Health inspection·February 25, 2025

Regulation: Title 42 CFR§483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. On 1/24/25 at 9:30 A.M., an unannounced visit was conducted at the facility to investigate an entity reported incident regarding a report of sexual relations between Resident 1 and CNA 1. It was determined that the facility failed to ensure Resident 1 was protected from sexual abuse by an employee. This failure placed Resident 1 at risk for emotional distress, psychological trauma, mistrust of health care providers, and disruption in the patient's ability to receive proper medical care. During a review of the clinical record for Resident 1, the facility's Admission Record indicated Resident 1 was admitted to the facility on 8/7/24 with Diagnoses which included bipolar disorder (a mental illness that causes extreme shifts in moods), post-traumatic stress disorder ( a condition in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and schizoaffective disorder (a disorder that includes symptoms such as hallucinations, delusions with mood disorder symptoms). During a review of the clinical record for Resident 1, the History and Physical dated 8/9/24 indicated, "[Resident 1] does not have capacity to make medical decisions..." A review of Resident 1's Electronic Health Record indicated Resident 1 was placed under conservatorship (a legal status in which a court appoints a person to assume guardianship over an adult) on 7/8/24. On 1/24/25 at 9:44 A.M., an interview was conducted with Resident 1. Resident 1 stated he met CNA 1 after he was admitted to the facility. Resident 1 stated, "...after a couple weeks we developed a friendship. We talked about books..." Resident 1 stated CNA 1 visited him at the facility on days when she was not scheduled to work. In addition, Resident 1 stated CNA 1 gifted him with three books and wrote messages for him inside on the inside cover. Resident 1 stated he had asked her to perform a sexual act on him and "...we were like friends with benefits." During an interview with CNA 1 on 1/24/25 at 12:36 P.M., CNA 1 stated, "Basically, I developed feelings for [Resident 1] and he developed feelings for me..." CNA 1 stated she had frequent conversations with Resident 1 that were unrelated to her role as his caregiver. CNA 1 stated "I know it's against policy...We shouldn't be talking to residents in a way that doesn't have to do with my job..." CNA 1 acknowledged purchasing books for Resident 1 as gifts. In addition, CNA 1 stated she wrote Resident 1 a letter to let him know, "I daydream about hanging out with him." CNA 1 stated she performed a sexual act with Resident 1 inside his bedroom. CNA stated, "...I know it was wrong because it was unprofessional to have a personal relationship with a patient. That's why I confessed, I felt guilty..." CNA 1 stated she believed she had in-services regarding inappropriate relationships but does not remember when. During a telephone interview with CNA 2 on 1/24/25 at 1:09 P.M., CNA 2 stated she was aware that CNA 1 had sexual relations with Resident 1. CNA 2 stated, "[CNA 1] verbalized that she [performed a sexual act] to [Resident 1] she told me, and I reported it to the abuse coordinator...because it sounds like sexual abuse." During an interview on 1/24/25 at 2:03 P.M., with the Director of Staff Development (DSD), the DSD stated, "I was very shocked, I never thought it was in [CNA 1]'s character [to perform a sexual act on a resident] ". The DSD stated, "[CNA 1] should have known better...you have to maintain boundaries for the benefit of the residents...because of the situation, you know, that it was between a CNA and a resident, I'd say it was abuse." During an interview on 2/6/25 at 11:30 A.M., with the Director of Nursing (DON), the DON stated her expectation was for staff to always maintain professionalism with residents. The DON stated any sexual relationship between a staff member and resident was never acceptable, per the facility's policy and Code of Conduct. According to the facility's Employee Handbook, "Standards of Conduct...All employees are expected to act in a mature, professional manner always...19. Resident Relationships. Unauthorized socializing, to include socializing through written or on-line communication, with current or former residents within or outside the Facility, which is beyond that of meeting the resident's needs and which serves no rehabilitative purpose..." A review of the facility's policy titled Abuse Prevention Program, dated 7/1/20 indicated, "Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from...mental, sexual or physical abuse..." In violation of the above cited standards, the facility failed to ensure that Resident 1 was protected from sexual abuse by an employee. This failure placed Resident 1 at risk for emotional distress, psychological trauma, mistrust of health care providers, and disruption in the patient's ability to receive proper medical care. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.