Health inspection·August 8, 2025

F600 §483.12 Freedom from Abuse, Neglect, and Exploitation 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. (a) The facility must— (1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

F689 §483.25(d) Accidents The facility must ensure that – (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 6/20/2025, at 2:32 PM, an unannounced visit was conducted to investigate a facility reported incident regarding a sexual abuse (non-consensual touching of one person for the sexual gratification of another) allegation. The facility failed to ensure Resident 1 was free from sexual abuse on 6/19/2025. The facility failed to: 1. Protect Resident 1 from Resident 2 by ensuring Resident 2 was provided with a one-to-one sitter (1:1, an intervention involving a nurse or healthcare professional providing constant observation and support to a resident who is at risk of harm) in accordance with the physician's order on 6/19/2025, from 11 PM to 11:20 PM. 2. Prevent abuse by ensuring facility licensed staff monitored and documented Resident 2's sexually inappropriate behavior of playing with his private area on 6/12/2025 and developed and implemented interventions to prevent abuse of Resident 1 and other residents in the facility. 3. Notify and inform Resident 2's primary physician (MD) of Resident 2's sexually inappropriate behavior of playing with his private area on 6/12/2025 and obtain orders to protect Resident 1 and other residents residing in the facility from safety and sexual abuse. These deficient practices resulted in Resident 1 experiencing sexual abuse from Resident 2 on 6/19/2025, at around 11:20 PM. Resident 2 who was positive for human immunodeficiency virus (HIV, a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases) and who should have been supervised with a 1:1 Sitter, was observed by Licensed Vocational Nurse (LVN) 1 on top of Resident 1 in Resident 1's room. Resident 1's pants and diaper were pulled down above her knees. Resident 2 stated he was having sex with Resident 1. Resident 1 was started on HIV prophylaxis (prevention) medication on 6/21/2025 which could result in Resident 1 suffering adverse side effects such as kidney and liver damage, depression (a mood disorder characterized by persistent feelings of sadness, loss of interest in activities, and a range of other symptoms that interfere with daily life), anxiety (excessive worry, fear, and unease that can interfere with daily life), and suicidal thoughts (thoughts, feelings, or ideas about ending one's own life). Resident 1 experienced dysphoric (experiencing a state of unease, dissatisfaction, or generalized unhappiness) mood during a consult with psychologist (specializes in the study of mind and behavior or in the treatment of mental, emotional, and behavioral disorders) on 6/25/2025. A review of Resident 1's Admission Record indicated Resident 1, a 76-year-old-female, was admitted to the facility on 4/22/2022, with diagnoses that included dementia (a progressive state of decline in mental abilities), depression and schizophrenia unspecified (a mental illness that is characterized by disturbances in thought). A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/26/2025, indicated Resident 1 had severe impairment with cognitive skills for daily decision making. Resident 1 required supervision or touching assistant (helper provides verbal cues and /or touching/steadying and/or contact guard assistance as resident completes activity) with bed mobility, transfer, walking, upper and lower body dressing, and toilet use. Resident 1 required substantial/ maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs but provides more than half the effort) with shower/ bathing self. During concurrent observation and interview on 6/23/2025, at 4:11 PM, Resident 1 was observed walking in the hallway. During the interview, Resident 1 was asked about the incident on 6/19/2025. Resident 1 stated, "There is nothing to talk about." A review of the General Acute Care Hospital (GACH) Emergency Department History and Physical (ED H&P), dated 6/20/2025, indicated Resident 1 had reported one of the residents (Resident 2) entered her room, lowered his pants, pinned her down, and started having sexual intercourse with her. The GACH ED H&P also indicated the Sexual Assault Response Team (SART, provides comprehensive care and support to individuals who have experienced sexual assault, including medical care, forensic evidence collection, and emotional support) nurse, Resident 1 does have positive findings on genitourinary (GU, it refers to the organs and systems involved in