse because there was no penetration. She revealed the facility was not required to report sexual abuse from resident to resident to the state agency. She revealed the facility had implemented and tried multiple interventions for the resident's hypersexual behaviors. She revealed they did medication adjustments, education, redirection and a one-on-one sitter now at the facility's cost.

Review of a letter provided by the facility from the one-on-one sitter company dated 02/28/25 revealed the company provided 24-hour one-on-one sitter for Resident #40 from 12/15/24 at 8:00 P.M. to 8:00 A.M. on 01/10/25 at which time the family chose to discontinue the service. The letter indicated the care services were resumed on 01/14/25 at 8:00 A.M. to 8:00 P.M. daily through 01/21/25 at which time the care services were discontinued.

On 02/28/25 at 3:53 P.M., interview with the Care Management Director from the one-on-one sitter company revealed the last day the company had a one-on-one private duty care giver was on 01/21/25 at the family's expense.

On 03/03/25 at 11:26 A.M. an interview with Resident #40's POA revealed the resident displayed hypersexual behavior following a cerebrovascular accident (CVA). The POA revealed her parents slept in separate rooms with Resident #4's door locked at night due to the hypersexual behaviors. The POA alerted the facility of the behaviors as soon as Resident #4 reported the groping and handsy

Based on review of fire drill reports and staff interview, the facility failed to conduct resident evacuations at least twice on each shift in the twelve-month review period. This had the potential to affect all 67 residents. The census was 67.

Findings include:

Review of fire drill reports for February 2023 through January 2024 revealed four day shift fire drills were completed on 04/19/23, 07/25/23, 10/27/23 and 01/23/24. These reports indicated no residents were evacuated during the day shift fire drills.

Review of fire drill reports for February 2023 through January 2024 revealed four evening shift fire drills were completed on 02/28/23, 05/25/23, 08/24/23 and 11/27/23. These reports indicated resident were only evacuated during one evening shift fire drill conducted on 11/27/23.

Review of fire drill reports for February 2023 through January 2024 revealed four night shift fire drills were completed on 03/29/23, 06/29/23, 09/27/23 and 12/22/23. These reports indicated resident were only evacuated during one night shift fire drill conducted on 12/22/23.

Interview on 02/08/24 at 12:24 P.M., with Director of Maintenance (DM) #200, verified residents were only evacuated during fire drills on 11/27/23 and 12/22/23. DM #200 stated he was not aware resident evacuation during fire drills was a regulatory requirement.