Every finding on record at Avalon Place Kirbyville

Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 1 of 15 residents (Resident #48) reviewed for respiratory care.The facility failed to change the oxygen reservoir weekly for Resident #48. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.Findings included:Record review of Resident #48's face sheet, dated 9/02/25 revealed a [AGE] year old female admitted on [DATE] with diagnoses that included Dementia (a general term for a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, and other cognitive functions), Chronic Obtrusive Pulmonary Disease (a progressive lung condition that causes breathing difficulties due to narrowed airways and damaged air sacs, leading to symptoms like chronic cough, shortness of breath, and wheezing), and Hypertension (a condition where the force of blood against artery walls is consistently too high, which can lead to serious health problems like heart attack and stroke)Record review of Resident #48's admission MDS assessment, dated 09/08/25, revealed Resident #48 had a BIMS score of 11, which indicated she had moderate cognitive impairment. The MDS showed that Resident #48 requires maximal assistance with ADLs.Record review of a physician's order for Resident #48, dated 9/29/25, showed that staff were to, Change oxygen humidifier every evening shift every Sunday and as needed. Record review of a physician's order for Resident #48, dated 9/29/25, showed that staff were to, O2 @ 2L/Minute via nasal cannula PRN to maintain O2 stats > 92%Record review of Resident #48's care plan dated 12/1/2025 showed no care planning for oxygen administration.During an interview and observation on 12/1/2025 at 8:58 a.m. it was observed that Resident #48's oxygen humidifier, or water reservoir, was dated 11/9/2025. Resident #48 said she uses her oxygen but rarely. She said she did not know how often her tubing is changed. During an interview on 12/03/2025 at 10:12 a.m., LVN A said nurses were responsible for ensuring that resident's oxygen tubing, reservoirs, and machines were maintained. She said residents' oxygen reservoirs should be changed per their orders. She said Resident #48's oxygen reservoir should be changed weekly or as needed. She said nighttime nurses on Sundays should change their reservoirs and clean up. During an interview on 12/03/25 at 12:00 p.m. with the DON she said that it was the responsibility of facility nurses on the nighttime Sunday shift to ensure that residents' oxygen reservoir was changed per orders and labeled with the new date. She stated that residents could be placed at risk for respiratory infections if their oxygen reservoir was not changed properly. She said that there could be a bacteria buildup inside the reservoir if it wasn't changed out regularly. During an interview on 12/03/25 at 12:05 p.m. with the ADM she said that it was the responsibility of night nursing staff to change the oxygen reservoir for oxygen concentrators as it was ordered. She said it was Sunday night nurses that were supposed to ensure that all residents who receive oxygen have their reservoirs clean. She said that residents could be placed at risk for respiratory infections if they were not supplied with clean oxygen reservoirs. Record review of an undated facility policy titled Oxygen Administration revealed that, Oxygen therapy includes the administration of oxygen (02) in liters/minute (I/min) by cannula or face mask to treat hypoxemic conditions caused by pulmonary or cardiac diseases. 02 therapy is also prescribed to ensure oxygenation of all body organs and systems. The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse. The nasal cannula delivers 22-40 % oxygen and is the most common, inexpensive, and easiest device to use. Common oxygen sources for long-term administration include cylinder (portable or stationary) or wall system near the resident's bed or concentrator. The resident will be free from infection.

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 4 resident personal refrigerators reviewed for food safety (Resident #46). The facility failed to ensure the refrigerator for Resident #46 did not contain a greenish/black substance in the freezer section. This failure could place residents at risk for food borne illnesses.Findings included: Record review of Resident #46's face sheet, dated 12/03/25, reflected he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included Parkinson's disease (a progressive neurodegenerative disorder that primarily affects movement due to the loss of dopamine-producing brain cells, leading to symptoms like tremors, stiffness, and balance problems), and type 2 diabetes mellitus (a chronic condition where the body doesn't use insulin properly, leading to high blood sugar levels). Record review of Resident #46's quarterly MDS assessment, dated 09/04/25, reflected he had a BIMS score of 6, which indicated severe cognitive impairment. During an observation and interview on 12/01/25 at 08:45AM, Resident #46 was lying in bed in his room. He gave this surveyor permission to check his refrigerator and there was a greenish/black substance in the freezer section. The Administrator came into the room and said she would have someone clean the refrigerator. During an interview on 12/03/2025 at 9:49 AM, the ADON said her expectation for the fridges was that family were to maintain and clean the fridges. She said she also expected the housekeeping staff to check the fridges with temperature checks. She said the risk was there could be contamination that could make a resident sick. During an interview on 12/03/25 at 12:06PM, the DON said the resident and responsible party were responsible for cleaning the refrigerator. She said in absence of the responsible party and resident then the housekeeper should clean it. She said the food can develop bacteria and potentially make a resident sick. During an interview on 12/03/25 at 12:08PM, the Administrator said the resident and responsible party were responsible for cleaning the refrigerator. She said if they needed help then they can ask staff for help. Record review of the facility's policy, Personal Refrigerators Policy, dated 2022, stated: .The care and maintenance of any refrigerator is the responsibility of the resident and/or responsible party. It is also the responsibility of the resident and/or resident representative to properly store non-facility supplied foods that require refrigerator in their personal refrigerator. If food is expired or appears spoiled or moldy, the facility reserves the right to discard it. Housekeeping can assist the resident and/or family member by inspecting the refrigerators at least weekly and assist with removal of outdated food items and cleanliness. Care and MaintenanceThe resident and/or resident representative should clean and maintain the refrigerators according to the manufacturer's user manual. If needed you can ask facility housekeeping or maintenance staff for assistance.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 14 residents (Resident #49) reviewed for infection control practices. The facility failed to ensure the proper disinfectant cleaner was used to clean Resident #49's isolation room with clostridium difficile (bacteria that causes infection in the large intestine). This failure could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: Record review of Resident #49's face sheet, dated 12/02/25, reflected she was a [AGE] year-old female, initially admitted to the facility on [DATE], and most recently re-admitted on [DATE]. Her diagnoses included dementia (a decline in mental ability that interferes with daily life, affecting memory, thinking, and behavior), and schizophrenia (a chronic mental health disorder characterized by a breakdown in the relationship between thought and reality). Record review of Resident #49's quarterly MDS assessment, dated 10/09/25, reflected that she had a BIMS score of 03, which indicated severe cognitive impairment. She was also frequently incontinent of bowel. Record review of Resident #49's physician's orders, reflected this order:*Resident Requires contact isolation for clostridium difficile. The start dated was 11/24/25. Record review of Resident #49's care plan reflected a focus of Resident #49 is on contact precautions related to clostridium difficile. The focus was initiated on 11/24/25. The goal was the resident's infection will not spread to other residents. Interventions included:*After resident care, remove gown and gloves in the residents room in the container for soiled PPE*Have PPE readily available outside of the residents room*Perform hand hygiene after removing gown and gloves*Wash hands or use hand sanitizer prior to entering the room. During an observation on 12/01/2025 at 1:43PM, there was a sign on Resident #49's door that stated contact isolation. There was an isolation cart outside the room that contained PPE. Resident #49 was lying in bed in her room. During an observation and interview on 12/01/2025 at 2:27PM, Housekeeper B was cleaning rooms on 100 hall. She said if she was cleaning a room that was on isolation for clostridium difficile she would use the K-Quat Plus Cleaner. She showed this surveyor the bottle of K-Quat plus on her housekeeping cart. She said she uses that product on clostridium difficile rooms and all bathrooms. During an interview on 12/01/2025 at 2:58 PM, Housekeeper C said she was just about to start cleaning the hall that Resident #49 was on. She said she uses the K-Quat Plus cleaner for Resident #49's room. She said she cleans Resident #49's room last, and she said she lets the cleaner sit for 10 minutes. During an interview and observation on 12/02/25 at 8:48AM, the Housekeeping Supervisor said she expected the housekeeping staff to use the K-Quat Select disinfectant on clostridium difficile rooms. She showed the bottle of K-Quat Select in the chemical closet. She said the house keepers use the K-Quat select bottle to fill the bottles they use on their carts. She said she was not aware the K-Quat cleaner did not kill clostridium difficile. She said the risk was that the staff could potentially spread the clostridium difficile bacteria to other residents and get them sick. She said she would call corporate and figure out what cleaner she should be using instead. During an interview on 12/02/2025 at 09:10 AM, the Housekeeping Supervisor said she spoke with corporate, and she was supposed to use a 1:10 bleach solution for the clostridium difficile room. She said she will in-service her staff on the bleach solution. During an interview on 12/03/2025 at 9:49 AM, the ADON said she expected the housekeeping staff to use the proper disinfectant to kill clostridium difficile. She said the risk was that the clostridium difficile could spread and cause an outbreak in the facility. During an interview on 12/03/25 at 12:06PM, the DON said she expected the housekeeping staff to use the proper disinfectant to kill clostridium difficile. She said the risk was that clostridium difficile could spread to other residents and staff and cause illness. During an interview on 12/03/25 at 12:08PM, the Administrator said she expected the staff to use the bleach solution to kill clostridium difficile. She said clostridium difficile was highly contagious and could spread to other residents. Record review of the following site was accessed on 12/01/25 at 03:30PM, and did not indicate the K-Quat Plus or K-Quat Select cleaner killed clostridium difficile bacteria:* List K: Antimicrobial Products Registered with EPA for Claims Against Clostridium difficile Spores | US EPA | https://www.epa.gov/pesticide-registration/epas-registered-antimicrobial-products-effective-against-clostridioides Record review of the following site was accessed on 12/01/25 at 03:35PM, and indicated the active ingredient in K-Quat Plus cleaner was registered under the name Maquat 64-PD.*Details for K-Quat Plus | US EPA | https://ordspub.epa.gov/ords/pesticides/f?p=PPLS:8:7342909364415::NO::P8_PUID,P8_RINUM:528655,10324-93-56864 Record review of the following site was accessed on 12/01/25 at 03:40PM, and did not indicate the Maquat 64-PD cleaner killed clostridium difficile bacteria.*Details for Maquat 64-PD | US EPA | https://ordspub.epa.gov/ords/pesticides/f?p=113:8:::NO::P8_PUID,P8_RINUM:35052,10324-93 Record review of the following site was accessed on 12/01/25 at 03:45PM, and indicated the active ingredient in K-Quat Select cleaner was registered under the name BTC 885 Neutral Disinfectant Cleaner-64.*Details for K-Quat Select | US EPA | https://ordspub.epa.gov/ords/pesticides/f?p=PPLS:8:7342909364415::NO::P8_PUID,P8_RINUM:479994,1839-169-56864 Record review of the following site was accessed on 12/01/25 at 03:50PM, and did not indicate the BTC 885 Neutral Disinfectant Cleaner-64 cleaner killed clostridium difficile bacteria.*Details for BTC 885 Neutral Disinfectant Cleaner-64 | US EPA | https://ordspub.epa.gov/ords/pesticides/f?p=113:8:::NO::P8_PUID,P8_RINUM:13680,1839-169 Record review of the facility's policy, Deep Cleaning Process - Resident Rooms with special precautions, dated 2022, stated: .6. Disinfect all contact surfaces using K-Quat Select. (or 10% bleach solution for [clostridium difficile]).

Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 2 of 2 days reviewed (12/1/25 and 12/2/25) for nurse staffing posting. The facility failed to post the required current daily staffing information on 12/1/25 and 12/2/25. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts. Findings included: During an observation on 12/1/25 at 8:20 AM, no nurse staffing data was posted in the facility. During an observation on 12/2/25 at 10:25 AM, no nurse staffing data was posted in the facility. During an interview on 12/2/25 at 11:00 AM, the DON said nurse staffing data was not posted. She said it used to be posted near the nurse's station, but it was no longer posted. She said she would run the staffing report and post it now. During an interview and observation on 12/2/25 at 11:25 AM, the DON said staffing was posted behind the nurse's station. This surveyor observed the daily nurse staffing posted behind the nurse's station. During an interview on 12/2/25 at 1:04 PM, the DON said she and the ADON were responsible for making sure staffing was posted. She said there was a miscommunication with her corporate. Corporate told her they did not need to post it. The DON said they use the staffing application for daily staffing and it could be printed out if needed. However, she understood it did not need to be posted. During an interview on 12/2/25 at 2:22 PM, the ADON said she used to post the daily staffing every day. She does not remember when she stopped. She understood from corporate that they did not have to post the daily staffing. She said corporate may have been misinformed or confused as well. She said she believed the last time she posted daily staffing was about 6 months ago. The ADON said the risk of not having daily staffing posted was residents/visitors would not know if there was enough staff to care for the residents. During an interview on 12/2/25 at 3:19 PM, the DON said the risk of not having staffing posting was that the residents would not know if there was an adequate number of staff to care for them for the day. During an interview on 12/2/25 at 3:52 PM the ADM said her Regional Area Director told her staffing had to be posted. She said it had not been posted in months, but she did not know how many. She said the risk of daily staffing not being posted was that personnel would not know what staffing was in the facility. During an interview on 12/2/25 at 12/03/2025 8:32 AM the ADM said they did not have a policy for posting daily staffing.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 7 residents (Resident #101) reviewed for accidents and supervision. The facility failed to provide adequate supervision for Resident #101 on 05/12/25 when the resident was removed from the secured unit and brought out to the main dining room for an activity. The resident exited the facility through a door that did not alarm and without staff knowledge and was found walking outside the back of the facility walking down a sidewalk. The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 05/12/2025 and ended on 05/12/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving appropriate supervision and interventions which could lead to residents sustaining serious injury or harm. Findings include: Record review of a face sheet dated 09/09/25 indicated Resident #101 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included catatonic schizophrenia (severe mental condition combined with pronounced psychomotor disturbances) dementia (loss of cognitive functioning), chronic obstructive pulmonary disease (lung disease that causes difficulty breathing by blocking airflow from the lungs), hemiplegia (paralysis of one side of the body associated with varying degrees of abnormal muscle tone, impaired sensation, visual impairment and loss of movement control on the affected side) and anxiety (persistent and excessive worry that interferes with daily activities). Record review of a quarterly MDS, dated [DATE], indicated Resident #101 had a BIMS score of 3 indicated severely impaired cognition and cognitive patterns of inattention and disorganized thinking continuously. Diagnoses were dementia, schizophrenia, anxiety, and chronic obstructive pulmonary disease. The assessment indicated Resident #101 wandered 1 to 3 days of the look back period and was independent of sitting to stand and walking 150 feet in a corridor or similar space. Record review of Resident #101's care plan, with a target date of 12/04/25, indicated Resident #101 was at risk for wandering related to impaired safety awareness and required secure unit placement due to being a wander threat, elopement risk, disorientation and impaired safety awareness. The care plan indicated Resident #101 had an actual elopement attempt; he wandered outside the facility unattended initiated on 05/12/25. Resident #101's care plan interventions included resident will reside in the secure unit. Record review of Resident #101's Elopement Risk assessment dated [DATE], indicated Resident #101 was a high elopement risk and resided on a secure unit. Record review of a progress note dated 05/12/25, LVN G indicated it was reported to the DON that Resident #101 was brought off the secured unit to attend a facility activity in the dining room and when staff were returning residents to the unit Resident #101 was not readily available. The progress note indicated staff immediately made a thorough search of the facility and surrounding premises and noted Resident #101 walking along the sidewalk. Resident was returned to the secure unit with no injury or pain noted. The progress note indicated a family member and physician were notified Resident #101 had wandered outside unsupervised. Record review of an Event Nurses' Note Elope or Attempt dated 05/12/25 indicated Resident #101 was brought off the secured unit to attend a facility activity in the dining room and when staff was returning residents to the secured unit, Resident #101 was not readily available. The note indicated staff immediately made a thorough search of the facility and surrounding premises and noted the resident outside the facility walking along the sidewalk. Resident was returned to the secured unit. The note indicated he exited the left side dining room door, was missing less than 5 minutes, and was discovered on the sidewalk at the left side rear of the building. The note indicated Resident #101 was cognitively impaired, wandered, and required cueing and acquired no injury. Record review of the investigation worksheet for Resident #101's dated 05/12/25 indicated the allegation was made on 05/12/25 at 3:00 p.m. and was reported to state on 05/12/25 at 5:14 p.m. Record review of Resident #101's Provider Investigation Report dated 05/12/25 indicated the nursing facility was hosting a carnival in the dining room. Several residents from the Secured unit were brought out to enjoy the festivities. Resident #101 was sitting on the left side of the dining room with several residents from the secure unit. Resident #101 was not at the table. The facility began a search and called code orange. The DON located Resident #101 as he was walking on the sidewalk. She asked why he was outside and his response was not clear, but the DON walked Resident #101 back inside with no hesitation. Resident #101 was assessed with no injury or pain. The investigation summary indicated Resident #101 was outside for 1-2 minutes at most. Resident 101 was returned to the Secured unit and not noted exit seeking. The facilities findings were inconclusive. Staff were in-serviced on Elopement prevention, Elopement prevention of secured unit resident attending activities away from the secured unit, Resident Rights, Abuse/ Neglect, color code system, no alarms are to be turned off and no doors propped open, demonstration for operation of doors in dining room and secured unit. The facility performed environmental rounds, reviewed Resident #101's care plan and MDS. The facility notified the family, physician, ombudsman and HHSC. A new mag-lock keypad alarm system was installed on exit door on left side of dining room and the Incident was presented during QAPI. Record review of Resident #101's Elopement Risk assessment dated [DATE], indicated Resident #101 was a high elopement risk, resided on a secure unit and had an elopement attempt. During an interview on 09/08/25 at 11:55 a.m., CNA L said on 05/12/25 CNA Y took Resident #101 out to the carnival and left him with a nurse. She said she was unsure which nurse. She said she was taking her dirty laundry barrel out to the end of Hall 200 to laundry and as she passed the dining room, she saw Resident #101 sitting at the table in front of the window in the dining room about 8 to 10 steps from the door to exit the dining area to the outside of building. CNA L said she took her barrel to the laundry at the end of Hall 200 when she came back, Resident #101 was not sitting in his chair and she asked the DON where Resident #101 was. She said she notified the Administrator who called for a Code Orange and she went down Hall 200 and exited to the left. CNA L said Resident #101 was brought back to the secured unit and started on q 15-minute checks for a few days. She said Resident #101 wandered but did not push on the doors. CNA L said the secured unit residents now attend activities on the unit only. During an Interview on 09/08/25 at 1:55 p.m., the AD said it was nursing home week, and the facility was having a carnival in the dining room on 05/12/25. She said she and the ADON went to the secured unit and chose 3 appropriate residents from the unit to enjoy the carnival. She said she was taking pictures of residents when she saw CNA Y bring Resident #101 into the carnival. The AD said she assisted the 3 residents from the secured unit playing games and did not see Resident #101 exit the facility. She said the last time she saw Resident #101 CNA Y was with him. The AD said when she was returning the 3 residents from the secured unit back to the unit, she asked CNA Y if Resident #101 was back there, and CNA Y said she had left him at the carnival. The AD said she immediately notified the Administrator to call a Code Orange, but the DON had already found and returned him into the building. The AD said CNA Y did not ask her to monitor Resident #101 before she left him. The AD said the residents on the secured unit were now enjoying on the unit activities at this time. She said after the incident, she was educated on abuse/ neglect, resident rights, and elopement prevention. She said she was educated on removing secured unit resident off the secured unit to include notifying the charge nurse when staff removed the resident from the unit, stay with them the whole time, and notifying the charge nurse when the resident was returned to the unit. The AD said if a resident eloped, she would notify the charge nurse, the DON, the Administrator and whole team, a Code Orange would be announced, and everyone would start looking for the missing resident inside and outside. The AD said she would start looking where the resident was last seen and spread out including resident rooms, closets, bathrooms in every room, the kitchen, and outside of the facility. During an interview on 9/8/25 at 3:50 p.m., CNA Y said she was educated on abuse/ neglect, resident rights and elopement prevention on hire. She said after the incident she was educated if a resident eloped, she would notify the charge nurse, a Code Orange would be called, and everyone would start looking for the resident inside and outside of the facility. She said she had been there 2 weeks when the incident with Resident #101 happened. She said a carnival was going on in the main dining room off the secured unit and some staff had come to the unit and asked if any residents wanted to go to the carnival. CNA Y said Resident #101 wanted to go, so she told LVN G on the secured unit at the time and she said to take him to the carnival, but she would have to come back to the unit. She said she and Resident #101 stayed in the main dining room for about 15 to 20 minutes and she handed him over to the ADON. CNA Y said, I asked the ADON do you have him I have to go back to the Unit. I had to say do you have him twice before she agreed. She said the ADON took a picture of Resident #101 and then CNA Y said she left Resident #101 sitting at a table by himself. She said after she returned to the secured unit, within a few minutes, she heard a Code Orange called. CNA Y said she believed the alarm was disabled on the door to exit the dining room and Resident #101 walked out the door and was found on the driveway behind the building. CNA Y said she verified with the ADON twice before she left Resident #101. She said when she left the carnival area, the ADON was taking Resident #101 to get popcorn. During an Interview on 09/08/25 at 3:40 p.m. the ADON said it was nursing home week and on 05/12/25, the facility was having a carnival in the main dining room. She said she and the AD went to the secured unit and chose 3 appropriate residents to come off the unit to enjoy the carnival. She said she noticed Resident #101 was in the dining room with CNA Y who was a new CNA to the facility. She said during the event she gave Resident #101 some popcorn while he was at the table at the corner of the main dining room with CNA Y with him. The ADON said when the residents from the secured unit were being taken back to the secured unit, she noticed Resident #101 was not there. The ADON said a Code Orange was called, and Resident #101 was found outside the back of the building. She said she was aware CNA Y said she left Resident #101 with her but she said she did not accept supervision of Resident #101 from CNA Y; she already was monitoring 3 residents from the secured unit that were chosen due to appropriateness to be removed from the secured unit. She said CNA Y did not ask her to monitor Resident #101. The ADON said the DON found Resident #101 and returned him to the unit, but she was not sure how long he was missing. She said the secured unit residents were now only attending activities on the secure unit and not leaving the unit for activities at this time. She was educated on abuse/ neglect, resident rights, elopement prevention, the procedures for removing residents from the secured unit, and on demonstration of operating the doors of secured unit and dining room exit doors, to remain locked and alarmed at all times. She said if a resident eloped, she would notify the charge nurse, the DON, the Administrator, a code orange would be announced, and everyone would start looking for the missing resident inside and outside of the facility. During an Interview on 09/08/25 at 3:35 p.m., the Maintenance Director said on 05/12/25 he was outside of the facility right outside Hall 100 talking to a painter and heard the DON outside. He said he then saw Resident #101 walking down the sidewalk behind the facility at the side of the building and the DON met Resident #101 and walked him back into the facility. He said before and after the incident he was educated on abuse/neglect, resident rights, and elopement prevention. During an interview on 09/08/25 at 5:25 p.m., the DON said she was down Hall 100 and ran out hall 100 exit door and toward the back of the building, she reached the driveway in the back of the building, she could see Resident #101 on the sidewalk and called for the Maintenance Director to get to him. She said the Maintenance Director was standing at the end of Hall 100. She said she ran past the Maintenance Director and met Resident #101 and walked him around the building and entered through the end of Hall 100. The DON said Resident #101 was outside the back of the building about 45 steps from the external exit door of kitchen. She said he walked out the door by the left side of the kitchen. She said a new keypad was installed on 05/12/25 to the dining room and new alarms on both exit doors. The DON said she sat in the kitchen all day on 05/12/25 with her laptop monitoring the exit doors to the dining room until the lock was installed and both door alarms were functioning. The DON said the facility had only on the secured unit activities at this time. She said she in-served staff on elopement prevention and resident rights before and after the incident. She said she in-serviced staff on doors not to be propped open and no alarms to be turned off after the incident. The DON said CNA Y did not come back to the facility after the incident and self-termed. The DON said she was unable to do a one-on-one training with CNA Y. The DON said she in-serviced all staff including ADON on the process of bringing residents off the secured unit, if they remove a resident from the unit they notify the charge nurse before and when they return the resident to the secured unit and to stay with the resident at all times when the resident was off the secured unit. During an interview on 09/08/25 at 3:45 p.m., HR said CNA Y no longer worked at the facility and she self-terminated after the incident on 05/12/25. During an interview on 09/08/25 at 5:00 p.m., the Administrator said on 05/12/25, she was notified Resident #101 was missing and she called a Code Orange. She said the DON ran down Hall 100 and out of Hall 100's exit door toward the back of the building and found Resident #101 on the sidewalk about 45 steps from the door by the kitchen at the back of the building. She said they determined the left side dining room exit door did not alarm when Resident #101 went out of it while at the carnival. She said the resident was found within 1 to 3 minutes and was about 20 feet from the Maintenance Director and a painter who were looking at the building roof. The Administrator said after the incident, they installed a new keypad on the left door to the dining room and new alarms on 05/12/25. She said the facility would do activities directly on the unit with residents who resided on the secured unit. The Administrator said the facility in-served staff on elopement prevention, alarms, doors not to be propped open, resident rights, no alarms to were to be turned off and if they removed a resident from the unit, they were to notify the charge nurse before and upon returning the resident to the unit. While off the unit, staff were instructed to stay with the resident at all times. She said she thought the alarm had malfunctioned. During an observation and interview on 09/08/25 at 12:05 p.m., Resident #101 was in his room on the secured unit lying in bed. He was confused and only able to answer simple questions. Resident #101 said he did not remember going outside on carnival day. During an observation on 09/08/25 at 3:15 p.m., with the Administrator the dining room exit doors were tested. The left side of the dining room exit to the outside door was pressed on the door and held for 15 seconds, the door immediately alarmed and released to open at 15 seconds. The right side of the dining room exit door to the outside of the facility opened with a loud alarm after pushing on the door. During an observation on 09/09/25 at 2:00 p.m., residents in the main area were participating in BINGO. There were no residents from the secured unit participating in BINGO off the secured unit. During an observation on 09/09/25 at 3:45 p.m., the left side of the dining room exit door to the outside was pressed and held for 15 seconds, and the door immediately alarmed and released to open at 15 seconds. The right side of the dining room exit door to the outside opened with a loud alarm on pushing door. During an observation on 09/10/25 at 8:00 a.m., the left side of the dining room exit door to the outside was pressed and held for 15 seconds, the door immediately alarmed and released to open at 15 seconds. The right side of the dining room exit door to the outside opened with a loud alarm on pushing door. During an Interview on 9/10/25 at 8:30 a.m., LVN G said on 05/12/25 she was the charge nurse responsible for the secured unit the day Resident #101 got out. She said CNA Y, a new CNA, took Resident #101 to an activity off the unit. She said she was unaware Resident #101 had left the unit until the facility staff started looking for him, but he was found within minutes. She said a Code Orange was called. LVN G said she was educated on abuse/ neglect, resident rights, elopement prevention and removing secured unit resident off the secured unit before and after the incident. During an interview on 09/10/25 at 10:30 a.m., the DON said her expectation was all residents be free from abuse/ neglect and stay safe and secure in the facility. She said all staff have been educated frequently on abuse/ neglect and elopement prevention. She said they now re-educate monthly on abuse/ neglect and elopement prevention. During an interview on 09/10/25 at 10:45 a.m., the Administrator said her expectation was all residents be free from abuse/ neglect and stay safe and secure in the facility. She said all staff have been educated frequently on abuse/ neglect and elopement prevention. Record review of an undated facility policy, titled Elopement Prevention indicated, .Every effort will be made to prevent elopement episodes while maintaining the lease restrictive environment for residents who are at risk for elopement. 1. The Elopement Risk Assessment will be completed upon admission. The resident's care plan will be modified to indicate that the resident is at risk of elopement episodes.7. If a resident is discovered to be missing, a search shall begin immediately. Intervention Strategies .keypad exit magnetic locks, Keyed Alarms, Secured Unit.Staff will receive training during their orientation process and then annually regarding Elopement prevention. During interviews on 09/08/25 from 11:30 a.m. - 09/09/25 at 4:00 p.m., 7 LVNs (4 days and 3 from nights shift- LVN A, LVN B, LVN C, LVN D, LVN E, LVN F, LVN G), 2 RNS, RN H and RN J were educated on abuse/neglect, resident rights, elopement prevention, removing secured unit residents off the secured unit, and demonstration of operating the doors. They said if a resident eloped, they would notify the charge nurse, DON, Administrator, a code orange would be announced, and everyone would immediately start looking for the missing resident inside and outside the facility. They said during the search all resident rooms, closets, bathrooms and all other rooms were searched, including outside the facility. They said the responsible party, physician, ombudsman and HHSC were notified. If the resident was not found the police would be notified. During interviews on 09/08/25 from 11:30 a.m. - 09/09/25 at 4:00 p.m., 16 CNAs (from each shift- CNA K, CNA L, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, CNA T, CNA U, CNAV, CNA X, CNA Z, CNA HH) were educated on abuse/ neglect, resident rights, elopement prevention, removing secured unit residents off the secured unit, and demonstration of operating the doors. They said if a resident eloped, they would notify the charge nurse, DON and Administrator and a code orange would be announced. They said everyone would immediately start looking for the missing resident inside and outside the facility. They said all resident rooms, closets, bathrooms and all other rooms were searched. They said outside area around the facility would also be searched. During interviews on 09/08/25 from 11:30 a.m. - 09/09/25 at 4:00 p.m., HR, DM, [NAME] AA, Dietary Aid BB, Dietary aid GG, Maintenance director, Laundry CC, HK Supervisor, HK DD, HK DD, HK EE, Floor Tech FF were educated on abuse/ neglect, resident rights, elopement prevention, removing a secured unit resident off the secured unit, and demonstration of operating the doors. They said if a resident eloped, they would notify the charge nurse, DON and Administrator and a code orange would be announced. They said everyone would immediately start looking for the missing resident both inside and outside the facility. They said the search would include all resident rooms, closets, bathrooms and all other rooms were searched. They said the outside the facility would also be searched. Record review of an in-service sign in sheet titled, No Alarms are to be turned off and no doors are to be Propped Open dated 05/12/25 for department Maintenance indicated 1 staff member Maintenance Director signature. Record review of in-service sign in sheet titled, Demonstration for operating the door(s) in the dining room dated 05/12/25, indicated 54 staff members signed the in-service record which included AD, LVN D, CNA W, LVN G, CNA L, ADON, CNA Y CNA X, CNA Z, HK DD, Laundry CC, Rehab Director, RN H, CNA R, CNA N, CNA HH, DM, CNA M, RN J, LVN A, and CNA S. Record review of in-service sign in sheet titled, Demonstration for operating the door(s) on the secure unit dated 05/12/25, indicated 54 staff members signed the in-service record which included AD, LVN D, CNA W, LVN G, CNA L, ADON, CNA Y CNA X, CNA Z, HK DD, Laundry CC, Rehab Director, RN H, CNA R, CNA N, CNA HH, DM, CNA M, RN J, LVN A, and CNA S. Record review of in-service sign in sheet for policy on Color code program dated 05/12/25, indicated it was important to know the color code when an emergency happened, and code orange indicated a resident elopement. 54 staff members signed the in-service record which included AD, LVN D, CNA W, LVN G, CNA L, ADON, CNA Y CNA X, CNA Z, HK DD, Laundry CC, Rehab director, RN H, CNA R, CNA N, CNA HH, DM, CNA M, RN J, LVN A, and CNA S. Record review of in-service sign in sheet for new policy on Elopement Prevention (Secured Unit Residents attending Activities away from the Secured Unit), dated 05/12/25, indicated 54 staff members signed the in-service record which included AD, LVN D, CNA W, LVN G, CNA L, ADON, CNA Y CNA X, CNA Z, HK DD, Laundry CC, Rehab Director, RN H, CNA R, CNA N, CNA HH, DM, CNA M, RN J, LVN A, and CNA S. Record review of an AD Hoc QAPI Contributors form, dated 05/12/25, indicated there was a meeting held on 09/15/25 consisting of the Administrator, the assistant Administrator, the DON, the ADON, the AD, Laundry Worker CC, Rehab Director and BOM. The following interventions were put in place: New Policy: Elopement Response. The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 05/12/2025 and ended on 05/12/2025. The facility had corrected the noncompliance before the survey began.

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 7 residents (Resident #50) reviewed for resident abuse. The facility failed to ensure Resident #50's was free from physical abuse when Resident #3 pushed a rolling bedside table into his roommate Resident #50 causing a skin tear and Resident #50 to fall to the ground on 03/25/25. This failure could place residents at risk of physical harm, mental anguish, or emotional distress.The findings include: 1. Record review of Resident #3's face sheet dated 09/09/25 indicated he was a [AGE] year-old-male admitted on [DATE] and readmitted [DATE] with diagnoses of Alzheimer's disease (progressive brain disorder that causes a gradual and irreversible loss of memory, thinking skills and the ability to carry out daily activities), dementia with psychotic disturbance (involves symptoms like hallucinations (seeing hearing or smelling things that are not there) delusion (false, fixed beliefs) such as paranoia) and anxiety disorder (a mental health condition characterized by excessive worry, fear or apprehension that is difficult to control and interferes with daily life). Record review of a skin assessment dated [DATE] for Resident #50 indicated he received a skin tear to his left forearm 8 cm x 5.1 cm in size. Record review of Resident #3's Annual MDS assessment dated [DATE] indicated he had a BIMS of 3 which indicated he was severely impaired of cognition. The assessment indicated Resident #3 behaviors present including inattention that comes and goes, disorganized thinking continuously. The assessment indicated Resident #3 had diagnoses of Alzheimer's disease and dementia with psychotic disturbance and received an antianxiety medication received during the last 7 days. Record review of Resident #3's Care plan updated 08/27/25 indicated he was at risk for delirium and confusion episodes related to Alzheimer's disease and dementia and had a behavior problem on 03/20/25 Resident #3 pushed a bedside table into another male resident causing Resident #50 to fall to the floor. The care plan did not indicate any other behavior problems. Record review of Resident #3's SBAR (a standard communication tool to communicate a resident's status) dated 03/20/25 indicated a behavior change of Resident #3 told his roommate to get out of their room, then pushed resident with a bedside table knocking Resident #50 to the floor. The SBAR indicated orders received to send Resident #3 to in patient hospice. Record review of Resident #3's nursing note dated 03/20/25 indicated a resident-to-resident behavior observed. Resident #3 pushed a bedside table into Resident #50 knocking him down. Resident #3 was redirected away from the area, placed on one-on-one supervision. The nurse's note indicated that Resident #3 stated his roommate stole his belongings. Record review of Q 15 Minute Monitoring dated 03/20/25 indicated Resident #3 was monitored one on one and every 15 minutes documentation until discharged to inpatient hospital. During an observation and interview on 09/08/25 at 12:30 p.m. Resident #3 was sitting in a chair and said he was treated well and denied any residents were rough, hit or pushed him. Resident #3 denied he pushed or hit Resident #50 with a bedside table or any other resident. 2. Record review of Resident #50's face sheet dated 09/09/25 indicated he was a [AGE] year-old-male admitted on [DATE] and readmitted [DATE] with diagnoses of Alzheimer's disease, dementia with psychotic disturbance, hallucinations and anxiety disorder. Record review of Resident #50's quarterly MDS assessment dated [DATE] indicated he had a BIMS of 3 which indicated that he was severely impaired of cognition. The assessment indicated Resident #50 diagnoses of Alzheimer's disease and received an antidepressant and antipsychotic medication received during the last 7 days. Record review of Resident #50's Care plan updated 09/08/25 indicated he had impaired cognition, refused care and had a communication problem, and had difficulty understanding some verbal content related to Alzheimer's disease and dementia. The care plan indicated Resident #50 had a fall on 03/20/25, he was knocked down by a bedside table pushed into him by his roommate. The care plan did not indicate any other behavior problems. Record review of Resident #50's nursing note dated 03/20/25 indicated Resident #50 received a skin tear to left upper arm. During an observation and interview on 09/08/25 at 12:20 pm, Resident #50 was sitting in a chair and denied any residents were rough, hit or pushed him. Resident #3 denied he pushed or hit Resident #50 with a bedside table or anything. Record review of the investigation worksheet for Resident #3's dated 03/20/25 indicated the allegation was made on 03/20/25 at 3:00 p.m. and was reported to state on 03/20/25 at 4:32 p.m. Record review of Resident #3's Provider Investigation Report dated 03/20/25 indicated a resident-to-resident altercation in which Resident #3 pushed a bedside table into Resident #50 causing a skin tear and Resident #50 to fall to the floor. The findings indicated inconclusive for the allegation of abuse. Investigation Summary indicated the intent of Resident #3 was not to hurt Resident #50 by pushing the table out of the way, but pushing the table caused Resident #50 to fall and resulted in a skin tear. Resident #3 was monitored one on one with documentation every 15 minutes until discharged from the facility to inpatient hospice. During an interview on 09/08/25 at 11:45 a.m., LVN A said she was providing care for Resident #3 and #50 today and she witnessed the incident between the residents on 03/20/25. She said on 03/20/35 she was sitting in the nurse's office looking at them. LVN A said Resident #50 was inside the room in her view with a rolling bedside table in front of him and Resident #3 was standing in front of him just talking. She said there was no yelling, arguing or aggression. She said there was no indication anything was wrong. LVN A said Resident #3 told Resident #50 he was looking for his suitcase, I know you took it and pushed the rolling bedside table into Resident #50 causing a skin tear and fall. She said there were no previous or prior incidents. LVN A said she immediately separated them, Resident #3 was immediately placed on one-on-one monitoring with documentation of every 15 minutes but watched constantly. LVN A said she provided wound care to Resident #50 and had him x-rayed with results of no fractures. She said Resident #3 was sent to the behavior hospital the next morning. LVN A said she was educated on abuse and neglect and notified the Administrator immediately. During an interview on 09/10/25 at 10:30 a.m., the DON said her expectation was all residents be free from abuse and neglect. She said all staff had been educated frequently on abuse and neglect and elopement prevention. She said related to the incident with Resident #3 and #50 there was no sign of a problem, no urinary tract infection or lab problems, or no new medication that could have caused behaviors. She said the residents had no prior signs or symptoms that would lead us to suspect an incident and no triggers or suspected behavior that could lead up to an incident. The DON said there was no way we could have predicted an incident would happen between these roommates. She said we addressed the situation, removed Resident #3 and monitored him one on one until he was sent to the hospital. The DON said when Resident #3 returned to the facility he had a different roommate. She said Residents #3 and #50 have not had any incidents since. During an interview on 09/10/25 at 10:45 a.m., the Administrator said her expectation was all residents be free from abuse and neglect and stay safe and secure in the facility. She said all staff were educated frequently on abuse and neglect. She said the incident with Resident #3 and #50 was unable to be predicted. She said there no signs of a problem; the residents had no prior incidents or behaviors. She said there have been no incidents since and the residents were no longer roommates. The Administrator said the residents were immediately separated; Resident #3 was placed on one-on-one monitoring until sent to the hospital and Resident #50 was assessed and x-rayed with no fracture. She said the facility investigated the incident, in-serviced staff, interviewed staff and residents and notifications as required. The Administrator said there was nothing to predict an incident would happen. Record review of and undated facility policy titled, Abuse/ Neglect indicated, The resident has the right to be free from abuse, neglect, . Residents should not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, . 5. Physical Abuse: Includes, hitting, slapping.Resident to Resident The above policy will apply to potential resident-to-resident abuse.

Based on interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen reviewed for food and nutrition services. The facility failed to designate a person to serve as the dietary manager who met the required qualifications. The facility designated Dietary Supervisor did not have a dietary manager's certification or any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met. The findings included: During an interview on 09/9/24 at 8:30 a.m., the DM said she had taken her food handler test, however had not been sent to classes for certified dietary manager. She said the company had talked about sending her for certification classes but did not send her to classes. She said she had worked as the Dietary Manager for almost a year. During an interview on 09/11/24 at 10:00 a.m., the Administrator said she had tried to send the DM to become certified and the class was canceled. She said the next class would be in February 2025. The Administrator said she was trying to help the DM become certified. During an interview on 09/11/24 at 12:30 p.m., the HR staff said the DM was not certified and thought she had been hired as the DM about a year ago was rehired by their new managing company. The HR staff said the Administrator had tried to send the DM to class and said the class was canceled. Record review of an email addressed to the Administrator dated 09/11/24 indicated the dietary manager class would be February 22, 2025. Record review of a list provided by HR staff dated 09/11/24 indicated the DM was hired on 04/22/21, then promoted to DM on 09/15/23. The HR staff said the Administrator had tried to send the DM to class and said the class was canceled. Record review of training indicated the dietary manager had completed a food handler for DM and had 8 hours of training dated 09/10/23. Record review of the undated job description indicated Clinical Dietary Manager The following is a non-exhaustive criteria that relates to the job of clinical dietary manager, and it is consistent with the business needs of the facility. These are legitimate measure of the qualifications, and are related to the functions that are essential to the job of a Clinical Dietary Manager. Base Knowledge: Must obtain and maintain Certified Dietary Manager (CDM), Certified Food Protection Professional (CFPP) credential from ANFP (Association of Nutrition and Foodservice Professionals).

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for essential equipment. The facility did not ensure the gas stove, and the convection ovens were in safe operating condition. This failure could place the residents at risk of a fire and not receiving their meals in a timely manner. Findings included: During an observation and interview on 09/09/24 at 7:50 a.m., [NAME] A turned on the burners on the stove. 2 of 6 burners did not light using their pilot lights and she picked up a long lighter and lit pilot. She turned the burners on and the burners lit. She said occasionally the pilot lights go out and we must light the pilots . She said the DM knew about the pilot lights going out. During an interview on 09/10/24 at 2:00 p.m., the Administrator said the portable AC in the kitchen might have blown out the pilot lights, but she would have the maintenance supervisor to check on the pilot lights. During an interview on 09/11/24 at 12:55 p.m. the DM said the pilot lights would have to be lit occasionally for the last month, but her staff knew to watch for the pilot lights and to light if needed. She said the pilot lights going out might have been related to the portable AC units. During an interview on 09/11/24 at 1:00 p.m., the Maintenance Supervisor said he would go to the kitchen and clean the pilot lights. He said the staff had not reported the pilot lights not being lit. He said the equipment should be in good working order and if not, the burner might not work as required. The maintenance supervisor said some pilot lights will leak small amounts of gas, and some do not, he said he was new and was unsure what type of pilots were on the stove. He said he would check the burners. Record review of the Preventive Maintenance dated March 2003 indicated The facility will ensure that a comprehensive preventive maintenance program is in place for essential operating equipment.