the production, storage, and excretion of urine and reproduction) examination evidence of sexual assault (any kind of sexual activity, contact, or experience that happens without one's consent). It also indicated, per SART nurse, there is confirmation that the offender (Resident 2) is HIV positive and Resident 1 was started on Post-Exposure Prophylaxis (PEP, a medication regimen taken after potential exposure to HIV to prevent infection). A review of Resident 1's Physician's Order, dated 6/20/2025, indicated to start Emtricitabine-Tenofovir Disoproxil Fumarate (Truvada, prescription medication used to treat HIV-1 infection, reduce the risk of HIV - 1 infection in high-risk individuals) oral tablet 200 to 300 milligrams (mg, unit of mass) on 6/21/2025. Give one tablet by mouth in the morning for HIV - 1 infection prophylaxis for 28 days. A review of Resident 1's Physician's order, dated 6/20/2025, the Physician's Order indicated Psychology referral. A review of Resident 1's Psychology Report, dated 6/25/2025, indicated Resident 1 was seen following a referral made by the staff on 6/24/2025, due to a report that Resident 1 experienced a suspected sexual assault. The report indicated Resident 1's mood appeared dysphoric and responded to questions with brief, simple answers. The report also indicated Resident 1 became visibly irritable when asked about the incident, expressing frustration with the repetitive nature of the inquiries. Resident 1 declined to provide any specific details and eventually ceased to respond altogether. A review of the Resident 1's Psychology Report, dated 6/26/2025, indicated Resident 1 was tearful at one point during evaluation, stating it was caused by the topic of the assault being brought up repeatedly. A review of Resident 2's Admission Record, indicated Resident 2, a 49-year-old-male, was initially admitted to the facility on 6/2/2025, with diagnoses that included paranoid schizophrenia (a mental disorder characterized by psychosis, where individuals experience a disconnect from reality), violent behavior, and positive for HIV. A review of Resident 2's Physician's Order, dated 6/3/2025, indicated Resident 2 may have 1:1 sitter. A review of Resident 2's MDS, dated 6/6/2025, indicated Resident 2 was moderately impaired with cognitive skills for daily decision making. Resident 2 also required supervision or touching assistance with toileting hygiene, shower/bathe self, change of position, and transfer. Resident 2 was independent for eating, oral hygiene, upper body dressing and personal hygiene. Resident 2 had episodes of wandering daily. A review of Resident 2's Progress Notes, dated 6/20/2025, timed at 5:30 AM, indicated at approximately 11:20 PM, the Charge Nurse (CN) notified RN supervisor that Resident 2 was allegedly having sexually inappropriate behavior. CN stated that Resident 2 was on top of Resident 1. MD was made aware and ordered Resident 1 to be transferred to GACH for further assessment. The facility notified the local police department who arrived at the facility around 1AM. The local police department took custody of Resident 2 and transferred Resident 2 to GACH for further investigation. During an interview on 6/24/2025, at 10 AM with Director of Nurses (DON), the DON stated LVN 1 called him on the phone on 6/19/2025, around 11:40PM, and notified him that LVN 1 found Resident 2 on top of Resident 1 in Resident 1's room. During an interview on 6/24/2025, at 12:35 PM, with Quality Assurance Nurse (QAN), QAN stated the sexual abuse happened during change of shift, between 11 PM to 11:20 PM on 6/19/2025. LVN 1 went to Resident 1's room upon hearing a screaming noise from Resident 1's room. QAN stated LVN 1 found Resident 2 on top of Resident 1. LVN 1 removed Resident 2 from Resident 1's room right away. LVN1 then notified Registered Nurse Supervisor (RNS) 1 and reported to the DON, physicians, families, police, ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and the Department of Public Health. During an interview on 6/24/2025, at 12:37 PM, QAN stated Resident 2 required a 1:1 sitter in accordance with the physician's order because of the resident's wandering behavior. During an interview on 6/24/2025, at 3:05 PM, with Certified Nursing Assistant (CNA) 3, CNA 3 stated she had seen Resident 2 playing with his private area sometime this month (6/2025) but does not remember exactly what date. CNA 3 stated she did not report the incident to the licensed nurse. During an interview on 6/24/2025 at 3:08 PM with CNA 2, CNA 2 stated she had seen Resident 2 playing with his private area in the restroom area during her shift but does not remember the date when this happened. CNA 2 stated she had reported it the charge nurse (LVN 3) a few days after it happened. During an interview on 6/24/2025 at 3:20 PM with Security Guard 1 (SG1), SG 1 stated that on 6/19/2025 at around 11:20 PM, while SG 1 was near the entrance door, he heard LVN 1 scream, "Hey get off her." SG 1 stated he followed where the voice was coming from and observed LVN 1 bringing Resident 2 out of Resident 1's room. SG 1 stated, "The resident (Resident 2) was holding his pants. It was unbuttoned and unzipped, and I can see his penis." SG 1 stated, "The resident (Resident 2) told me that he was having sex with that lady (Resident 1)." During an interview on 6/24/2025, at 4:20 PM, with RNS 1, RNS 1 stated LVN 1 reported to RNS 1 on 6/19/2025, around 11:20 PM, that Resident 2 sexually assaulted Resident 1. RNS 1 stated immediately after receiving the report, she went to Resident 1's room with LVN 1. Resident 1 was observed on her bed with her pants and diaper pulled down above her knees. RNS 1 stated she observed Resident 2 standing with SG 1 in front of his room, across Resident 1's room. RNS 1 stated Resident 2 had an order for a 1:1 sitter but there were no staff assigned to supervise and sit with Resident 2. RNS 1 added there was no CNA providing 1:1 supervision for Resident 2 for the shift of 11 PM to 7 AM on 6/19/2025. RNS 1 added having a 1:1 sitter could have protected Resident 1 from sexual abuse from Resident 2. During a concurrent interview and record review on 6/24/2025, at 4:30 PM, with RNS 1, Resident 2's medical records were reviewed. RNS 1 stated there was a nursing progress note, dated 6/15/2025, which indicated that CNA 2 observed and had reported to LVN 3 that Resident 2 was playing with his private area on 6/12/2025. RNS 1 stated Resident 2's sexually inappropriate behavior was a change of condition (COC, any noticeable alteration in a resident's physical or mental status that deviates from their baseline or established pattern, potentially indicating a new illness, worsening condition, or need for intervention) and should have been reported to the MD. RNS1 stated the nurses should have completed a COC report, monitored Resident 2 for 72 hours, and should have notified the MD in accordance with the facility's COC policy. During an interview on 6/24/2025, at 3 PM, with the DON, the DON stated the facility did not have a process, such as having a "1:1 sitter" log to monitor and ensure that any resident requiring a 1:1 sitter was provided with a facility staff to supervise and sit with the resident at all times. The DON stated the facility should have had a "1:1 sitter" log, which will be filled out at the beginning of each shift where information such as the name of the resident requiring a sitter, the name of the sitter assigned to the resident, and the date and shift the sitter was assigned will be entered. The DON stated having a 1:1 sitter for Resident 2 could have prevented the sexual assault on 6/19/2025. During an interview on 6/24/2025, at 7 PM, with LVN 1, LVN 1 stated that on 6/19/2025, at around 11:20 PM, he found Resident 2 on top of Resident 1 after he heard a screaming noise from Resident 1's room. LVN1 stated he immediately pulled Resident 2 away from Resident 1 while LVN 1 screamed for assistance. LVN 1 stated SG 1 came to assist, and he instructed SG 1 to monitor Resident 2 while LVN 1 went to the nurses' station to report the incident to RNS 1. LVN 1 stated there was an order for Resident 2 to have a 1:1 sitter however Resident 2 was not assigned a sitter on 6/19/2025, for the 11 PM to 7AM shift. During an interview on 6/24/2025, at 7:28 PM, with LVN 3, LVN 3 stated one of the CNAs (unnamed) who was assigned as 1:1 sitter to Resident 2 reported on 6/15/2025 that Resident 2 was playing with his private area in his room on 6/12/2025. LVN 3 stated the CNA should have reported the incident on 6/12/2025. LVN 3 stated the RN Supervisor (unnamed) also heard Resident 2's sexually inappropriate behavior from the CNA and instructed LVN 3 to document the report on the nursing progress notes. LVN 3 stated a COC report and monitoring for Resident 2's sexual inappropriate behavior should have been done. LVN 3 stated it should have been also reported to MD so proper interventions could have been developed and implemented. A review of the facility's Policy and Procedure (P&P) titled, "Abuse Prevention and Prohibition Program," revised on 8/1/2023, indicated each resident has the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The Facility has zero tolerance for abuse, neglect, mistreatment, a