Based on interviews and record review the facility failed to ensure that when the facility anticipated discharge, a resident must have a discharge summary that included, but was not limited to, the following: A recapitulation of the resident's stay that included, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results for 1 of 3 residents reviewed for discharge summary (Resident #48). The facility did not furnish a completed and physician signed Discharge Summary at the time of discharge for Resident #48. These failures could place discharged residents at risk for a lack of continued care and services. Findings included: Record review of a face sheet printed 09/11/24 indicated Resident #48 was a [AGE] year-old male admitted [DATE]. His diagnoses included diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar), respiratory failure (inadequate gas exchange by the respiratory system), kidney failure (a condition in which the kidneys lose the ability to remove waste and balance fluids), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and hypertension (elevated/high blood pressure). The face sheet also indicated he was discharged home on 06/22/24. Record review of Resident #48's discharge MDS dated [DATE] indicated this was a planned discharge, to home/community and Resident #48 was cognitively intact with a BIMS score of 15. Record review of Resident #48's discharge summary with an effective date of 06/24/24 opened by the medical records personnel, indicated Resident #48 went home but did not include a discharge date , discharge disposition, rehabilitation potential, admission diagnosis, discharge diagnosis, summary of care, prognosis or nursing documentation and no physician signature or date. The discharge summary did include therapy documentation, activity documentation, dietary documentation, and social service documentation. Record review of Resident #48's progress note dated 06/22/2024 indicated he was discharged home with medication, oxygen and set up of a company to provide oxygen and was completed by the ADON. During an interview on 09/11/24 at 12:07 p.m., the ADON said she wrote the discharge note, educated the resident and family on medication, oxygen and provided the medication list and appointments for Resident #48 on discharge. She said when Resident #48 discharged floor nurses did not complete the discharge summary. She said that was before the change in management companies. The ADON said she was not responsible for completing the discharge summary for Resident #48. During an interview on 09/11/24 at 12:10 p.m., the DON said at the time of Resident #48's discharge on 6/22/24 she was on vacation and RN A was responsible for ensuring discharge summaries were completed and signed by the physician. She said at that time the policy was the medical records person, was responsible for opening the discharge summary in the computer system and notify the IDT (interdisciplinary team) of a discharge and the IDT were responsible for completing their sections and then physician came in and signed the discharge summary in the system within 20 days. She said as of 07/01/24 they had a change in management and the staff and physicians were unable to access the old computer system. The DON said Resident #48 should have had a completed discharge summary, she said all residents discharged home should have a discharge summary completed. She said the IDT was responsible for ensuring the discharge summary was completed. The DON said the risk for the resident with a discharge summary not completed and signed by the physician was potential improper education or instruction given to the resident at the time of discharge and a potential delay in care or treatment. The DON said her expectation was she would be trained next week on the requirements of discharge summaries. Attempted phone interview with RN A on 09/11/24 at 12:20 p.m., with no return call or answer. Attempted phone interview with medical records person on 09/11/24 at 12:24 p.m., with no return call or answer. During an interview on 09/11/24 at 12:30 p.m., the Administrator said the DON was now responsible for completing the discharge summary and ensuring the physician signed it. She said the ADON would now be her back up to ensure the discharge summary was completed and signed by the physician. She said the DON and ADON would be educated on the completion and signature by physician for discharge summaries this week. She said Resident #48 should have had a discharge summary completed and they were completing a 100% audit of all discharges for June 2024. She said there was a change in management on 07/01/24 and the staff were unable to access the previous records. She said the resident risk of a discharged resident with an incomplete discharge summary not signed by the physician was a Resident may not receive continued proper care. She said her expectation was all discharge summaries be completed timely. Record review of a facility policy titled, Discharge Summary/ Discharge Plan effective before 7/1/24 dated 2015 indicated 1. The entire discharge summary will be completed with each resident that discharges regardless of where they discharge to, or if they expire in house. For electronic discharge summaries, once completed, the DC summary will be printed on blue paper, a white copy made to be placed in the medical record and the original will be sent out for physician's signature. The white copy will remain in place until the signed original returns. Record review of a facility policy effective after 07/01/24 titled, Discharge Summary/ Discharge Plan dated 2015 indicated1. The entire discharge summary will be completed with each resident that discharges regardless of where they discharge to, or if they expire in house. For electronic discharge summaries, once completed, the DC summary will be printed on blue paper, a white copy made to be placed in the medical record and the original will be sent out for physician's signature. The white copy will remain in place until the signed original returns.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 4 errors out of 30 opportunities, resulting in an 13.33% percent medication error involving 2 of 4 residents reviewed for medication pass. (Residents #43 and #18) -LVN B failed to administer 2 scheduled medications (Metoprolol and Spironolactone) and 1 prn medication (clonidine) (all to treat high blood pressure) as ordered by the physician for Resident #43 -LVN C did not administer 1 scheduled medication (ascorbic acid 500mg) (used to treat wound healing) as ordered by the physician for Resident #18. This failure could place residents at risk for inaccurate drug administration resulting in decline in health and decreased quality of life. Findings included: 1. Record review of the face sheet dated indicated Resident #43 was a [AGE] year-old male admitted on [DATE]. His diagnoses included cerebral infarction (disrupted blood flow to the brain (stroke)), hypertension (elevated/high blood pressure), diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar), convulsions (burst of uncontrolled electrical activity between brain cells), and atrial fibrillation (a type of irregular heartbeat). Record review of an MDS dated [DATE] indicated Resident #43 had moderately impaired cognition with a BIMS score of 08 out of 15 and had diagnoses of hypertension and stroke. Record review of a care plan reviewed on 04/29/23 indicated Resident #43 was at risk for complications related to hypertension and included interventions of give medications as ordered and monitor/document/report prn any headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, or difficulty breathing (signs/symptoms of elevated blood pressure). During an observation and interview on 08/22/23 (Tuesday) at 07:27 a.m. LVN B administered medications to Resident #43. Prior to administering his medications she obtained vital signs of BP and P. She said his BP was elevated at 231/180 (normal BP level was 120/80). She then obtained his medications and administered hydralazine (medication used to treat high blood pressure) 50mg, Losartan (to treat high blood pressure) as well as his other medications and administered them with a glass of water. She did not ask the resident any questions about how he was feeling or anything else. Record review of the August 2023 physician order summary on 08/22/23 at 11:45 a.m. indicated Resident #43 was to also receive medications to help treat high blood pressure to include: Metoprolol 75 mg at 08:00 AM; Spironolactone 25 mg on Tuesdays, Thursdays, and Saturdays on Day; and a prn order for Clonidine 0.1 mg every 8 hours prn for BP 170/90 or greater. During a record review and interview on 08/22/23 at 11:55 a.m. with LVN B and the DON the August 2023 MAR for Resident #43 indicated he was to receive Metoprolol 75 mg at 08:00 AM, Spironolactone 25mg was to be administered on 08/22/23 on Day, and Clonidine 0.1 mg every 8 hours as needed for BP 170/90 or greater; there was no indication the medications were administered by LVN B. LVN B said she asked Resident #43 if he wanted his prn medication and he said no. The DON said a resident should not be asked if they want a prn blood pressure medication because the medication should be administered if the parameters warrant it to be given. 2. Record review of the face sheet dated 08/22/23 indicated Resident #18 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included hypertension (elevated/high blood pressure), vitamin deficiency, and gastroesophageal reflux disease (GERD) stomach contents leak backward from the stomach into the esophagus (food pipe)). Record review of an MDS dated [DATE] indicated Resident #18 had moderately impaired cognition with a BIMS score of 08 out of 15 and had diagnosis of vitamin deficiency. Record review of a care plan dated 03/08/23 indicated Resident #18 had vitamin deficiency with interventions including to give medications as ordered. During an observation and interview on 08/22/23 at 08:10 a.m. LVN C administered medications to Resident #18. Prior to administering her medications she obtained vital signs of BP and P. She said her BP was low at 94/42. She said because Resident #18's BP was below the parameters to administer the blood pressure medications she was to hold them.She then administered aspirin 325mg, Ducolax 5mg, Calcium 600mg + Vitamin D 5mcg, Cetirizine 10mg, Colace 100mg, Vitamin B12 1000mcg, Famotadine 20mg, Magnesium oxide 400mg, Miralax 17 gm with 5 ounces of water, multivitamin with minerals, Protonix 20mg, sodium chloride 1 gm, Vitamin D3 125mcg, zinc 50 mg, and Nitro Bid apply 2 inches to each leg. Record review of the August 2023 physician order summary on 08/22/23 at 11:25 a.m. indicated Resident #18 was to receive the medications administered by LVN C. The orders also indicated she was to receive ascorbic acid (Vitamin C) 500mg for wound healing. During a record review and interview on 08/22/23 at 11:35 a.m. with LVN C she said there was an order on the August 2023 physician orders dated 07/03/23 for Resident #18 to have ascorbic acid 500mg for wound healing. She said she did not see the ascorbic acid order on the August MAR for Resident #18. Reviewing the EMR MAR LVN C said it listed on the wrong MAR and was missed by the staff including her to administer the medication since the first of August. During an interview on 08/22/23 at 02:06 p.m. the DON said she expected all staff to administer medications as ordered by the physician. She said missed doses of the ascorbic acid ordered for wound healing could result in the wound not healing or worsening. An Administering Medications policy and procedure revised December 2012 indicated Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed In Accordance with Orders: 3. Medications must be administered in accordance with orders, including any required timeframe

Based on observation, interview, and record review the facility failed to ensure all drugs were stored in a locked compartment and not left on top of the medication cart for 1 of 3 medication carts (400 hall medication cart); failed to ensure expired medications were not stored with current medications for 1 of 3 medication carts (200 hall) and 1 of 1 medication room (Secured Unit); and medications of different routes were not stored together for 2 of 3 medication carts (400 hall and Secured Unit) observed for medication storage. -The facility did not ensure the 400 hall medication cart was secured and unable to be accessed by unauthorized personnel, residents, or visitors. -The facility did not ensure medications were not stored on top of the 400 hall medication cart when unattended. -The facility did not ensure expired medications were not accessible and available for use on the 200 hall medication cart and the Secured Unit medication room. -The facility did not ensure medications of different routes were not stored together on the 400 hall medication cart and the Secured Unit medication cart. These failures could place residents at risk for not receiving drugs and biologicals as needed, medications being used past their effective or expiration date, and drug diversion. Findings include: 1. During an observation on 08/22/23 at 7:27 a.m., LVN B performed FSBS and drew up insulin to administer to Resident #43. LVN B left the 400 hall medication cart outside of the resident room with the drawers facing the hallway, the cart was unlocked, and a vial of Lantus insulin was left on top of the cart while she entered the resident room and administered his insulin. LVN B was in the resident's room with her back to the doorway. LVN B then went back to the medication cart and obtained Resident #43's medications. LVN B again she left the medication cart outside of the resident room with the drawers facing the hallway, the cart was unlocked, and a vial of Lantus insulin was left on top of the cart while she entered the resident room and administered his insulin. LVN B was in the resident's room with her back to the doorway. During an interview on 08/22/23 07:45 a.m. LVN B said she did not think leaving the insulin on top of the cart unlocked was an issue because the medication cart was within her eyesight, and it was at the end of the hall. She said she forgot to lock the cart before walking away from it. During an interview on 08/23/23 at 01:10 p.m., the DON said medications were not to be left on top of medication carts and medication carts were to be locked when staff walked away from them because any confused resident or visitor could access the cart. 2. During an observation and interview on 08/23/23 at 10:50 a.m. of the 200-hall medication cart, the CN indicated there was a card of Allopurinol 100 mg with an expiration date of 05/23/23. The CN said expired medications should not be on the medication cart. During an interview on 08/23/23 at 01:10 p.m. the DON said expired medications were not to be on the medication carts available for use; they were to be pulled to be destroyed. 3. During an observation and interview on 08/23/23 at 11:15 a.m. of the 400-hall medication cart with the CN indicated there was a box of acetaminophen 650mg rectal suppositories and an enema stored with oral medications. The CN said the rectally administered items should not be stored with oral medications; they should be stored separately. During an observation and interview on 08/23/23 at 11:40 a.m. of the Secured Unit medication cart with the CN indicated a bottle of nitroglycerin oral medication, a box of Exelon topical patches, and a vial of Vitamin B-12 injectable medication were stored together in the top drawer of the medication cart. LVN D said she did not know the medications were not supposed to be stored together on the cart. During an interview on 08/23/23 at 01:10 p.m. the DON said medications of different routes should not be stored together on the medication carts. 4. During an observation and interview on 08/23/23 at 01:55 p.m. of the Secured Unit medication room with LVN D indicated a box of prescribed promethegan suppositories expired 11/2022. LVN D said expired medications should be pulled to be destroyed and not available for use. An Administering Medications policy and procedure revised December 2012 indicated Safety of Medication Cart 16. During administration of medications, the medication cart will be kept closed and locked when out of the sight of the medication nurse of aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to resident or others passing by A Storage of Medications policy and procedure revised April 2007 indicated Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: Unusable Drugs or Biologicals 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed Marking Drugs for External Use/Poisons: 4. Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications Orderly Storage and Dispensing: 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems

Based on observation, interview, and record review the facility failed to maintain infection control prevention and practices for point of care equipment by 3 of 3 LVNs reviewed for infection control. (LVN A, LVN B, and LVN C) * The facility failed to ensure LVN A, LVN B, and LVN C cleaned and disinfected glucometers appropriately after resident use. This failure could place residents at risk of infections or diseases from blood borne pathogens. Findings included: 1. During an observation and interview on 08/21/23 at 10:55 a.m. LVN A pulled a glucometer out of the top drawer of the medication cart. She cleaned the glucometer with a wipe from a red topped container for less than a minute. She performed a FSBS test on a resident. She then cleaned the glucometer again with the wipe from the red topped container and cleaned the glucometer for less than a minute and placed the glucometer into the top drawer of the medication cart. LVN A said she would not have done anything differently. 2. During an observation and interview on 08/21/23 at 11:20 a.m., LVN B pulled a glucometer out of the top drawer of the medication cart and did not clean the glucometer. She performed FSBS on a resident. Without cleaning the glucometer, she placed it in the top drawer of the medication cart. LVN B said she would not have done anything different. During an observation and interview on 08/22/23 at 07:27 a.m., LVN B pulled a glucometer out of the top drawer of the medication cart and did not clean the glucometer. She performed FSBS on a resident. Without cleaning the glucometer, she placed it in the top drawer of the medication cart. LVN B said she would not have done anything different. 3. During an observation and interview on 08/22/23 at 11:10 a.m., LVN C pulled a glucometer out of the top drawer of the medication cart and did not clean the glucometer. She performed FSBS on a resident. She then placed the glucometer on top of the medication cart. LVN C said she would not have done anything differently. LVN C said the glucometer was to be cleaned before and after the resident's FSBS was done. LVN C said the glucometer was supposed to be cleaned with an alcohol wipe. LVN C said she had been trained in the proper cleaning/disinfecting of a glucometer but did not remember all the steps to be done or what to clean with. LVN C pulled the red top container (Micro Kill +) on the medication cart out of the bottom drawer. She said the contact time on the container was 2 minutes for most pathogens so the glucometer needed to be cleaned for 2 minutes with the wipe before the next use. During an interview on 08/22/23 at 11:50 a.m., the DON said staff were to use the purple top container of wipes to clean the glucometers. She said staff staff were provided with 2 glucometers on each medication cart so that one was wrapped with the wipe while the other one could be used. She said the glucometers were to be cleaned before and after each resident use. An Obtaining a Fingerstick Glucose Level Policy and Procedure revised December 2011 indicated Equipment and Supplies: .3. Disinfected blood glucose meter (glucometer) Steps in Procedure: 3. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses 18. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice An undated manufacturer guide indicated on page 46 Cleaning and Disinfecting Your Meter and Lancing Device: 4. To clean your meter, clean the meter with one of the validated disinfecting wipes listed below Medline Micro Kill + Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipe's directions for use

Based on observation, interview, and record review, the facility failed to ensure the right to formulate an advance directive was provided for 1 of 4 residents reviewed for advanced directives. (Resident #7). - The facility did not have a valid OOH-DNR for Resident #7. This failure could place residents at risk of lifesaving procedures performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state. Findings included: 1. Record review of a face sheet dated 05/10/23 indicated Resident #7 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included high blood pressure, progressive disease that destroys memory and other important mental functions, and loss of cognitive functioning. She was designated as DNR. Record review of the current MDS dated [DATE] indicated Resident #23 was alert to person, place, and time with a BIMS of 99 indicating she was unable to complete the interview. Record review of physician orders for May 2023 indicated Resident #23 had an order dated 09/20/22 for DNR. Record review of the EMR for Resident #7 indicated a scanned OOH-DNR with physician signature dated 04/01/13 indicated the following: -Section B had nothing marked as to who the declarant was signing the OOH-DNR for the resident, -Section B had nothing marked as to why they are implementing the OOH-DNR, -Section B had no printed name of the Declarant signing the OOH-DNR and no date when they signed it, -#3 Witness Section had no date when it was signed by and no printed name for the 1st witness signature, and -#3 Witness Section had no date when it was signed by the 2nd witness signature. During an interview on 08/22/23 at 02:08 p.m. the DON said the OOH-DNR was incomplete like it was. She said the resident would be a full code because the OOH-DNR was null and void. She said it was hers and nursing responsibility to ensure the OOH-DNR was complete and accurate to be valid. Record review of the Out-of-Hospital Do-Not-Resuscitate Order nstructions for Issuing An OOH-DNR Implementation: The OOH-DNR Order may be executed as follows: Section B - If an adult person is incompetent or otherwise mentally or physically incapable of communication and has either a legal guardian, agent in a medical power of attorney, managing conservator, or a qualified relative, the guardian, agent, a qualified relative, or parent of a minor child may execute the OOH-DNR Order by signing and dating it in Section B . In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in section B.

Based on interview and record review, the facility failed to ensure individuals identified with MI, DD or ID were evaluated for 1 of 6 residents reviewed for PASRR (Resident #3) The facility did not have an accurate PASRR level 1 screening for Resident #3. This failure could place residents who have a diagnosis of mental disorder, developmental disability or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Record review of a face sheet dated 08/21/23 indicated Resident #3 admitted [DATE], and readmitted [DATE] was an [AGE] year-old female, with diagnoses of major depressive disorder (mental disorder characterized by persistent hopelessness, disinterest in and lack of enjoyment of normal activities, and prolonged sadness that affects people on a daily basis and can be recurring) and anxiety (intense, excessive, and persistent worry and fear about everyday situations) Record review of PASRR level 1 screening completed by the transferring facility dated 05/15/22 indicated Resident #3 was negative for mental illness, intellectual disability, and developmental disability. No PASRR Level II (PE) Screening or form 1012 (Mental Illness/Dementia Resident Review) was found in the clinical record from 05/18/22 through 8/21/23. Record review of an annual MDS dated [DATE] indicated Resident #3 had a BIMS score of 11 indicating she had moderately impaired cognition, was negative for PASRR, and had a diagnosis of depression and received medication for depression 7 of 7 days. Record review of a care plan revised 03/21/23 indicated Resident #3 was currently taking psychotropic medication for depression and anxiety and required monitoring for side effects, behaviors, and mood problems. Record Review of physician orders dated August 2023 indicated Resident #3 had a diagnosis of major depressive disorder. The orders indicated Resident #3 was prescribed Remeron (an antidepressant medication) 15 mg daily for major depressive disorder with a start date of 02/26/23; sertraline (a medication to treat depression and anxiety) 100 mg at bedtime for depression related to major depressive disorder with a start dated of 02/26/22; and buspirone (an antianxiety medication) 10 mg three times a day for anxiety with a start date of 07/18/23. During an interview on 08/21/23 at 2:06 p.m., the MDS nurse said she was responsible for PASRR forms. She said when the facility had a social worker the social worker would help with PL1s. She said no one double checked the PASRR forms. The MDS nurse said she received education on PASRR including webinars and training with the most recent training in May or June 2023. The MDS nurse said Resident #3's PL1 was negative and should have been corrected. She said it was missed. The MDS nurse said she reviewed the residents' admission documentation and diagnoses to ensure the PL1s were correct. She said the risk of an incorrect PL1 was a resident may not receive needed services. During an interview on 08/21/23 at 2:12 p.m., the DON said Resident #3's PL1 was negative and should have been positive. She said it was just missed. The DON said the MDS nurse was responsible for PASRR forms. She said the MDS nurse was educated on completing PASRR forms. The DON said her expectation was PASRR form be completed correctly and timely. She said the risk of an incorrect PL1 was a resident could miss needed services. During an interview on 08/22/23 at 12:14 p.m., Corporate Nurse F said the facility did not have a policy on PASRR, they followed best practice and the RAI. During an interview on 08/22/23 at 2:30 p.m., the administrator said the MDS nurse was responsible for making sure the PL1 was correct and uploaded into the system. She said her expectation was for all residents to receive the required services. She said Resident #3's PL1 was just missed. The administrator said she expected PASRR forms to be completed timely and correctly. She said the potential risk was a resident might not receive services they deserved. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual titled, A1500: Preadmission Screening and Resident Review (PASRR) Item Rationale Health-related Quality of Life indicated . o All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD), or related conditions o Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State.

Based on interviews and record review the facility failed to have a final summary of the resident's status at the time of the discharge that is available for release to authorized persons for 1 of 3 residents reviewed for discharge summary (Resident #50). The facility did not have a physician signed Discharge Summary within 20 business days after Resident #50 discharged from the facility and did not return. This failures could place discharged residents at risk for a lack of continued care and services. Findings included: Record review of the face sheet printed 08/23/23 indicated Resident #50 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. His diagnoses included diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar), benign neoplasm of cerebral meninges (non-cancer tumor that arises from the membranes that surround the brain), obstructive hydrocephalus (any condition that blocks the flow of fluid in the brain or spinal cord), hypertension (elevated/high blood pressure), and convulsions (burst of uncontrolled electrical activity between brain cells). The face sheet also indicated he was discharged to the hospital on 06/07/23. Record review of Nurse Notes indicated on 06/07/23 Resident #50 had with issues of penile swelling and pus drainage; he had an elevated potassium level of 6.9; and the physician ordered the resident to be sent to the hospital for evaluation. The ambulance arrived and the resident was sent to the hospital due to lab values. Record review of the EMR indicated Resident #50 had a Discharge Summary with effective date of 06/07/23. The form had no information filled out on it and was not signed by the physician. During an interview on 08/23/23 at 12:15 p.m. the DON said she and the MR staff were responsible for filling out the Discharge Summary reports and either sending or taking over to the physician office for him to sign. She said Resident #50 was sent and admitted to the hospital on 06/07/23. She said when she reviewed Resident #50's Discharge Summary it was blank and so she filled it out today and it was taken to the physician for him to sign. According to the Texas Administration Code S554.1202(4) The physician must: (4)write, sign, and date a physician's discharge summary within 20 working days of being notified by the facility of the discharge, except as specified in S19.1912(e) of this title (relating to Additional Clinical Record Service Requirements), if the resident has been temporarily discharged for 30 days or less, and readmitted to the same facility.

Based on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 13 residents reviewed for respiratory care and services. (Resident #29) The facility failed to administer the correct dose of oxygen to Resident #29. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: Record review of physician orders dated August 2023 indicated Resident #29, admitted [DATE], was [AGE] years old with a diagnosis of congestive heart failure (a chronic condition in which the heart does not pump blood adequately). The orders indicated the resident received oxygen at 3 liters per minute via nasal cannula continuously effective 05/01/22. Record review of the most recent MDS assessment dated [DATE] indicated Resident #29 was alert, oriented with a BIMS of 9 (indicates moderate cognitive impairment) and received oxygen therapy in the last 14 days. Record review of a care plan updated 08/02/23 indicated Resident #29 was short of breath with exertion/activity secondary to congestive heart failure. One of the interventions was to administer oxygen at 3L NC continuously. During the following observations, Resident #29's oxygen was administered at 4.5L NC. The resident's speech was garbled and was not comprehensible for interview. *on 08/21/23 at 9:43 a.m., *on 08/21/23 at 11:55 a.m., *on 08/22/23 at 9:35 a.m., *on 08/22/23 at 3:11 p.m., and *on 08/23/23 at 9:42 a.m. During observation and interview on 08/23/23 at 9:42 a.m., after observing Resident #29's oxygen setting, LVN C said Resident #29's oxygen was in progress via NC at 4.5 L NC. She said the resident's oxygen should be set at 3L NC and the resident received the incorrect dose of oxygen. She said she was responsible for checking to ensure the resident received the correct dose, but she had not checked it. She said the possible negative outcome of the resident receiving oxygen at 4.5L could be the resident would receive too much oxygen and it would cause increased confusion. During an interview on 08/23/23 at 10:00 a.m., the DON said her expectations were for the oxygen to be administered as prescribed. She said administering too high of a dose of oxygen could cause Resident #29 to become dependent on it. She said it was the charge nurses' responsibility to check the resident's oxygen dosage to ensure they received the correct dose, and they should be checking it every shift. Record review of an Oxygen Administration policy revised October 2010 indicated: . Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 2 residents (Resident #43) reviewed for significant medication errors. -LVN B failed to administer 2 scheduled medications (Metoprolol and Spironolactone) and 1 prn medication (clonidine) (all to treat high blood pressure) as ordered by the physician for Resident #43 when his blood pressure was elevated at 231/180. This failure could place residents at risk of not receiving the therapeutic effect of the mediations and could result in declining health status. Findings included: Record review of the face sheet dated indicated Resident #43 was a [AGE] year-old male admitted on [DATE]. His diagnoses included cerebral infarction (disrupted blood flow to the brain (stroke)), hypertension (elevated/high blood pressure), diabetes mellitus type 2 (chronic condition that affects the way the body processes blood sugar), convulsions (burst of uncontrolled electrical activity between brain cells), and atrial fibrillation (a type of irregular heartbeat). During an observation and interview on 08/22/23 (Tuesday) at 07:27 a.m. LVN B administered medications to Resident #43. Prior to administering his medications, she obtained vital signs of BP and P. She said his BP was elevated at 231/180 (normal BP level was 120/80). She then administered Hydralazine (medication used to treat high blood pressure) 50mg, Jardiance (to treat elevated blood sugar) 25mg, Eliquis (to treat a type of irregular heartbeat) 5 mg, Keppra (to treat seizures (a burst of uncontrolled electrical activity between brain cells)) 750mg, Losartan (to treat high blood pressure) 100mg, Metformin (to treat elevated blood sugar) 1000mg, and Vitamin D3 (to treat vitamin deficiency) 125mcg with a glass of water. She did not ask the resident any questions about how he was feeling or anything else. Record review of the August 2023 physician order summary on 08/22/23 at 11:45 a.m. indicated Resident #43 indicated Resident #43 was to receive medications to help treat high blood pressure to include: Metoprolol 75 mg at 08:00 AM; Spironolactone 25 mg on Tuesdays, Thursdays, and Saturdays on Day; and a prn order for Clonidine 0.1 mg every 8 hours prn for BP 170/90 or greater. These medications were not administered to the resident. During a record review and interview on 08/22/23 at 11:55 a.m. with LVN B and the DON the August 2023 MAR for Resident #43 indicated there was no indication the Metoprolol, Spironolactone, or Clonidine were administered by LVN B on the eMAR. LVN B said she asked Resident #43 if he wanted his prn Clonidine and he said no. She said she did not realize she missed the Metoprolol and Spironolactone. The DON said a resident should not be asked if they want a prn blood pressure medication when their blood pressure level was elevated and required the medication per orders and parameters. The DON said not administering the blood pressure medications could result in the resident having a stroke or dying. An Administering Medications policy and procedure revised December 2012 indicated Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed In Accordance with Orders: 3. Medications must be administered in accordance with orders, including any required timeframe

Based on observation, interview, and record review the facility failed to ensure the right to be free from abuse was provided for 3 of 5 residents reviewed for abuse. (Resident #s 1, 2, and 3) The facility did not prevent Resident #1, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was seen walking out of Resident #2's room. Resident #1 had blood on his thumb. Resident #2 was found with blood in her brief. Resident #1 was heard trying to get Resident #3 to go to his room. An Immediate Jeopardy (IJ) situation was identified on 9/3/22 at 2:59 p.m. While the IJ was removed on 9/4/22, the facility remained out of compliance at no actual harm with a potential for more than minimal harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, emotional distress, and death. Findings included: Record review of the facility's Abuse Prohibition Guideline dated 2022 indicated : .will ensure a safe environment for residents by prohibiting physical and mental abuse including involuntary seclusion, neglect, exploitation and misappropriation of property . E. Sexual Abuse is defined as non-consensual contact of any type with a resident, includes but is not limited to any unnecessary touching or exposure of the resident's breast or any part of the genitals without voluntary, informed consent and with the intention to arouse or gratify the sexual desire of any person. This definition is to include sexual harassment, sexual coercion, or any sexual assault. Prevention: 3. Residents identified as exhibiting abusive behaviors will be assessed and appropriate interventions included in the plan of care. 4.staff will immediately report and protect the resident if an allegation or observation of abuse has occurred. Protection: 1. All residents will be immediately protected from harm. 3. Allegations involving residents will necessitate assessment and interventions appropriate to protect the victim which may include a. temporary one on one supervision. b. transfer to another level of care. c. discharge home or to a family member/responsible party. Record review of face sheet dated 9/4/22, indicated Resident #1 was a [AGE] year-old male, admitted on [DATE] and his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MDS dated [DATE], indicated Resident #1 had moderate cognitive impairment, ambulated with a walker. He had Other behavioral symptoms not directed toward others which occurred 1 to 3 days. Resident #1 did not exhibit any wandering behaviors. Record review of Resident #1's care plan dated 04/11/22 indicated he displayed socially inappropriate behavior and inappropriate sexual gesture with a female resident. Interventions included 15-minute monitoring and sent out to behavioral hospital for evaluation and treatment. 5/6/22 Care plan meeting held with RP & ombudsman. Aware that any inappropriate behaviors would be immediate discharge. Record review of August 2022 behavior monitoring indicated Resident #1 did not display any behaviors. Record review of September 2022 behavior monitoring indicated Resident #1 was 8 - redirected on the 6:00 p.m. - 6:00 a.m. shift. Record review of face sheet dated 9/4/22, indicated Resident #2 was a [AGE] year-old female, admitted on [DATE], and her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MDS dated [DATE] indicated Resident #2 had severely impaired cognitive skills for daily decision making, had physical behaviors which occurred last 4 to 6 days but not daily, wandered last 4 to 6 days and used a wheelchair for mobility. Record review of face sheet dated 9/4/22, indicated Resident #3 was a [AGE] year-old female, admitted on [DATE], and her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MDS dated [DATE] indicated Resident #3 had severe cognitive impairment, had no behaviors, and used a wheelchair for mobility. Record review of care plan dated 12/30/21 indicated Resident #3 required placement on the secure unit due to wandering and significant safety awareness due to dementia. Interventions included assist with location of room with verbal cues, notify physician if behavior increases (1/18/22- in and out of other residents' rooms, at times will take things out of other residents' rooms, 2/6/22 altercation with another resident, 2/11/22 attempted to take another resident's walker, 4/11/22 victim of inappropriate sexual gesture). During an observation on 9/3/22 at 9:43 a.m. with the DON, who verified staff and residents on the secure unit, of the facility's camera recordings on 9/1/22 from 6:16 p.m. to 7:28 p.m. indicated: At 7:18 p.m. Resident #1 walked out of his room using his walker and stood near the common area. At 7:21 p.m. CNA A went into Resident #3's room and closed the door. At 7:23 p.m. LVN B left the secure unit, leaving no staff to monitor residents. At 7:24 p.m. Resident #1 walked to his room and leaned against the wall in the hallway. At 7:25 p.m. Resident #1 walked across the hall into Resident #2's room. At 7:27 p.m. CNA A left Resident #3's room and walked down the hall. She looked in Resident #1's room and then continued to a closet on hall. At 7:28 p.m. Resident #1 walked out of Resident #2's room. During an observation on 9/3/22 at 11:20 a.m., Resident #2 was in her bed. There were no visible injuries in her periarea. She had a scab on her right 3rd toenail. Resident #2 was non-verbal and not able to answer questions. She did not appear afraid. Record review of progress note dated 04/11/22 at 4:08 p.m., completed by LVN L, indicated CNA F heard Resident #3 scream no don't do that when she entered the room. The door was open and she witnessed Resident #1 standing behind Resident #3. Resident #1 was holding on to Resident #3 with one hand, his pants were down and he was exposed. Resident #3's pants were down and she was exposed. Record review of In-service training for CNA A on 7/12/22 and LVN B on 8/22/22 indicated they were trained on Supervision & Monitoring of hall 3 secure unit .There must be hallway monitor in hall 3 at all times-especially when wandering residents or residents at high risk for adverse behaviors are active. One CNA or other staff is to stay in hallway & be alert for residents wandering into other resident's rooms. CNA's can take turns being hall monitor and if a resident requires two CNA's for care there must be a nurse or other staff member to fill hall monitor roll. Record review of a progress note dated 8/31/22 at 9:00 p.m., completed by LVN B, indicated Resident #1 asked an unidentified aide if he could have her while making rounds. Record review of a progress note dated 9/1/22 at 10:23 a.m., completed by LVN D, indicated Resident #1 was noticed standing at his door looking into the hallway masturbating. The CNA that saw this told him to go to his room, to his bed to do that and he cannot do it outside of his room. After this occurred, he also was asking a female resident to come into his room. The CNA heard this and told him to stop asking female residents to his room, he said OK. Later that day he was seen looking in on female resident lying in bed and redirected by CNA. Record review of a progress note completed by LVN B dated 9/1/22 at 7:37 p.m. indicated Resident #1 was found in Resident #2's room by aide and was asked to leave the room. Aide on the hall called for another nurse to come into the unit to assess the residents. This resident (#1) was found with blood on his left thumb by other nurse. Other nurse asked this resident not to wash his hands so that she could take a picture while she was on the phone with the DON. This nurse was in the room assessing resident #2, found blood in resident #2's brief and around the vaginal and rectal area. DON notified. Record review of an incident report dated 9/1/22, prepared by the DON, indicated alleged by a staff nurse that this resident (Resident #1) went into a female resident room and allegedly touched her inappropriately. Record review of a progress note dated 9/2/22 at 7:10 a.m. completed by the DON indicated Incorrect charting with staff education provided: resident confidentiality, charting of facts and not assumptions, and charting incorrect chart. This nurse was at facility for assessment of this resident and concern. This charting is not fact. Record review of a progress note dated 9/2/22 at 12:28 p.m. completed by the DON indicated Resident (#1) has been referred to behavioral hospital related to his inappropriate behaviors this week. This nurse spoke with LVN at behavioral and all paperwork sent to her. Residents RP is aware of referral. Resident is agreeable to go to behavioral if accepted. Record review of a progress note dated 9/1/22 at 7:56 p.m. completed by LVN B indicated Resident #2 found with blood in her brief and on her peri area after Resident #1 left her room. Resident also has dried blood on the bed. DON notified. Assessed resident and she does not appear in any pain at this time. During an interview on 9/3/22 at 8:48 AM, RN J asked surveyors if they were at the facility for the incident. When asked which incident, RN J said the incident with Resident #1. She said he had another incident and thinks it was sexual. She said she did not know the details. She said she thought resident #1 was on 15-minute checks and thought the incident had been reported to the state agency. She was the DON in April 2022 when Resident #1 was found with Resident #3. During an interview on 9/3/22 at 8:50 a.m., CNA F said Resident #1's supervision level was 15 minutes checks. She said the 15 minutes checks had been discontinued (unknown date) and then started back on 9/1/22 due to his behaviors. She said he was sexually inappropriate. She said he would masturbate in the doorway of his room. She said there was supposed to be someone in the hallway at all times to monitor residents and ensure Resident #1 did not wander into other female residents' rooms. She said there was only one CNA assigned to the secure unit from 6:00 p.m. through 6:00 a.m. and the nurse worked multiple halls. She said she was not supposed to leave the hall to do care if there was no staff to monitor the hall. She said there was not a dedicated staff to monitor the hall after 6:00 p.m. She had been trained on abuse and neglect. During an interview on 9/3/22 at 8:59 a.m., CNA G said she was aware of Resident #1's sexually inappropriate behaviors. She said there was always supposed to be a staff on the hall to supervise the residents and ensure Resident #1 did not go into other residents' rooms. During an interview on 9/3/22 at 9:00 a.m., CNA H said there was always supposed to be a staff in the hallway of the secure unit to monitor residents and to ensure Resident #1 did not go into female resident rooms. During an interview on 9/3/22 at 9:24 AM, the DON said resident #1 was having inappropriate sexual behaviors like masturbating in the hall and saying inappropriate things to staff. The nurses called her around 7 PM on Thursday night and said Resident #1 was seen coming out of resident #2's room. She was told there was blood on Resident #2's sheet. She was told LVN C had seen blood on resident #1's thumb. CNA A said there was blood in the middle of Resident #2's bed. She said she took a flashlight to Resident #2's room to assess the resident in order to see any tears in the periarea. She said she did not see any blood or tears in Resident #2's private area. She said Resident #2 had feces and urine in her brief. She said there was a toenail that had been ripped off and assumed that was where the blood had come from on the bed. She said the staff jumped to conclusions about sexual abuse. She did not think Resident #2 was sexually abused because the blood had come from the toenail and she did not see any blood, just brown feces in the brief. She said Resident #2 was not able to answer any questions. The DON said Resident #1 was sent to a behavior hospital on 9/2/22 due to his increased sexual behaviors. She said she did not report to the state agency or to the police because she did not think there was any sexual abuse. She said she documented in the progress notes about incorrect documentation from the LVN B who thought Resident #2 had been abused. During an interview on 9/3/22 at 9:44 AM, the DON said the nurse was supposed to be on the secure unit when the aide was working in a room so there would be somebody monitoring the hall. During an interview on 9/3/22 at 10:32 a.m., LVN D said she was the charge nurse on the secure unit. She said Resident #1 had been placed on every 15-minute checks on 9/1/22 due to having increased sexual behaviors. She said he had been on 15-minute checks after the incident with Resident #3 in April 2022, but they had been stopped because he had not been having any sexual behaviors. She said there was supposed to be someone monitoring the hall to keep residents from wandering into other resident rooms. During an interview on 9/3/22 at 11:35 AM, LVN B said she saw blood in resident #2's brief and near the resident's buttocks on the evening of 9/1/22. She said CNA A also saw the blood. LVN B she was not told someone was to be monitoring the halls prior to the incident on 9/1/22. She was aware of Resident #1 having a previous sexual incident but said he was not on any special supervision prior to 9/1/22. During an interview on 9/3/22 at 12:34 PM, LVN C said she saw resident #1 with blood on his left thumb. When asked if she was sure it was blood, she said she was 100% sure it was blood on his thumb. She said she saw resident #2's brief pulled to the side when CNA A asked her to look. CNA A thought the brief looked out of place. When she asked Resident #1 why he had blood on his thumb, he said I don't know, I don't know. During an interview on 9/3/22 at 2:42 PM CNA A said Resident #2's brief was not centered. She said she saw blood on the sheets and began to look to see where the blood came from. She decided to change resident #2's brief. When she pulled the front down off the Resident, she saw the blood and ran to get the nurse. She said she did not change the resident until the DON arrived. She was not sure what time the DON got to the facility but thought it was about an hour or so after the incident. CNA A said she saw blood on resident #2's private area too. She said the DON said there was no blood on the resident when she arrived later that evening. She said it was still red when the DON got to the facility. CNA A said she knew they were supposed to have a monitor on the hall, but the nurse wasn't always on the hall when she needed to provide care. Resident #1 had been in the hall when she started her rounds and LVN B was still on the hall. CNA A said she had only worked at the facility since the end of July. She said a few days after she started working at the facility Resident #1 asked her if he could lick it, referring to her private area. She said CNA F told her Resident #1 was trying to coax Resident #3 into his room and they started 15-minute checks on 9/1/22. During an interview on 9/3/22 at 3:27 p.m., CNA K, who works the day shift, said the weekend prior (8/27/22 or 8/28/22) to the incident of Resident #1 going into Resident #2's room, she notified the charge nurse Resident #1 was looking into Resident #2's room and asked Resident #3 if she would go to his room. She said she thought the nurse was an agency nurse and could not recall her name. She said she told LVN D of the incident on 9/01/22. She said Resident #1 was put on 15 minutes checks. She said Resident #1 was taken off previous 15-minute checks but started to act weird and not his usual self. He was staring at Resident #2 when she was in her room. She said there was supposed to be one staff monitoring the hall of the secure unit at all times to ensure Resident #1 did not exhibit inappropriate sexual behaviors (masturbating) or go into other residents' rooms. During an interview on 9/4/22 at 11:16 a.m., the interim administrator said the DON was the abuse coordinator until a permanent administrator was hired. He said he was not told there was any allegation of sexual abuse involving the two residents. He only was told Resident #1 was in Resident #2's room and there was blood on her sheets. During an interview on 9/4/22 at 1:43 p.m., NP E said she was the NP for Resident #1. She said she told the facility not to take Resident #1 back when he had gone to the behavior hospital in April 2022 due to his sexual behaviors. She said the nurse from the secure unit sent a fax to the office on 9/1/22 informing her of the incident with Resident #1 and #2. She said she saw the fax on 9/2/22. NP E said she was not scheduled to be at the facility on 9/2/22 but felt she needed to visit the facility to find out more about the incident. She said when she got to the facility, the DON told her nothing had happened between the residents. She said if the facility was not able to meet the needs of Resident #1. She said if the facility took him back, she would be giving the resident a 30-day discharge and he would need to find another physician. During an interview on 9/4/22 at 1:50 p.m., the DON said all staff were trained on monitoring the hallway on the secure unit at the time of the previous incident with Resident #1 and then all new hires received the training at time of hire. The facility was notified of the Immediate Jeopardy on 9/3/22/22 at 2:59 p.m. and the DON was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 9/4/22 at 11:59 a.m. and reflected the following: Please accept the following plan of removal: 1. Notify V.P of Clinical Operations of immediate Jeopardy status - Done- 09/3/22@ 3:16 PM per DON 2. Notify Regional Director of operations of Immediate Jeopardy status - Done -09/03/22@ 3:24 PM per DON. 3. Notify facility Medical Director of Immediate Jeopardy status- Notified via E-mail by DON on 09/03/22 @ 6:59 PM. 4. Initiate report of incident to HHSC. Done 09/03/22@ 3:42 per DON. 5. Notify Kirbyville Police Department of incident. Done 09/03/22 @ 5:15 PM Per DON. 6. Resident #1-Was immediately placed on 15 minute beginning @ 1040AM on 09/01/22. Attending MD /Designee were notified on 9/1@ 10:40 AM. Responsible party were notified on 9/1 @ 10:40 AM. Medication orders were received on 9/1 @ 1040 AM for [MEDICATION(S)] 0.3 MG Daily and initiated on 9/1 @ 11AM. He remained on 15 minute monitoring until transferred to a Behavioral Hospital @ 5:06 PM on 9/2. He remains at a behavioral hospital at time of this report. Regarding resident #1 -A meeting to discuss Resident #1's readmission status to the facility will be scheduled and conducted with representatives to include ADM, Behavior Hospital, Ombudsman, Responsible Party, Med Dir, PCP, Psyche Services NP, Ombudsman and facility IDT committee. If Resident #1 returns to the facility, he will be placed on 1:1 monitoring until status is determined. 7. Resident #2 was assessed by facility DON on 9/1 @ 8:30 PM with no visible injuries noted. She was calm. Attending MD /Designee were notified on 9/2 @ 4:59 AM. Responsible party was notified on 9/2@ 4:59AM. 8. Residents who reside on the secure unit have had skin assessments completed by the Treatment Nurse for any unidentified concerns with zero concerns identified. Initiated 9/3 @ 630 PM by DON. Completed 9/3 @ 845 PM by Treatment Nurse. 9. Residents who reside on the secure unit were evaluated for any physical aggressive behaviors with none identified. Initiated 9/3/22 @ approximately 6PM by DON. Completed 9/3/22 @ 7:45 PM by DON. Care plans for Residents #1 and #2 were updated to reflect identified event and interventions were reviewed /updated if indicated 10.Facility staff were provided education by DON/Designee on: 10a) Procedures for Inappropriate Resident to Resident touching and /or Sexually Inappropriate Behaviors. Staff were instructed to separate and protect the residents. Evaluate residents involved for any injury, pain or emotional impact. Notify MD, Responsible party, DON and ADM promptly. Initiate monitoring or increased supervision if indicated and document interventions. Initiated 9/3/22 @ 6PM and completed at 7:30 PM. 36 attendees. Follow-up sessions will resume on 9/4/22. 10b) Supervision and Monitoring of Hall 3/Secure Unit. Discussion of procedures to be utilized to facilitate monitoring of unit by staff. Staff were instructed that one staff member would be responsible for being stationed in the hallway to monitor Residents in the hallway while care is being provided in other areas of the unit by another staff member. The staff member in the hallway is to monitor Residents for any wandering into other Residents' rooms or inappropriate behavior and provide redirection or request assistance from other staff if needed. Staff were educated to communicate their location with each other when leaving the unit or going into an unobserved area (i.e. Resident's room, shower, etc) to make sure the other staff member is aware of need to be on hallway monitoring duty during that time period. Staff can rotate the roles as needed to complete tasks and maintain monitoring. If two staff are required for Resident cares, then a nurse or other staff member must be in place to provide hall monitoring role. Staff were advised to call for assistance from staff outside unit if needed for additional monitoring assistance if needed. Notify DON or ADM of any concerns promptly. Initiated on 9/3/22 @ 6pm, completed 7:30 PM. 36 attendees. Follow-up sessions will resume on 9/4/22. 10c) Resident to Resident Altercations - Interventions and approaches to be implemented. Evaluate for any injuries or psychosocial impact. Increase supervision if indicated. Notify MD, Responsible party and DON/ADM promptly. Initiated 9/3/22 @6 pm, completed 7:30 PM. 36 attendees. Follow-up sessions will resume on 9/4/22. 10d) Abuse-Content. Abuse Coordinator - contact #s and the facility Abuse Prohibition Guideline. Initiated 9/3/22 @ 6pm, completed 7:30 PM. 36 attendees. Follow-up sessions will resume on 9/4/22. The DON is the Abuse Coordinator. 11. Staff who were not on duty will be notified, to come to the facility for education by the DON/designee. No staff will be allowed to work on the floor until education has been completed for items 10a-10d. Administrator, DON, and MDS Coordinator will monitor for employee completion of required education topics. Administrator, DON, MDS Coordinator and HR Director will conduct audits of current facility employees and indicate completion dates for required education. Staff are being notified to report to facility for education completion via phone and texts. Notifications started on 9/3/22 @ 5PM and are continuing 9/4/22. Administrator, DON and MDS Coordinator will continue to audit, notify and provide education items until all employees have completed the requirement. 12. Safe surveys were conducted for Residents on the secure unit who could be interviewed and reside in the facility general population area with no safety or abuse concerns identified. Initiated 9/3/22 @ 6pm per social worker. Completed 9/3/22 @ 7:15PM per Social Worker. 8 Residents interviewed. 14. Facility Administrator and the DON were provided education on compliance and monitoring procedures. The facility Abuse Prohibition Guide was reviewed and discussion on investigation and reporting processes reviewed. Education provided by VP of Clinical Operations. Initiated 9/3/22 @ 9PM, completed @ 9:30PM. On 9/4/22, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Observations, interviews, and record reviews were conducted on 9/4/22 from 12:00 p.m. through 3:35 p.m. and included 5 alert residents, 5 nurses including 1 RN, 4 LVNs, and 4 CNAs (who work all shifts), SW, and DON. Staff were able to identify inappropriate resident to resident touching and reporting procedures, supervision/monitoring on the secure unit, resident-resident altercations, and who the abuse coordinator was. Staff provided appropriate resident supervision and redirection. There were no observed concerns. Staff were able to discuss the required supervision and monitoring of Hall 3/Secure Unit. Staff were able to identify the Abuse Coordinator, indicated reporting was immediate to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. Staff were able to give examples of behavior monitoring on unit 3/secure unit. Staff were able to give examples of resident-to-resident touching and/or sexually inappropriate behaviors. Resident #1 remained at the behavioral hospital. Record review of his care plan was updated to reflect the incident. Resident #2 did not appear in distress and did not recall the incident. Record review of her care plan indicated it was updated to reflect the incident. Resident #3 did not appear in any distress. The in-services/staff training provided by the DON/Designee included: Inappropriate Resident to Resident touching and reporting procedures. Supervision and Monitoring of Hall 3/Secure Unit. Content discussed and procedures discussed to facilitate monitoring of unit. Staff were educated that one staff would be monitoring Residents and the hallway on Hall 3 while care is being delivered by the other staff member. Staff were instructed to take turns with these roles and to notify the nurse if additional monitoring assistance is needed. Abuse-Content Abuse Coordinator - contact #s and the facility Abuse Prohibition Guideline. Facility staff were provided education by DON/Designee on: Behavior Assessment, Intervention and Monitoring and Unmanageable Residents. Facility staff were provided education by DON/Designee on resident to resident altercations, content including reporting procedures, interventions, and documentation procedures. Staff who were not on duty were notified to come to the facility for education by the DON/designee. All staff working in the facility were educated. Administrator, DON and MDS Coordinator indicated they will continue to audit, notify, and provide education items until all employees have completed the requirement. Safe surveys were conducted for residents on the secure unit and reside in the facility general population area with no safety or abuse concerns identified. No residents indicated they were afraid of any residents. The facility Administrator and the DON were provided education on compliance and monitoring procedures by V.P. Of Clinical Operations. On 9/4/22 at 4:05p.m., the interim Administrator was informed the IJ was removed; however, the facility remained out of compliance with no actual harm with a potential for more than minimal harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent abuse for 3 of 11 residents (Resident #s 1, 2, and 3) reviewed for supervision. The facility staff did not provide supervision to prevent Resident #1 from sexually abusing Resident #2 on 9/1/22. Resident #1 was seen walking out of Resident #2's room. Resident #1 had blood on his thumb. Resident #2 was found with blood in her brief. Resident #1 was heard trying to get Resident #3 to go to his room. An Immediate Jeopardy (IJ) situation was identified on 9/3/22 at 2:59 p.m. While the IJ was removed on 9/4/22, the facility remained out of compliance at no actual harm with a potential for more than minimal harm with a scope identified as an isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, emotional distress, and death. Findings included: 1. Record review of face sheet dated 9/4/22, indicated Resident #1 was a [AGE] year-old male, admitted on [DATE] and his diagnoses included adjustment disorder (emotional or behavioral reaction to a stressful event or change in a person's life), [CONDITION(S)] (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), cognitive communication deficit (difficulty with thinking and how someone uses language), and [CONDITION(S)] (a serious mental disorder in which people interpret reality abnormally). Record review of MDS dated [DATE], indicated Resident #1 had moderate cognitive impairment, ambulated with a walker. He had Other behavioral symptoms not directed toward others which occurred 1 to 3 days. Resident #1 did not exhibit any wandering behaviors. Record review of Resident #1's care plan dated 04/11/22 indicated he displayed socially inappropriate behavior and inappropriate sexual gesture with a female resident. Interventions included 15-minute monitoring and sent out to behavioral hospital for evaluation and treatment. 5/6/22 Care plan meeting held with RP & ombudsman. Aware that any inappropriate behaviors would be immediate discharge. Record review of face sheet dated 9/4/22, indicated Resident #2 was a [AGE] year-old female, admitted on [DATE], and her diagnoses included Alzheimer's (a progressive neurologic disorder that causes the brain to shrink (atrophy) and brain cells to die). Record review of MDS dated [DATE] indicated Resident #2 had severely impaired cognitive skills for daily decision making, had physical behaviors which occurred last 4 to 6 days but not daily, wandered last 4 to 6 days and used a wheelchair for mobility. Record review of face sheet dated 9/4/22, indicated Resident #3 was a [AGE] year-old female, admitted on [DATE], and her diagnoses included Alzheimer's (a progressive neurologic disorder that causes the brain to shrink (atrophy) and brain cells to die) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of MDS dated [DATE] indicated Resident #3 had severe cognitive impairment, had no behaviors, and used a wheelchair for mobility. Record review of care plan dated 12/30/21 indicated Resident #3 required placement on the secure unit due to wandering and significant safety awareness due to dementia. Interventions included assist with location of room with verbal cues, notify physician if behavior increases (1/18/22- in and out of other residents' rooms, at times will take things out of other residents' rooms, 2/6/22 altercation with another resident, 2/11/22 attempted to take another resident's walker, 4/11/22 victim of inappropriate sexual gesture). During an observation on 9/3/22 at 9:43 a.m. with the DON, who verified staff and residents on the secure unit, of the facility's camera recordings on 9/1/22 from 6:16 p.m. to 7:28 p.m. indicated: At 7:18 p.m. Resident #1 walked out of his room using his walker and stood near the common area. At 7:21 p.m. CNA A went into Resident #3's room and closed the door. At 7:23 p.m. LVN B left the secure unit, leaving no staff to monitor residents. At 7:24 p.m. Resident #1 walked to his room and leaned against the wall in the hallway. At 7:25 p.m. Resident #1 walked across the hall into Resident #2's room. At 7:27 p.m. CNA A left Resident #3's room and walked down the hall. She looked in Resident #1's room and then continued to a closet on hall. At 7:28 p.m. Resident #1 walked out of Resident #2's room. During an observation on 9/3/22 at 11:20 a.m., Resident #2 was in her bed. There were no visible injuries in her periarea. She had a scab on her right 3rd toenail. Resident #2 was non-verbal and not able to answer questions. She did not appear afraid. Record review of progress note dated 04/11/22 at 4:08 p.m., completed by LVN L, indicated CNA F heard Resident #3 scream no don't do that when she entered the room. The door was open and she witnessed Resident #1 standing behind Resident #3. Resident #1 was holding on to Resident #3 with one hand, his pants were down and he was exposed. Resident #3's pants were down and she was exposed. Record review of a progress note dated 8/31/22 at 9:00 p.m., completed by LVN B, indicated Resident #1 asked an unidentified aide if he could have her while making rounds. Record review of a progress note dated 9/1/22 at 10:23 a.m., completed by LVN D, indicated Resident #1 was noticed standing at his door looking into the hallway masturbating. The CNA that saw this told him to go to his room, to his bed to do that and he cannot do it outside of his room. After this occurred, he also was asking a female resident to come into his room. The CNA heard this and told him to stop asking female residents to his room, he said OK. Later that day he was seen looking in on female resident lying in bed and redirected by CNA. Record review of Resident #1's Q (every) 15 Min (minute) Monitoring indicated the facility began monitoring Resident #1 every 15 minutes beginning 9/1/22 at 10:45 a.m. Record review of a progress note completed by LVN B dated 9/1/22 at 7:37 p.m. indicated Resident #1 was found in Resident #2's room by aide and was asked to leave the room. Aide on the hall called for another nurse to come into the unit to assess the residents. This resident (#1) was found with blood on his left thumb by other nurse. Other nurse asked this resident not to wash his hands so that she could take a picture while she was on the phone with the DON. This nurse was in the room assessing resident #2, found blood in resident #2's brief and around the vaginal and rectal area. DON notified. Record review of a progress note dated 9/1/22 at 7:56 p.m. indicated Resident #2 found with blood in her brief and on her peri area after Resident #1 left her room. Resident also has dried blood on the bed. DON notified. Assessed resident and she does not appear in any pain at this time. Record review of a progress note dated 9/2/22 at 7:10 a.m. completed by the DON indicated Incorrect charting with staff education provided: resident confidentiality, charting of facts and not assumptions, and charting incorrect chart. This nurse was at facility for assessment of this resident and concern. This charting is not fact. Record review of a progress note dated 9/2/22 at 12:28 p.m. completed by the DON indicated resident has been referred to behavioral hospital related to his inappropriate behaviors this week. This nurse spoke with LVN at behavioral and all paperwork sent to her. Residents RP is aware of referral. Resident is agreeable to go to behavioral if accepted. During an interview on 9/3/22 at 8:48 AM, RN J asked surveyors if they were at the facility for the incident. When asked which incident, RN J said the incident with Resident #1. She said he had another incident and thinks it was sexual. She said she did not know the details. She said she thought resident #1 was on 15-minute checks and thought the incident had been reported to the state agency. She was the DON in April 2022 when Resident #1 was found with Resident #3. During an interview on 9/3/22 at 8:50 a.m., CNA F said Resident #1's supervision level was 15 minutes checks. She said the 15 minutes checks had been discontinued (unknown date) and then started back up due to his behaviors. She said he was sexually inappropriate. She said he would masturbate in the doorway of his room. She said there was supposed to be someone in the hallway at all times to monitor residents and ensure Resident #1 did not wander into other female residents' rooms. She said there was only one CNA assigned to the secure unit from 6:00 p.m. through 6:00 a.m. and the nurse worked multiple halls. She said she was not supposed to leave the hall to do care if there was no staff to monitor the hall. She said there was not a dedicated staff to monitor the hall after 6:00 p.m. During an interview on 9/3/22 at 9:24 AM, the DON said resident #1 was having inappropriate sexual behaviors like masturbating in the hall and saying inappropriate things to staff. The nurses called her around 7 PM on Thursday night and said Resident #1 was seen coming out of resident #2's room. She was told there was blood on Resident #2's sheet. She was told LVN C had seen blood on resident #1's thumb. CNA A said there was blood in the middle of Resident #2's bed. She said she took a flashlight to Resident #2's room to assess the resident. She said she did not see any blood or tears in Resident #2's private area. She said Resident #2 had feces and urine in her brief. She said there was a toenail that had been ripped off and assumed that was where the blood had come from on the bed. She said the staff jumped to conclusions about sexual abuse. She did not think Resident #2 was sexually abused because the blood had come from the toenail and she did not see any blood, just brown feces in the brief. The DON said Resident #1 was sent to a behavior hospital on 9/2/22 due to his sexual behaviors. During an interview on 9/3/22 at 9:44 AM, while viewing the video footage, the DON said the nurse was supposed to be on the secure unit when the aide was working in a room so there would be somebody monitoring the hall. She said she could see on the video, the halls were not being monitored when Resident #1 went into Resident #2's room between the 15-minute checks. During an interview on 9/3/22 at 10:32 a.m., LVN D said she was the charge nurse on the secure unit. She said Resident #1 had been placed on every 15-minute checks on 9/1/22 due to having increased sexual behaviors. She said he had been on 15-minute checks after the incident with Resident #3 in April 2022, but they had stopped because he had not been having any sexual behaviors. She said there was supposed to be someone monitoring the hall to keep residents from wandering into other resident rooms. During an interview on 9/3/22 at 11:35 AM, LVN B said she saw blood in resident #2's brief and near the resident's buttocks on the evening of 9/1/22. She said CNA A also saw the blood. LVN B she was not told someone was to be monitoring the halls prior to the incident on 9/1/22. She was aware of Resident #1 having a previous sexual incident but said he was not on any special supervision prior to 9/1/22. During an interview on 9/3/22 at 12:34 PM, LVN C said she saw resident #1 with blood on his left thumb. When asked if she was sure it was blood, she said she was 100% sure it was blood on his thumb. She said she saw resident #2's brief pulled to the side when CNA A asked her to look. CNA A thought the brief looked out of place. When she asked Resident #1 why he had blood on his thumb, he said I don't know, I don't know. During an interview on 9/3/22 at 2:42 PM CNA A said Resident #2's brief was not centered. She said she saw blood on the sheets and began to look to see where the blood came from. She decided to change resident #2's brief. When she pulled the front down off the Resident, she saw the blood and ran to get the nurse. She said she did not change the resident until the DON arrived. She was not sure what time the DON got to the facility but thought it was about an hour or so after the incident. CNA A said she saw blood on resident #2's private area too. She said the DON said there was no blood on the resident when she arrived later that evening. She said it was still red when the DON got to the facility. CNA A said she knew they were supposed to have a monitor on the hall, but the nurse wasn't always on the hall when she needed to provide care. Resident #1 had been in the hall when she started her rounds and LVN B was still on the hall. CNA A said she had only worked at the facility since the end of July. She said a few days after she started working at the facility Resident #1 asked her if he could lick it, referring to her private area. She said CNA F told her Resident #1 was trying to coax Resident #3 into his room and they started 15-minute checks on 9/1/22. During an interview on 9/3/22 at 3:27 p.m., CNA K, who works the day shift, said the weekend prior (8/27/22 or 8/28/22) to the incident of Resident #1 going into Resident #2's room, she notified the charge nurse Resident #1 was looking into Resident #2's room and asked Resident #3 if she would go to his room. She said she thought the nurse was an agency nurse and could not recall her name. She said she told LVN D of the incident on 9/01/22. She said Resident #1 was put on 15 minutes checks. She said Resident #1 was taken off previous 15-minute checks but started to act weird and not his usual self. He was staring at Resident #2 when she was in her room. She said there was supposed to be one staff monitoring the hall of the secure unit at all times to ensure Resident #1 did not exhibit inappropriate sexual behaviors (masturbating) or go into other residents' rooms. During an interview on 9/3/22 at 1:46 p.m., NP I said the facility notified him on 9/1/22 of Resident #1's increased behaviors. He said he advised the facility to contact Resident #1's physician and obtain a prescription for [MEDICATION(S)] (a female hormone). He said it would have prevented sexual urges. During an interview on 9422 at 12:53p.m., the SW said she was not aware of any incidents involving Resident #1. She said she should have been told and she would have done a mental health assessment. The SW said she was employed by the facility at the time of the previous incident in April 2022 with Resident #1 when he was found behind Resident #3 and both of them had their pants down. She said there had been a care plan meeting with Resident #1's family and ombudsman. She said they talked about Resident #1's sexual behaviors and if it happened again, he would be immediately discharged . She said it should be in the care plan. During an interview on 9/4/22 at 1:43 p.m., NP E said she was the NP for Resident #1. She said she told the facility not to take Resident #1 back when he had gone to the behavior hospital in April 2022 due to his sexual behaviors. She said the nurse from the secure unit sent a fax to the office on 9/1/22 informing her of the incident with Resident #1 and #2. She said she saw the fax on 9/2/22. NP E said she was not scheduled to be at the facility on 9/2/22 but felt she needed to visit the facility to find out more about the incident. She said when she got to the facility, the DON told her nothing had happened between the residents. She said if the facility was not able to meet the needs of Resident #1. She said if the facility took him back, she would be giving the resident a 30-day discharge and he would need to find another physician. Record review of the facility's Safety and Supervision of Residents policy revised July 2017 indicated Facility-Oriented Approach to Safety -1. Our facility-oriented approach to safety addresses risks for groups of residents . Individualized, Resident-Centered Approach to Safety - .2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. Systems Approach to Safety - 1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazard identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. W. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition. The facility was notified of the Immediate Jeopardy on 9/3/22/22 at 2:59 p.m. and the DON was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 9/4/22 at 11:59 a.m. and reflected the following: Please accept the following plan of removal: 1. Notify V.P of Clinical Operations of immediate Jeopardy status - Done- 09/3/22@ 3:16 PM per DON 2. Notify Regional Director of operations of Immediate Jeopardy status - Done -09/03/22@ 3:24 PM per DON. 3. Notify facility Medical Director of Immediate Jeopardy status- Notified via E-mail by DON on 09/03/22 @ 6:59 PM. 4. Initiate report of incident to HHSC. Done 09/03/22@ 3:42 per DON. 5. Notify Kirbyville Police Department of incident. Done 09/03/22 @ 5:15 PM Per DON. 6. Resident #1-Was immediately placed on 15 minute beginning @ 10:40AM on 09/01/22. Attending MD /Designee were notified on 9/1@ 10:40 AM. Responsible party were notified on 9/1 @ 10:40 AM. Medication orders were received on 9/1 @ 1040 AM for [MEDICATION(S)] 0.3 MG Daily and initiated on 9/1 @ 11AM. He remained on 15 minute monitoring until transferred to a Behavioral Hospital @ 5:06 PM on 9/2. He remains at a behavioral hospital at time of this report. Regarding resident #1 -A meeting to discuss Resident #1's readmission status to the facility will be scheduled and conducted with representatives to include ADM, Behavior Hospital, Ombudsman, Responsible Party, Med Dir, PCP, Psyche Services NP, Ombudsman and facility IDT committee. If Resident #1 returns to the facility, he will be placed on 1:1 monitoring until status is determined. 7. Resident #2 was assessed by facility DON on 9/1 @ 8:30 PM with no visible injuries noted. She was calm. Attending MD /Designee were notified on 9/2 @ 4:59 AM. Responsible party was notified on 9/2@ 4:59AM. 8. Residents who reside on the secure unit have had skin assessments completed by the Treatment Nurse for any unidentified concerns with zero concerns identified. Initiated 9/3 @ 630 PM by DON. Completed 9/3 @ 845 PM by Treatment Nurse. 9. Residents who reside on the secure unit were evaluated for any physical aggressive behaviors with none identified. Initiated 9/3/22 @ approximately 6PM by DON. Completed 9/3/22 @ 7:45 PM by DON. Care plans for Residents #1 and #2 were updated to reflect identified event and interventions were reviewed /updated if indicated. 10.Facility staff were provided education by DON/Designee on: 10a) Procedures for Inappropriate Resident to Resident touching and /or Sexually Inappropriate Behaviors. Staff were instructed to separate and protect the residents. Evaluate residents involved for any injury, pain or emotional impact. Notify MD, Responsible party, DON and ADM promptly. Initiate monitoring or increased supervision if indicated and document interventions. Initiated 9/3/22 @ 6PM and completed at 7:30 PM. 36 attendees. Follow-up sessions will resume on 9/4/22. 10b) Supervision and Monitoring of Hall 3/Secure Unit. Discussion of procedures to be utilized to facilitate monitoring of unit by staff. Staff were instructed that one staff member would be responsible for being stationed in the hallway to monitor Residents in the hallway while care is being provided in other areas of the unit by another staff member. The staff member in the hallway is to monitor Residents for any wandering into other Residents' rooms or inappropriate behavior and provide redirection or request assistance from other staff if needed. Staff were educated to communicate their location with each other when leaving the unit or going into an unobserved area (i.e. Resident's room, shower, etc) to make sure the other staff member is aware of need to be on hallway monitoring duty during that time period. Staff can rotate the roles as needed to complete tasks and maintain monitoring. If two staff are required for Resident cares, then a nurse or other staff member must be in place to provide hall monitoring role. Staff were advised to call for assistance from staff outside unit if needed for additional monitoring assistance if needed. Notify DON or ADM of any concerns promptly. Initiated on 9/3/22 @ 6pm, completed 7:30 PM. 36 attendees. Follow-up sessions will resume on 9/4/22. 10c) Resident to Resident Altercations - Interventions and approaches to be implemented. Evaluate for any injuries or psychosocial impact. Increase supervision if indicated. Notify MD, Responsible party and DON/ADM promptly. Initiated 9/3/22 @6 pm, completed 7:30 PM. 36 attendees. Follow-up sessions will resume on 9/4/22. 10d) Abuse-Content. Abuse Coordinator - contact #s and the facility Abuse Prohibition Guideline. Initiated 9/3/22 @ 6pm, completed 7:30 PM. 36 attendees. Follow-up sessions will resume on 9/4/22. The DON is the Abuse Coordinator. 11. Staff who were not on duty will be notified, to come to the facility for education by the DON/designee. No staff will be allowed to work on the floor until education has been completed for items 10a-10d. Administrator, DON, and MDS Coordinator will monitor for employee completion of required education topics. Administrator, DON, MDS Coordinator and HR Director will conduct audits of current facility employees and indicate completion dates for required education. Staff are being notified to report to facility for education completion via phone and texts. Notifications started on 9/3/22 @ 5PM and are continuing 9/4/22. Administrator, DON and MDS Coordinator will continue to audit, notify and provide education items until all employees have completed the requirement. 12. Safe surveys were conducted for Residents on the secure unit who could be interviewed and reside in the facility general population area with no safety or abuse concerns identified. Initiated 9/3/22 @ 6pm per social worker. Completed 9/3/22 @ 7:15PM per Social Worker. 8 Residents interviewed. 14. Facility Administrator and the DON were provided education on compliance and monitoring procedures. The facility Abuse Prohibition Guide was reviewed and discussion on investigation and reporting processes reviewed. Education provided by VP of Clinical Operations. Initiated 9/3/22 @ 9PM, completed @ 9:30PM. On 9/4/22, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Observations, interviews, and record reviews were conducted on 9/4/22 from 12:00 p.m. through 3:35 p.m. and included 5 alert residents, 5 nurses including 1 RN, 4 LVNs, and 4 CNAs (who work all shifts), SW, and DON. Staff were able to identify inappropriate resident to resident touching and reporting procedures, supervision/monitoring on the secure unit, resident-resident altercations, and who the abuse coordinator was. Staff provided appropriate resident supervision and redirection. There were no observed concerns. Staff were able to discuss the required supervision and monitoring of Hall 3/Secure Unit. Staff were able to identify the Abuse Coordinator, indicated reporting was immediate to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. Staff were able to give examples of behavior monitoring on unit 3/secure unit. Staff were able to give examples of resident-to-resident touching and/or sexually inappropriate behaviors. Resident #1 remained at the behavioral hospital. Record review of his care plan was updated to reflect the incident. Resident #2 did not appear in distress and did not recall the incident. Record review of her care plan indicated it was updated to reflect the incident. Resident #3 did not appear in any distress. The in-services/staff training provided by the DON/Designee included: Inappropriate Resident to Resident touching and reporting procedures. Supervision and Monitoring of Hall 3/Secure Unit. Content discussed and procedures discussed to facilitate monitoring of unit. Staff were educated that one staff would be monitoring Residents and the hallway on Hall 3 while care is being delivered by the other staff member. Staff were instructed to take turns with these roles and to notify the nurse if additional monitoring assistance is needed. Abuse-Content Abuse Coordinator - contact #s and the facility Abuse Prohibition Guideline. Facility staff were provided education by DON/Designee on: Behavior Assessment, Intervention and Monitoring and Unmanageable Residents. Facility staff were provided education by DON/Designee on resident-to-resident altercations, content including reporting procedures, interventions, and documentation procedures. Staff who were not on duty were notified to come to the facility for education by the DON/designee. All staff working in the facility were educated. Administrator, DON and MDS Coordinator indicated they will continue to audit, notify, and provide education items until all employees have completed the requirement. Safe surveys were conducted for residents on the secure unit and reside in the facility general population area with no safety or abuse concerns identified. No residents indicated they were afraid of any residents during interviews of residents on the secure unit. The facility Administrator and the DON were provided education on compliance and monitoring procedures by V.P. Of Clinical Operations. On 9/4/22 at 4:05p.m., the interim Administrator was informed the IJ was removed; however, the facility remained out of compliance with no actual harm with a potential for more than minimal harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure all alleged violations involving of mistreatment, neglect, abuse, or misappropriation of resident property were reported immediately, but not later than 24 hours after the allegation was made to other officials (including to the State Agency) for 2 of 7 residents (Resident #1 and #2) reviewed for reporting. An allegation of sexual abuse was made on 9/1/22. The facility did not report the allegation of abuse until surveyor intervention on 9/3/22. Resident #2 allegedly sexually abused Resident #1. This failure could place residents at risk of continued abuse, neglect, or misappropriation. Findings included: Record review of the facility's Abuse Prohibition Guideline 2022 indicated The Health Care Center will conduct an investigation of all alleged or suspected cases of abuse, neglect or misappropriation of property, and will provide notifications and information to the proper authorities according to state and federal regulations . Investigations 1. The Health Care Center will thoroughly investigate all alleged violations/allegations and take appropriate actions. No later than 2 hours if the allegation involves abuse or results in serious bodily injury, and no later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury. Record review of face sheet dated 9/4/22, indicated Resident #1 was a [AGE] year-old male, admitted on [DATE] and his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MDS dated [DATE], indicated Resident #1 had moderate cognitive impairment, ambulated with a walker. He had Other behavioral symptoms not directed toward others which occurred 1 to 3 days. Resident #1 did not exhibit any wandering behaviors. Record review of Resident #1's care plan dated 04/11/22 indicated he displayed socially inappropriate behavior and inappropriate sexual gesture with a female resident. Interventions included 15-minute monitoring and sent out to behavioral hospital for evaluation and treatment. 5/6/22 Care plan meeting held with RP & Ombudsman. Aware that any inappropriate behaviors would be immediate discharge. Record review of face sheet dated 9/4/22, indicated Resident #2 was a [AGE] year-old female, admitted on [DATE], and her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MDS dated [DATE] indicated Resident #2 had severely impaired cognitive skills for daily decision making, had physical behaviors which occurred last 4 to 6 days but not daily, wandered last 4 to 6 days and used a wheelchair for mobility. Record review of an incident report dated 9/1/22 at 7:25 p.m., prepared by the DON, indicated Alleged by a staff nurse that this resident (Resident #1) went into a female resident room and allegedly touched her inappropriately. Record review of a progress note dated 8/31/22 at 9:00 p.m., completed by LVN B, indicated Resident #1 asked an unidentified aide if he could have her while making rounds. Record review of a progress note dated 9/1/22 at 10:23 a.m., completed by LVN D, indicated Resident #1 was noticed standing at his door looking into the hallway masturbating. The CNA that saw this told him to go to his room, to his bed to do that and he cannot do it outside of his room. After this occurred, he also was asking a female resident to come into his room. The CNA heard this and told him to stop asking female residents to his room, he said OK. Later that day he was seen looking in on female resident lying in bed and redirected by CNA. Record review of a progress note completed by LVN B dated 9/1/22 at 7:37 p.m. indicated Resident #1 was found in Resident #2's room by aide and was asked to leave the room. Aide on the hall called for another nurse to come into the unit to assess the residents. This resident (#1) was found with blood on his left thumb by other nurse. Other nurse asked this resident not to wash his hands so that she could take a picture while she was on the phone with the DON. This nurse was in the room assessing resident #2, found blood in resident #2's brief and around the vaginal and rectal area. DON notified. Record review of a progress note dated 9/1/22 at 7:56 p.m. indicated Resident #2 found with blood in her brief and on her peri area after Resident #1 left her room. Resident also has dried blood on the bed. DON notified. Assessed resident and she does not appear in any pain at this time. Record review of a progress note dated 9/2/22 at 7:10 a.m. completed by the DON indicated Incorrect charting with staff education provided: resident confidentiality, charting of facts and not assumptions, and charting incorrect chart. This nurse was at facility for assessment of this resident and concern. This charting is not fact. Record review of a progress note dated 9/2/22 at 12:28 p.m. completed by the DON indicated resident has been referred to behavioral hospital related to his inappropriate behaviors this week. This nurse spoke with LVN at behavioral and all paperwork sent to her. Residents RP is aware of referral. Resident is agreeable to go to behavioral if accepted. During an interview on 9/3/22 at 8:48 AM, RN J asked surveyors if they were at the facility for the incident. When asked which incident, RN J said the incident with Resident #1. She said he had another incident and thinks it was sexual. She said she did not know the details. She said she thought resident #1 was on 15-minute checks and thought the incident had been reported to the state agency. During an interview on 9/3/22 at 9:24 AM, the DON said Resident #1 was having inappropriate sexual behaviors like masturbating in the hall and saying inappropriate things to staff. She was made aware on 9/1/22 of the behaviors. The nurses called her around 7 PM on Thursday night (9/1/22) and said Resident #1 was seen coming out of resident #2's room. She was told there was blood on Resident #2's sheet. She was told LVN C had seen blood on resident #1's thumb. CNA A said there was blood in the middle of Resident #2's bed. She said she took a flashlight to Resident #2's room to assess the resident. Using the flashlight to see, she said there was no blood or tears in Resident #2's private area. She said Resident #2 had feces and urine in her brief. She said there was a toenail that had been ripped off and assumed that was where the blood had come from on the bed. She said the staff jumped to conclusions about sexual abuse. She did not think Resident #2 was sexually abused because she assumed the blood had come from Resident #2's toenail and she did not see any blood, just brown feces in the brief. She said Resident #2 was not able to answer any questions. The DON said Resident #1 was sent to a behavior hospital on 9/2/22 due to his sexual behaviors. She said she did not report the incident to the State agency because she did not think there was any abuse. She said she made an entry in both Residents' charts because the documentation indicated there was sexual abuse when she felt there was no abuse. She said she did get statements from the staff involved. During an interview on 9/3/22 at 12:34 PM, LVN C said she saw resident #1 with blood on his left thumb. When asked if she was sure it was blood, she said she was 100% sure it was blood on his thumb. She said he washed his hand before she could get a picture of the blood. She said she saw resident #2's brief pulled to the side when CNA A asked her to look. CNA A thought the brief looked out of place. When she asked Resident #1 why he had blood on his thumb, he said I don't know, I don't know. During an interview on 9/4/22 at 11:16 a.m., the interim administrator said the incident with Resident #1 was never given to him as an allegation of abuse or he would have reported the incident. He was only told Resident #1 was in Resident #2's room and there was blood on the sheets. He said from his understanding there was never an allegation of any abuse. He said the DON was the abuse coordinator until a permanent administrator was hired.

Based on observation, interview and record review, the facility failed to ensure nursing staff demonstrated competencies and skill sets necessary to care for resident needs for 4 of 11 residents (Resident #s 1, 2, 4, and 5) reviewed for competent nursing staff. The facility did not ensure LVN A, NA B and CNA F were trained to supervise and intervene for residents with behaviors. The facility did not provide required monitoring and supervision to prevent Resident #1 from sexually abusing Resident #2 on 04/11/22. Resident #2 wandered into Resident #1's room. Resident #2 was heard yelling. Resident #1 was found behind Resident #2, his hand on her shoulder, holding his partially erect penis while thrusting toward Resident #2. Residents #1 and #2's briefs were down. The facility staff did not intervene and protect Resident #5 from Resident #4's verbal and physical abuse. On 4/9/22 Resident #4 was found hovering over Resident #5 yelling at him. The NA B opened the door to see what was occurring and then closed the door and called for the nurse. NA B left Resident #5 in imminent harm. An Immediate Jeopardy (IJ) situation was identified on 04/14/22 at 3:00 p.m. While the IJ was removed on 04/15/22, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of receiving supervision and interventions from staff without the needed skills and competencies. Findings included: Record review of face sheet dated 04/13/22, indicated Resident #1 was a [AGE] year-old male, admitted on [DATE] and his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MDS dated [DATE], indicated Resident #1's BIM score was 7 (severe cognitive impairment), he wandered every 1-3 days, ambulated with a walker. There were no behaviors noted. Record review of Resident #1's care plan dated 04/11/22 indicated he displayed socially inappropriate behavior and inappropriate sexual gesture with a female resident. Interventions included 15-minute monitoring and sent out to behavioral hospital for evaluation and treatment. There was no previous care plan for sexually inappropriate behavior available for review. Record review of face sheet dated 04/13/22, indicated Resident #2 was a [AGE] year-old female, admitted on [DATE], and her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MDS dated [DATE] indicated Resident #2 had a BIMS score of 2 (severe cognitive impairment), wandered daily, and ambulated without assistance. Record review of care plan dated 12/30/21 indicated Resident #2 required placement on the secure unit due to wandering and significant safety awareness due to dementia. Interventions included assist with location of room with verbal cues, notify physician if behavior increases (1/18/22- in and out of other residents' rooms, at times will take things out of other residents' rooms, 2/6/22 altercation with another resident, 2/11/22 attempted to take another residents walker, 4/11/22 victim of inappropriate sexual gesture). The care plan did not address supervision. Observation conducted on 04/14/22 with the Administrator, DON and ADON, who verified the identity of the staff and residents, of the facility's two separate camera recordings on 04/08/22 from 7:30 a.m. through 8:30 a.m. indicated: At 8:09 a.m. there were no aides on the hall, Resident #2 wandered on hall and then back into her room. Camera error exact time unknown-CNA F went into another resident's room while CNA C was in the shower room. At 8:13 a.m. Resident #2 wandered into the hall, then into a resident room next to the shower room. At 8:14 a.m., CNA C out of shower to get a wheelchair and then back into shower room. At 8:16 a.m., CNA C opened the shower door and took a resident in a wheelchair out of the shower. CNA C walked past the resident room next to the shower room. CNA C walked into Resident #1's room, escorted Resident #2 out of Resident #1's room and walks back toward Resident #2's room at the opposite end of the hall. At 8:19 a.m. CNA F comes out of other residents' room. Record review of nurse note dated 04/11/22 at 4:08 p.m., completed by LVN D, indicated CNA C heard Resident #2 scream no don't do that when she entered the room. The door was open and she witnessed Resident #1 standing behind Resident #2. Resident #1 was holding on to Resident #2 with one hand, his pants were down and he was exposed. Resident #2's pants were down and she was exposed. Record review of nurse note dated 04/11/22 at 4:18 p.m., completed by the DON, indicated CNA C exited the shower room at approximately 8:15 a.m. and heard Resident #2's raised voice coming Resident #1's room. CNA C entered the room and noted Resident #2 had his pants down and was standing behind Resident #2. Resident #1 had his penis in his hand and was saying 'get it, get it'. Resident #2's incontinence protective wear and pants were down. CNA C separated Resident #1 and #2 and immediately removed Resident #2 from the room. DON and Treatment nurse examined Resident #2 in her room and did not notice any redness or drainage to rectal or perineal/vaginal area. Resident #2 was calm at the time of the examination. No injuries noted. The physician was notified and new orders to send Resident #1 to behavioral hospital for evaluation and treatment. The administrator was notified. Resident #2's daughter was notified. Psych services was notified. Record review of NP E's visit report dated 04/11/22 indicated Resident #1 denied any inappropriate behaviors occurred. Resident #1's BIMS was assessed and scored at 15. Record review of Resident #1's behavior monitoring from 01/01/22 through 04/08/22 indicated no behaviors were documented. Record review of Resident #2 behavior monitoring from 01/01/22 through 04/08/22 indicated there were 79 incidents of wandering into other residents' rooms and the nurse was notified. During an interview on 04/13/22 at 8:35 a.m. the Administrator said CNA C came out of the shower room and heard Resident #2 say 'stop'. She said the door was open and she saw Resident #1 standing behind Resident #2. She said both residents' pants and briefs were down. She said Resident #1 had his penis in his hand. She said Resident #2 was assessed and it was not determined she was penetrated. She said psych services was contacted and increased Resident #1's [MEDICATION(S)] (an antidepressant medication). She said Resident #1 denied the allegations. She said Resident #1's last BIMS score was a 7 but he was re-assessed and it was 15. She said Resident #1 had previous sexually inappropriate behaviors and would masturbate on the porch. She said he was easily re-directed. During an interview on 04/13/22 at 9:10 a.m., CNA C said she was previously trained on abuse and neglect prevention. She said approximately 2 or 3 weeks prior she had previously caught Resident #1 with another resident sitting on his bed. She said Resident #1 was standing between the other resident's legs as she was sitting on his bed. She said both residents were fully dressed. She said Resident #1 stepped back and said he was trying to help the other resident. She said she thought she told LVN G of the incident. She said the most recent incident occurred after breakfast at approximately 8:15 a.m. She said she was in the shower room when heard Resident #2 scream No don't do that no no no. She said she brought the other resident out of the shower room and walked to Resident #1's room. She said both Resident #1 and Resident #2's pants were down. She said Resident #1 had his penis in his hand and was holding Resident #2's left shoulder as he was telling Resident #2 to get it, get it as he was thrusting. She said Resident #1 sat down on his bed when he walked into the room. She said Resident #2 was crying. She said she dressed Resident #2 and walked her out of the room. She said she and CNA F were working the secure unit together. She said they had cell phones to call the nurse if there as an emergency. During an interview on 04/14/22 at 10:15 a.m., the DON said she was not able to locate LVN A, NA B, or CNA C's training for sexually inappropriate behaviors or resident abuse. She said the staff are trained through computer and as needed in the facility. During an interview on 04/14/22 at 1:30 p.m., the Administrator said she was not aware LVN A, NA B, or CNA C were not trained. She said she became the new Administrator in January 2022 and was not aware staff was not trained. She said she and the DON or designee were responsible for ensuring staff was trained. During an interview on 04/14/22 at 1:54 p.m., the DON said both aides on the secure unit should not be providing resident care at the same time. She said one of the aides was supposed to monitor and supervise the other residents and the hall to ensure residents do not wander or to be able to intervene for resident safety. She said she could not locate the training records of the staff on the unit. She said she or designee were responsible for ensuring staff was trained. She could not say why the staff were not trained or she could not locate the training records. During an interview on 04/14/22 at 2:05 p.m., CNA F said a resident came out of his room and the resident required incontinent care. She said she went into the shower room to gather supplies. She said CNA C was almost finished showering a different resident so she left the shower room and assisted the other resident with his incontinent care. She said she did not see Resident #2 wandering in the hall. She said she had been working for 2 months and did not recall specific training related to monitoring the residents prior to the incident on 04/08/22. During an interview on 04/15/22 at 3:34 p.m. the administrator and DON said they had re-inserviced staff and educated staff working on hall 300 to have one staff monitoring and the other staff providing care. They said staff were also trained to request help when they need to take care of residents and they were monitoring the hall. The DON said she was not able locate any staff training records that contained the names of the staff that worked during the incident. She said NA B was not a certified aide and there was no record she was trained regarding resident-to-resident aggression prior to the incident between Resident #4 and Resident #5. During an interview on 04/15/22 at 4:14 p.m., Psych NP J said staff have to monitor, intervene, and divert residents' behaviors. 2. Record review of face sheet dated 04/04/22 indicated Resident #4 was a [AGE] year-old male who was admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MDS dated [DATE] indicated Resident #4 had severe cognitive impairment and wandered every 1 to 3 days. There were no behaviors documented. Record review of care plan dated 10/08/21 indicated Resident #4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of care plan dated 04/09/22 indicated Resident #4 exhibited aggressive behavior noted by staff standing over another resident and yelling, threatening and physical aggression directed at staff trying to diffuse the situation. Interventions included placing Resident #4 in an area for frequent observation social services to evaluate and visit, activities staff to visit and provide diversional activities, talk in a calm voice when behavior is disruptive, and remove from public area when behavior is disruptive and unacceptable, and sent to behavior hospital for evaluation/treatment. There was no care plan to address the verbal and physical aggression towards his roommate that occurred on 03/19/22. Record review of Resident #4's behavior monitoring from 01/01/22 through 04/09/22 indicated on 04/05/22 CNA C noted verbal behaviors directed at others included threatening others, screaming/yelling at others, and cursing at others-nurse notified. There were no additional dates completed. Record review of nurse note dated 03/19/22 at 2:22 p.m., completed by LVN L, indicated LVN L heard shouting from Resident #4's room. LVN L observed Resident #4 shouting aggressively as he stood over Resident #5. Resident #4 was redirected to the dining room and offered snacks. Resident #4 refused snacks. LVN L notified CNAs to be on alert for any aggressive behavior towards other residents. Resident #5 had no apparent injuries and denied pain. Record review of a face sheet dated 04/04/22 indicated Resident #5 was a [AGE] year-old male, admitted on [DATE], and his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an MDS dated [DATE] indicated Resident #5 had severe cognitive impairment. Wandered every 1 to 3 days. There were no physical or verbal behaviors noted. Record review of Resident Incident Report dated 04/09/22 at 5:25 a.m. and completed by LVN A indicated NA B entered Resident #4 and Resident #5's room and found Resident #4 bent over Resident #5. Resident #4 was yelling at Resident #5. LVN A separated the residents. Resident #4 sat at the foot of his bed. LVN A sat on the floor by the foot of his bed. LVN A reached down to assist Resident #4 from the floor and Resident #4 swung his fist and struck LVN A's upper right arm. Resident #4 yelled he was going to kill LVN A. Resident #5 was moved to a different room. During an interview on 04/13/22 at 2:08 p.m., NA B said she heard voices and yelling and went to Residents #4 and #5's room. She said she opened the door and saw Resident #4 standing over Resident #5 while Resident #5 lay in his bed. She said she shut the door and told the other staff to get LVN A. She said she did not know why she did not intervene. She said she was not a certified aide and was not trained on behaviors. She said she was not trained on how to redirect residents. She said LVN A came to the room and directed Resident #4 to his bed. She said Resident #4 went toward his bed and said, I'll [OBSCENITY] ing kill you. She said CNA K was on shift with her. Record review of CNA K's undated statement included in the ongoing facility's investigation indicated CNA C told her she heard shouting and rumbling in the room and for her (CNA K) to go and get LVN A. LVN A opened the door and LVN A, CNA C and CNA K walked into Resident #4 and Resident #5's room. Resident #4 was standing over Resident #5 hitting him and cursing at him. LVN A was able to get Resident #4 off Resident #5. Resident #4 started to swing and curse at LVN A. Resident #4 fell on the floor as he swung. LVN A directed CNA K to get LVN I. LVN I tried to talk to Resident #4 and he started cursing at LVN A and picked up a shoe. LVN A moved Resident #5 to another room. All staff left Resident #4's room for their safety. During an interview on 04/13/22 at 4:27 p.m., LVN A said he was not trained on dementia for the secure unit. He said he was not aware of any specific care plans for Resident #4. He said there were other incidents of Resident #4 yelling at Resident #5 but he was able to redirect him. He said if resident #4 was not able to see' Resident #5 then he would calm down. He said he did not do a nurse note or an incident report. He could not say why he did not document the incident. He said the most recent incident, Resident #4 was screaming at the top of his lungs at Resident #5. He said Resident #4 continued to yell at Resident #5 when he (LVN A) got between the residents. He said Resident #5 said Resident #4 hit him in the back. He said Resident #5 did not have any marks on his back. He said Resident #4 was pretty traumatized for a day or two. Record review of nurse note dated 04/09/22 at 10:47 a.m., completed by LVN A, indicated LVN A was called to Resident #4 and Resident #5's room at 5:25 a.m. LVN A found Resident #4 standing over Resident #5, yelling. LVN A directed Resident #4 to sit on his bed but he sat on the floor. LVN A attempted to help him up but Resident #4 hit LVN A on the right upper arm and started to yell he was going to kill LVN A. LVN A moved Resident #5 to another room for safety. Resident #5 stated Resident #4 hit him in the back. There was no visible injury. Resident #5 was resting in a safe bed. Notified on-call ADON, and the ADON notified the DON. DON stated she was going to send Resident #4 to a behavioral hospital. During an interview on 04/14/22 at 2:08 p.m., NA B said she realized after she shut the door of Residents #4 and #5 room that she had left Resident #5 in danger. She said she stood right outside of the door until LVN A arrived and intervened. During an interview on 04/15/22 at 3:34 p.m. the administrator and DON said NA B should have intervened and not shut the door. The DON said NA B was a new aide and she needed more experience and training. The DON said staff were also trained to request help when they need to take care of residents. The DON said she was not able locate staff training records for LVN A, NA B and CNA F. During an interview on 04/15/22 at 4:14 p.m., psych NP J said he was not made aware of previous incidents of aggression from Resident #4. He said he would have addressed the aggressions and recommended Residents #4 and #5 be separated and not continued their status as roommates. Record Review of LVN A (DOH 09/09/21), NA B (DOH 04/01/22) and CNA F (DOH 02/01/22)'s personnel files indicated there was no records of training or competency checks for interventions and supervision of residents with behaviors. Record review of the facility's Nurse Aide Qualifications and Requirements dated 2001 indicated . 4. Our facility will not use any individual as a nurse aide for more than (4) months full-time, temporary, per diem, or other basis unless: a. That individual is competent to provide nursing and nursing related services; and b. That person has completed a training program and competency evaluation program, or a competency evaluation program approved by the state; or c. That individual has been deemed competent as provided in §483.150) and (b) of the Requirements of Participation. 5. Our facility will not sue any induvial as a nurse aide who has worked less than 4 months unless the individual: a. Is a full-time employee and participating in a state-approved training and competency evaluation program; or b. Has demonstrated competence through satisfactory participation in a state-approved nurse aide training and competency evaluation program; or c. Has been deemed competent as provided in §483.150) and (b) of the Requirements of Participation. Record review of In-Service Training Report dated 09/21/21 indicated the topic was safety monitoring-Hall-3: Hall-3 staff are to have safety monitoring of hall at all times. Staff may take turns, being safety monitor. Observe for potential abuse behaviors, wandering, and/or falls and attempt to prevent altercations and incidents. The in-service did not include the names of the LVN A, NA B or CNA F. The facility was notified of the Immediate Jeopardy on 04/14/22 at 3:00 p.m. and the administrator was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/15/22 at 1:55 p.m. and reflected the following: Facility failed to prevent Resident #1 from sexually abusing Resident #2. On 4/11/22 Resident #2 was heard yelling please don't no no no Resident #1 was found behind Resident #2 , his pants down and his hand on her shoulder . Resident #1 had a partially erect penis and was thrusting toward resident #2. Resident #2's brief was down. Approximately 2-3 weeks earlier Resident #3 was found sitting on Resident #1's bed. He was standing between her legs hovering over her. Both were fully clothed. There were no interventions put in place. Facility failed to prevent Resident #4 from verbally and physically abusing Resident #5. On 3/19/22 Resident #4 was seen standing over Resident #5, while Resident #5 was in bed, yelling aggressively at him. No interventions were put in place at the time. On 4/9/22 Resident #4 was found hovering over Resident #5 yelling at him. The nurse aide opened the door to see what was happening and then closed the door and called for the nurse. She did not intervene and separate the Residents. She had not been trained on dealing with behaviors. Please accept the following plan of removal: 1. Notify V.P. of Clinical Operations of immediate Jeopardy status - On site 4/14/22 @ 3 pm 2. Notify Regional Director of operations of Immediate Jeopardy status - Onsite 4/14/22@ 3 pm. 3. Notify facility Medical Director of Immediate Jeopardy status- Notified via phone by ADON -4/14/22@ 4pm. 4. Resident #1 was immediately placed on 1:1 monitoring beginning @ 8:30 am on 4/11/22. Attending MD /Designee and responsible party were notified. Medication orders were received. He remained on 1:1 monitoring until transferred to a Behavioral Hospital @3:30 pm on 4/11/22. He remains at the Behavioral Hospital at time of this report. 5. Resident #2 was assessed by facility licensed nursing staff on 4/11/22@ 8:21 am with no visible injuries noted. She was calm. Attending MD /Designee and responsible party were notified. Responsible party later called facility and requested she be sent out for exam .MD/Designee were notified of family's request and order received to send to ER for evaluation and examination. She was transferred to a hospital on 4/11/22 @ 8:30 pm. She returned to the facility on [DATE] @ 3 am. Verbal report was received from nurse at Hospital indicating no abrasions, tears or injuries on physical exam, specimens were collected during exam and are pending completion by forensics lab. She has been noted to be in pleasant mood and in no immediate distress or discomfort noted. 6. Resident #3 has been assessed on numerous occasions for the past 3 weeks with no noted skin issues or obvious discomfort observed. 7. Resident #4 was placed on 15-minute interval monitoring beginning 4/9/22 @ 6am. Attending MD/Designee were notified. Order received to transfer to behavioral hospital. Resident remained on 15-minute monitoring until transferred to Behavioral Hospital on 4/9/22 @4:45 pm. He remains at a Behavioral Hospital at the time of this report. 8. Resident #5 was assessed by licensed nursing staff on 4/9/22 with no injuries noted. He was placed on 15-minute monitoring beginning 4/9/22 @ 6 am and monitoring was discontinued on 4/12/22@ 7am with no further incidents noted. 9. Residents who reside on the secure unit have had skin assessments completed by licensed nursing staff treatment nurse for any unidentified concerns with none identified. Initiated 4/13/22 @t 11 am and Completed 4/13/22 @ 3:30 pm by Treatment Nurse. 10. Residents who reside on the secure unit were evaluated for any physical aggressive behaviors with none identified. Initiated 4/14/22@ approx. 4:30 pm and Completed 4/14/22@ 5:30 pm by ADON. Care plans for Residents #1, 2 , 4 & 5 were updated to reflect identified event and interventions were reviewed . 11. Facility staff were provided education by DON/Designee on: 11a) Inappropriate Resident to Resident touching. Reporting procedures discussed. Initiated 4/13/22@ 12:30 pm, Follow up sessions @2:30 pm and 6pm Completed @ 6:30pm on 4/13/22 Total attendees on 4/13/22-51 Subsequent sessions on 4/14 /22@beginning @ 10am, Completed @ 10:30 am on 4/14/22 -Total attendees 11. Follow up sessions conducted @ 4/15/22 beginning @ 6am completed by 9am. Total Attendees 29. 11b) Supervision and Monitoring of Hall 3/Secure Unit. Content discussed and procedures discussed to facilitate monitoring of unit. Staff were educated that one staff would be monitoring Residents and the hallway on Hall 3 while care is being delivered by the other staff member. Staff were instructed to take turns with these roles and to notify the nurse if additional monitoring assistance is needed. Initiated 4/13/22@ 11am, Follow up sessions @ 2:30 pm. and 6:00 pm. Completed @ 6:30 pm on 4/13/22. Total attendees 50 Subsequent sessions on 4/14/22@ 10 am, Completed@ 10 :30 am. 12 attendees Follow up sessions beginning 4/15/22 @ 6 am completed @ 945 am. Total attendees 29. 11c) Abuse -Content Abuse Coordinator - contact #s and the facility Abuse Prohibition Guideline. Initiated 4/13/22@10:30 am, Follow up sessions @2:30 pm and 6 pm. Completed @ 6:30 pm on 4/13/22. Total attendees 63 Subsequent sessions 4/14/22 beginning @10 am, Completed @ 10:30 am on 4/14/22- 17 attendees Follow up sessions on 4/15/22 beginning at 6am completed at 945 am. Total attendees 29. 12. Facility staff were provided education by DON/Designee on: 12a) Behavior Assessment, Intervention and Monitoring - content included facility policy. Initiated 4/14/22@ 5:30 pm, Completed @ 5:50 pm on 4/14/22 Attendees 32. Follow up session on 4/15/22 beginning at 6 am completed by 945 am. Total attendees 22. 12b) Unmanageable Residents - content included facility policy. Initiated 4/14/22@ 5:30 pm Completed @ 6:00 pm on 4/14/22 Attendees 35 Follow up sessions on 4/15/22 beginning at 6 am completed at 945 am. Total attendees 29. 13. Facility were provided education by DON/Designee on resident to resident-resident altercations, content including reporting procedures, interventions and documentation procedures. Initiated 4/15/22 at 6am completed at 945 am. Total attendees 27. 14. Staff who were not on duty will be notified, to come to the facility for education by the DON/designee. No staff will be allowed to work on the floor until education has been completed for items #13, #14a, #14b, #14c, 15a, and 15b . Administrator ,DON, and MDS Coordinator will monitor for employee completion of required education topics . Administrator, DON, MDS Coordinator and HR Director will conduct audits of current facility employees and indicate completion dates for required education . Staff are being notified to report to facility for education completion via phone and texts. Notifications started on 4/14/22 @ 3:30 pm and are continuing on 4/15/22. Administrator, DON and MDS Coordinator will continue to audit , notify, and provide education items until all employees have completed the requirement . 15. Safe surveys were conducted for Residents on the secure unit and reside in the facility general population area with no safety or abuse concerns identified. Initiated 4/13/22 @ 4:00 per Social Worker and Completed 4/14/22@8:20 pm per facility Administrator . 10 Residents interviewed. 16. Compliance will be monitored through: 16a) Review of 24-Hour Reports, A/I Reports and Medical record review by Nursing Management and Administrator during Clinical meetings with corrective actions taken for identified concerns. The DON and administrator will conduct clinical meetings 3 x weekly and this will be an ongoing process. 16b) Findings will submitted to the facility QAPI Committee for review and additional Audits and corrective actions if indicated. 17. Facility Administrator and the DON were provided education on compliance and monitoring procedures by V.P. Of Clinical Operations. Monitoring of the facility's plan or removal occurred on 04/15/22 and included the following: Observations, interviews, and record reviews were conducted on 04/15/22 from 12:00 p.m. through 4:35 p.m. and included 9 residents, 6 nurses including charge nurses, treatment nurse, MDS nurse, 6 certified nurse aides, activity director, activity coordinator, BOM, housekeeping, dietary staff, and the ADON and DON that were on duty during this time. Staff were able to identify inappropriate resident to resident touching and reporting procedures. Staff provided appropriate resident supervision and redirection. There were no observed concerns. Staff were able to discuss the required supervision and monitoring of Hall 3/Secure Unit. Staff were able to identify the Abuse Coordinator, indicated reporting was immediate to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. Staff were able to give examples of behavior monitoring and documentation, appropriate notification, and facility assessment procedures. Staff were able to identify Unmanageable Residents and indicated appropriate facility policy. Staff were able to give examples of resident to resident-resident altercations, reporting procedures, interventions, and documentation procedures. Resident #1 remained at the behavioral hospital. Resident #2 did not appear in distress and did not recall the incident. Resident #3 continued wandering around the secure unit and did not appear anxious or distressed. Resident #4 remained at a behavioral hospital. Resident #5 did not recall the incident and displayed no signs of anxiety. Care plans for Residents #1, #2, #4 and #5 were updated to reflect identified event and interventions were reviewed. The in-services/staff training provided by the DON/Designee included: Inappropriate Resident to Resident touching and reporting procedures. Supervision and Monitoring of Hall 3/Secure Unit. Content discussed and procedures discussed to facilitate monitoring of unit. Staff were educated that one staff would be monitoring Residents and the hallway on Hall 3 while care is being delivered by the other staff member. Staff were instructed to take turns with these roles and to notify the nurse if additional monitoring assistance is needed. Abuse-Content Abuse Coordinator - contact #s and the facility Abuse Prohibition Guideline. Facility staff were provided education by DON/Designee on: Behavior Assessment, Intervention and Monitoring and Unmanageable Residents. Facility staff were provided education by DO [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure the right to be free from abuse was provided for 4 of 11 residents reviewed for abuse. (Resident #s 1, 2, 4, and 5) 1. The facility did not provide required monitoring and supervision to prevent Resident #1 from sexually abusing Resident #2 on 04/11/22. Resident #2 wandered into Resident #1's room. Resident #2 was heard yelling. Resident #1 was found behind Resident #2, his hand on her shoulder, holding his partially erect penis while thrusting toward Resident #2. Residents #1 and #2's briefs were down. 2. The facility staff did not intervene and protect Resident #5 from Resident #4's verbal and physical abuse. On 4/9/22 Resident #4 was found hovering over Resident #5 yelling at him. The NA B opened the door to see what was occurring and then closed the door and called for the nurse. The nurse aide left Resident #5 in imminent harm. An Immediate Jeopardy (IJ) situation was identified on 04/14/22 at 3:00 p.m. While the IJ was removed on 04/15/22, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, emotional distress, and death. Findings included: 1. Record review of face sheet dated 04/13/22, indicated Resident #1 was a [AGE] year-old male, admitted on [DATE] and his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MDS dated [DATE], indicated Resident #1's BIMS score was 7 (severe cognitive impairment), he wandered every 1-3 days, ambulated with a walker. There were no behaviors noted. Record review of Resident #1's care plan dated 04/11/22 indicated he displayed socially inappropriate behavior and inappropriate sexual gesture with a female resident. Interventions included 15-minute monitoring and sent out to behavioral hospital for evaluation and treatment. There was no previous care plan for sexually inappropriate behavior available for review. Record review of face sheet dated 04/13/22, indicated Resident #2 was a [AGE] year-old female, admitted on [DATE], and her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MDS dated [DATE] indicated Resident #2 had a BIMS score of 2 (severe cognitive impairment), wandered daily, and ambulated without assistance. Record review of care plan dated 12/30/21 indicated Resident #2 required placement on the secure unit due to wandering and significant safety awareness due to dementia. Interventions included assist with location of room with verbal cues, notify physician if behavior increases (1/18/22- in and out of other residents' rooms, at times will take things out of other residents' rooms, 2/6/22 altercation with another resident, 2/11/22 attempted to take another resident's walker, 4/11/22 victim of inappropriate sexual gesture). The care plan did not address supervision. Observation conducted on 04/14/22 with the Administrator, DON and ADON, who verified the identity of the staff and residents, of the facility's two separate camera recordings on 04/08/22 from 7:30 a.m. through 8:30 a.m. indicated: At 8:09 a.m. there were no aides on the hall, Resident #2 wandered on hall and then back into her room. Camera error exact time unknown-CNA F went into another resident's room while CNA C was in the shower room. At 8:13 a.m. Resident #2 wandered into the hall, then into a resident room next to the shower room. At 8:14 a.m., CNA C out of shower to get a wheelchair and then back into shower room. At 8:16 a.m., CNA C opened the shower door and took a resident in a wheelchair out of the shower. CNA C walked past the resident room next to the shower room. CNA C walked into Resident #1's room, escorted Resident #2 out of Resident #1's room and walks back toward Resident #2's room at the opposite end of the hall. At 8:19 a.m. CNA F comes out of other residents' room. Record review of nurse note dated 04/11/22 at 4:08 p.m., completed by LVN D, indicated CNA C heard Resident #2 scream no don't do that when she entered the room. The door was open and she witnessed Resident #1 standing behind Resident #2. Resident #1 was holding on to Resident #2 with one hand, his pants were down and he was exposed. Resident #2's pants were down and she was exposed. Record review of nurse note dated 04/11/22 at 4:18 p.m., completed by the DON, indicated CNA C exited the shower room at approximately 8:15 a.m. and heard Resident #2's raised voice coming Resident #1's room. CNA C entered the room and noted Resident #2 had his pants down and was standing behind Resident #2. Resident #1 had his penis in his hand and was saying 'get it, get it'. Resident #2's incontinence protective wear and pants were down. CNA C separated Resident #1 and #2 and immediately removed Resident #2 from the room. DON and Treatment nurse examined Resident #2 in her room and did not notice any redness or drainage to rectal or perineal/vaginal area. Resident #2 was calm at the time of the examination. No injuries noted. The physician was notified and new orders to send Resident #1 to behavioral hospital for evaluation and treatment. The administrator was notified. Resident #2's daughter was notified. Psych services was notified. Record review of NP E's visit report dated 04/11/22 indicated Resident #1 denied any inappropriate behaviors occurred. Resident #1's BIMS was assessed and scored at 15. Record review of nurse note dated 04/11/22 at 7:48 p.m., completed by the DON, indicated new recommendations from NP and corporate nurse to inform police department of incident due to Resident #1's BIMS score of 15. Resident #1 already left facility and sent to behavioral hospital. Officer arrived at facility to obtain report. Resident #2's daughter advised of police notification. Resident #2's daughter requested the facility send Resident #2 to the hospital for evaluation. Record review of NP E's visit report dated 04/11/22 indicated Resident #1 denied any inappropriate behaviors occurred. Resident #1's BIMS was assessed and scored at 15. Record review of hospital records dated 04/11/22 a SANE exam was performed. There was genital injury noted. Crime lab and diagnostic specimens were collected. There were no results available for review. Record review of nurse note dated 04/12/22 at 6:27 p.m., completed by LVN A, indicated the hospital nurse reported no findings and waiting for labs. Record review of Resident #1's behaviors from 01/01/22 through 04/08/22 indicated no behaviors were documented. Record review of Resident #2 behaviors from 01/01/22 through 04/08/22 indicated there were 79 incidents of wandering into other residents' rooms and the nurse was notified. During an interview on 04/13/22 at 8:35 a.m. the Administrator said CNA C came out of the shower room and heard Resident #2 say 'stop'. She said the door was open and she saw Resident #1 standing behind Resident #2. She said both residents' pants and briefs were down. She said Resident #1 had his penis in his hand. She said Resident #2 was assessed and it was not determined she was penetrated. She said psych services was contacted and increased Resident #1's [MEDICATION(S)] (an antidepressant medication). She said Resident #1 denied the allegations. She said Resident #1's last BIMS score was a 7 but he was re-assessed and it was 15. She said police was notified and Resident #2 was sent to the hospital for evaluation/treatment. She said initially, resident #2's daughter did not want Resident #2 sent to the hospital for an evaluation, but she changed her mind. She said Resident #1 had previous sexually inappropriate behaviors and would masturbate on the porch. She said he was easily re-directed. During an interview on 04/13/22 at 9:10 a.m., CNA C said she was previously trained on abuse and neglect prevention. She said approximately 2 or 3 weeks prior she had previously caught Resident #1 with another resident sitting on his bed. She said Resident #1 was standing between the other resident's legs as she was sitting on his bed. She said both residents were fully dressed. She said Resident #1 stepped back and said he was trying to help the other resident. She said she thought she told LVN G of the incident. She said the most recent incident occurred after breakfast at approximately 8:15 a.m She said she was in the shower room when heard Resident #2 scream No don't do that no no no. She said she brought the other resident out of the shower room and walked to Resident #1's room. She said both Resident #1 and Resident #2's pants were down. She said Resident #1 had his penis in his hand and was holding Resident #2's left shoulder as he was telling Resident #1 to get it, get it as he was thrusting. She said Resident #1 sat down on his bed when he walked into the room. She said Resident #2 was crying. She said she dressed Resident #2 and walked her out of the room. She said she and CNA F were working the secure unit together. She said they had cell phones to call the nurse if there as an emergency. During an interview on 04/13/22 at 9:47 a.m., the DON said she had heard of the incident of another resident being in Resident #1's room but she was not told the incident was sexual. During an interview on 04/13/22 at 11:35 a.m., LVN I said she had witnessed an incident approximately 2 - 3 months prior where another resident had taken off her clothes in her room and her roommate had opened the door as Resident #1 walked by. She said he stopped and stared, and when asked why he did that he said because he could. She said she had heard of the incident where he stood over the same resident while she sat on his bed. During an interview on 04/13/22 at 11:53 a.m., LVN G said she had not noticed Resident #1 having inappropriate sexual behaviors. She said Resident #1 did stare at the resident that was found sitting on his bed. During an interview on 04/14/22 at 10:15 a.m., the DON said staff are trained on abuse, neglect, and exploitation. She said the staff are trained through computer and as needed in the facility. She said she was not able to locate any staff training for sexually inappropriate behaviors or resident abuse. During an interview on 04/14/22 at 1:30 p.m., the Administrator said she was said she was not aware of any previous incidents related to inappropriate sexual behavior. She said no staff reported the behaviors to her during the morning meetings. She said the DON, ADON, and charge nurse were responsible for monitoring behaviors were documented. She said she became the new Administrator in January 2022 and was not aware staff was not trained. She said she and the DON or designee were responsible for ensuring staff was trained. During an interview on 04/14/22 at 1:54 p.m., the DON said both aides on the secure unit should not be providing resident care at the same time. She said one of the aides was supposed to monitor the other residents and the hall to ensure residents do not wander or to be able to intervene for resident safety. She said she could not locate the training records of the staff on the unit. She said she or designee were responsible for ensuring staff was trained. She could not say why the staff were not trained or she could not locate the training records. During an interview on 04/14/22 at 2:05 p.m., CNA F said a resident came out of his room and the resident required incontinent care. She said she went into the shower room to gather supplies. She said CNA C was almost finished showering a different resident so she left the shower room and assisted the other resident with his incontinent care. She said she did not see Resident #2 wandering in the hall. She said she had been working for 2 months and did not recall specific training related to monitoring the residents prior to the incident on 04/08/22. During an interview on 04/15/22 at 3:34 p.m. the administrator and DON said they had re-inserviced and educated three staff on 04/13/22 working on hall 300 to have one staff monitoring and the other staff providing care. They said staff were also trained to request help when they need to take care of residents and they were monitoring the hall. The DON said she was not able locate any staff training records that contained the names of the staff that worked during the incident. She said NA B was not a certified aide and there was no record she was trained regarding resident to resident During an interview on 04/15/22 at 4:14 p.m., Psych NP J said he received a call from the facility the morning of the incident with Residents #1 and #2. He said he had worked with Resident #1 for many years. He said Resident #1 had multiple hypersexual behaviors in the past that included exposing himself to others and masturbating. He said he had just recently started seeing Resident #2 as she was wandering and stealing items from other residents' rooms. He said staff have to monitor, intervene, and divert residents' behaviors. 2. Record review of face sheet dated 04/04/22 indicated Resident #4 was a [AGE] year-old male who was admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MDS dated [DATE] indicated Resident #4 had severe cognitive impairment and wandered every 1 to 3 days. There were no behaviors documented. Record review of care plan dated 10/08/21 indicated Resident #4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of care plan dated 04/09/22 indicated Resident #4 exhibited aggressive behavior noted by staff standing over another resident and yelling, threatening and physical aggression directed at staff trying to diffuse the situation. Interventions included placing Resident #4 in an area for frequent observation social services to evaluate and visit, activities staff to visit and provide diversional activities, talk in a calm voice when behavior is disruptive, and remove from public area when behavior is disruptive and unacceptable, and sent to behavior hospital for evaluation/treatment. There was no care plan to address the verbal and physical aggression towards his roommate that occurred on 03/19/22. Record review of Resident #4's behavior monitoring from 01/01/22 through 04/09/22 indicated on 04/05/22 CNA C noted verbal behaviors directed at others included threatening others, screaming/yelling at others, and cursing at others-nurse notified. There were no additional dates completed. Record review of a face sheet dated 04/04/22 indicated Resident #5 was a [AGE] year-old male, admitted on [DATE], and his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an MDS dated [DATE] indicated Resident #5 had severe cognitive impairment. Wandered every 1 to 3 days. There were no physical or verbal behaviors noted. Record review of Resident Incident Report dated 04/09/22 at 5:25 a.m. and completed by LVN A indicated NA B entered Resident #4 and Resident #5's room and found Resident #4 bent over Resident #5. Resident #4 was yelling at Resident #5. LVN A separated the residents. Resident #4 sat at the foot of his bed. LVN A sat on the floor by the foot of his bed. LVN A reached down to assist Resident #4 from the floor and Resident #4 swung his fist and struck LVN A's upper right arm. Resident #4 yelled he was going to kill LVN A. Resident #5 was moved to a different room. During an interview on 04/13/22 at 2:08 p.m., NA B said she heard voices and yelling and went to Residents #4 and #5's room. She said she opened the door and saw Resident #4 standing over Resident #5 while Resident #5 lay in his bed. She said she shut the door and told the other staff to get LVN A. She said she did not know why she did not intervene. She said she was not a certified aide and was not trained on behaviors. She said she was not trained on how to redirect residents. She said LVN A came to the room and directed Resident #4 to his bed. She said Resident #4 went toward his bed and said, I'll [OBSCENITY] ing kill you. She said CNA K was on shift with her. Record review of CNA K's undated statement included in the facility's investigation indicated CNA C told her she heard shouting and rumbling in the room and for her (CNA K) to go and get LVN A. LVN A opened the door and LVN A, CNA C and CNA K walked into Resident #4 and Resident #5's room. Resident #4 was standing over Resident #5 hitting him and cursing at him. LVN A was able to get Resident #4 off Resident #5. Resident #4 started to swing and curse at LVN A. Resident #4 fell on the floor as he swung. LVN A directed CNA K to get LVN I. LVN I tried to talk to Resident #4 and he started cursing at LVN A and picked up a shoe. LVN A moved Resident #5 to another room. All staff left Resident #4's room for their safety. During an interview on 04/13/22 at 4:27 p.m., LVN A said he was not trained on dementia for the secure unit. He said he was not aware of any specific care plans for Resident #4. He said there were other incidents of Resident #4 yelling at Resident #5 but he was able to redirect him. He said if resident #4 was not able to see' Resident #5 then he would calm down. He said he did not do a nurse note or an incident report. He could not say why he did not document the incident. He said the most recent incident, Resident #4 was screaming at the top of his lungs at Resident #5. He said Resident #4 continued to yell at Resident #5 when he (LVN A) got between the residents. He said Resident #5 said Resident #4 hit him in the back. He said Resident #5 did not have any marks on his back. He said Resident #4 was pretty traumatized for a day or two. Record review of nurse note dated 04/09/22 at 10:47 a.m., completed by LVN A, indicated LVN A was called to Resident #4 and Resident #5's room at 5:25 a.m. LVN A found Resident #4 standing over Resident #5, yelling. LVN A directed Resident #4 to sit on his bed but he sat on the floor. LVN A attempted to help him up but Resident #4 hit LVN A on the right upper arm and started to yell he was going to kill LVN A. LVN A moved Resident #5 to another room for safety. Resident #5 stated Resident #4 hit him in the back. There was no visible injury. Resident #5 was resting in a safe bed. Notified on-call ADON, and the ADON notified the DON. DON stated she was going to send Resident #4 to a behavioral hospital. During an interview on 04/13/22 at 8:35 a.m. the Administrator said she was not aware of any previous incidents between Residents #4 and #5. She said she was new to the facility as of January 2022 and no one reported anything during the morning meetings. She said they were roommates. She said Resident #4 was found standing over Resident #5. She said Resident #4 was recently put on [MEDICATION(S)] (antipsychotic medicine) for talking to inanimate objects. She said he was put on 1-1 staffing with 15-minute monitoring and sent to a behavior hospital for evaluation and treatment. During an interview on 04/14/22 at 1:54 p.m., The DON said she would have separated Residents #4 and #5 and they would not have continued as roommates if she was made aware of the previous incidents. She said no one told her of the previous incidents and nothing was reported during morning meeting. During an interview on 04/14/22 at 2:08 p.m., NA B said she realized after she shut the door of Residents #4 and #5 room that she had left Resident #5 in danger. She said she stood right outside of the door until LVN A arrived and intervened. During an interview on 04/15/22 at 3:34 p.m. the administrator and DON said NA B should have intervened and not shut the door. She said NA B was a new aide hired on and she needed more experience and training. They said staff were also trained to request help when they need to take care of residents. She said LVN A should have documented the prior incident and notified the administrator (the abuse coordinator and/or designee). The DON said she was not able locate staff training records that contained the names of the staff that worked during the incident. During an interview on 04/15/22 at 4:14 p.m., psych NP J said he was not made aware of previous incidents of aggression from Resident #4. He said he was in the facility every two weeks and more as needed. He said he received reports from staff if residents had behaviors. He said he would have addressed the aggressions and recommended Residents #4 and #5 be separated and not continued their status as roommates. Record review of nurse note dated 03/19/22 at 2:22 p.m., completed by LVN L, indicated LVN L heard shouting from Resident #4's room. LVN L observed Resident #4 shouting aggressively as he stood over Resident #5. Resident #4 was redirected to the dining room and offered snacks. Resident #4 refused snacks. LVN L notified CNAs to be on alert for any aggressive behavior towards other residents. Resident #5 had no apparent injuries and denied pain. Record review of In-Service Training Report dated 09/21/21 indicated the topic was safety monitoring-Hall-3: Hall-3 staff are to have safety monitoring of hall at all times. Staff may take turns, being safety monitor. Observe for potential abuse behaviors, wandering, and/or falls and attempt to prevent altercations and incidents. The in-service did not include the names of the LVN A, NA B, CNA C, or CNA K. Record review of the facility's Abuse Prohibition Guideline dated 2022 indicated : .will ensure a safe environment for residents by prohibiting physical and mental abuse including involuntary seclusion, neglect, exploitation and misappropriation of property. A. physical abuse includes but is not limited to hitting, slapping, and kicking, shoving, pinching, and corporal punishment. B. Verbal abuse includes but is not limited to the sue of oral, written or gestural language that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples include cursing, yelling, name calling, threatening or saying things to frighten a resident. E. Sexual Abuse is defined as non-consensual contact of any type with a resident, includes but is not limited to any unnecessary touching or exposure of the resident's breast or any part of the genitals without voluntary, informed consent and with the intention to arouse or gratify the sexual desire of any person. This definition is to include sexual harassment, sexual coercion, or any sexual assault. Prevention: 3. Residents identified as exhibiting abusive behaviors will be assessed and appropriate interventions included in the plan of care. 4.staff will immediately report and protect the resident if an allegation or observation of abuse has occurred. Protection: 1. All residents will be immediately protected from harm. 3. Allegations involving residents will necessitate assessment and interventions appropriate to protect the victim which may include a. temporary one on one supervision. b. transfer to another level of care. c. discharge home or to a family member/responsible party. The facility was notified of the Immediate Jeopardy on 04/14/22 at 3:00 p.m. and the administrator was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/15/22 at 1:55 p.m. and reflected the following: Facility failed to prevent Resident #1 from sexually abusing Resident #2. On 4/11/22 Resident #2 was heard yelling please don't no no no Resident #1 was found behind Resident #2 , his pants down and his hand on her shoulder . Resident #1 had a partially erect penis and was thrusting toward resident #2. Resident #2's brief was down. Approximately 2-3 weeks earlier Resident #3 was found sitting on Resident #1's bed. He was standing between her legs hovering over her. Both were fully clothed. There were no interventions put in place. Facility failed to prevent Resident #4 from verbally and physically abusing Resident #5. On 3/19/22 Resident #4 was seen standing over Resident #5, while Resident #5 was in bed, yelling aggressively at him. No interventions were put in place at the time. On 4/9/22 Resident #4 was found hovering over Resident #5 yelling at him. The nurse aide opened the door to see what was happening and then closed the door and called for the nurse. She did not intervene and separate the Residents. She had not been trained on dealing with behaviors. Please accept the following plan of removal: 1. Notify V.P. of Clinical Operations of immediate Jeopardy status - On site 4/14/22 @ 3 pm 2. Notify Regional Director of operations of Immediate Jeopardy status - Onsite 4/14/22@ 3 pm. 3. Notify facility Medical Director of Immediate Jeopardy status- Notified via phone by ADON -4/14/22@ 4pm. 4. Resident #1 was immediately placed on 1:1 monitoring beginning @ 8:30 am on 4/11/22. Attending MD /Designee and responsible party were notified. Medication orders were received. He remained on 1:1 monitoring until transferred to a Behavioral Hospital @3:30 pm on 4/11/22. He remains at the Behavioral Hospital at time of this report. 5. Resident #2 was assessed by facility licensed nursing staff on 4/11/22@ 8:21 am with no visible injuries noted. She was calm. Attending MD /Designee and responsible party were notified. Responsible party later called facility and requested she be sent out for exam .MD/Designee were notified of family's request and order received to send to ER for evaluation and examination. She was transferred to a hospital on 4/11/22 @ 8:30 pm. She returned to the facility on [DATE] @ 3 am. Verbal report was received from nurse at Hospital indicating no abrasions, tears or injuries on physical exam, specimens were collected during exam and are pending completion by forensics lab. She has been noted to be in pleasant mood and in no immediate distress or discomfort noted. 6. Resident #3 has been assessed on numerous occasions for the past 3 weeks with no noted skin issues or obvious discomfort observed. 7. Resident #4 was placed on 15-minute interval monitoring beginning 4/9/22 @ 6am. Attending MD/Designee were notified. Order received to transfer to behavioral hospital. Resident remained on 15-minute monitoring until transferred to Behavioral Hospital on 4/9/22 @4:45 pm. He remains at a Behavioral Hospital at the time of this report. 8. Resident #5 was assessed by licensed nursing staff on 4/9/22 with no injuries noted. He was placed on 15-minute monitoring beginning 4/9/22 @ 6 am and monitoring was discontinued on 4/12/22@ 7am with no further incidents noted. 9. Residents who reside on the secure unit have had skin assessments completed by licensed nursing staff treatment nurse for any unidentified concerns with none identified. Initiated 4/13/22 @t 11 am and Completed 4/13/22 @ 3:30 pm by Treatment Nurse. 10. Residents who reside on the secure unit were evaluated for any physical aggressive behaviors with none identified. Initiated 4/14/22@ approx. 4:30 pm and Completed 4/14/22@ 5:30 pm by ADON. Care plans for Residents #1, 2 , 4 & 5 were updated to reflect identified event and interventions were reviewed . 11. Facility staff were provided education by DON/Designee on: 11a) Inappropriate Resident to Resident touching. Reporting procedures discussed. Initiated 4/13/22@ 12:30 pm, Follow up sessions @2:30 pm and 6pm Completed @ 6:30pm on 4/13/22 Total attendees on 4/13/22-51 Subsequent sessions on 4/14 /22@beginning @ 10am, Completed @ 10:30 am on 4/14/22 -Total attendees 11. Follow up sessions conducted @ 4/15/22 beginning @ 6am completed by 9am. Total Attendees 29. 11b) Supervision and Monitoring of Hall 3/Secure Unit. Content discussed and procedures discussed to facilitate monitoring of unit. Staff were educated that one staff would be monitoring Residents and the hallway on Hall 3 while care is being delivered by the other staff member. Staff were instructed to take turns with these roles and to notify the nurse if additional monitoring assistance is needed. Initiated 4/13/22@ 11am, Follow up sessions @ 2:30 pm. and 6:00 pm. Completed @ 6:30 pm on 4/13/22. Total attendees 50 Subsequent sessions on 4/14/22@ 10 am, Completed@ 10 :30 am. 12 attendees Follow up sessions beginning 4/15/22 @ 6 am completed @ 945 am. Total attendees 29. 11c) Abuse -Content Abuse Coordinator - contact #s and the facility Abuse Prohibition Guideline. Initiated 4/13/22@10:30 am, Follow up sessions @2:30 pm and 6 pm. Completed @ 6:30 pm on 4/13/22. Total attendees 63 Subsequent sessions 4/14/22 beginning @10 am, Completed @ 10:30 am on 4/14/22- 17 attendees Follow up sessions on 4/15/22 beginning at 6am completed at 945 am. Total attendees 29. 12. Facility staff were provided education by DON/Designee on: 12a) Behavior Assessment, Intervention and Monitoring - content included facility policy. Initiated 4/14/22@ 5:30 pm, Completed @ 5:50 pm on 4/14/22 Attendees 32. Follow up session on 4/15/22 beginning at 6 am completed by 945 am. Total attendees 22. 12b) Unmanageable Residents - content included facility policy. Initiated 4/14/22@ 5:30 pm Completed @ 6:00 pm on 4/14/22 Attendees 35 Follow up sessions on 4/15/22 beginning at 6 am completed at 945 am. Total attendees 29. 13. Facility were provided education by DON/Designee on resident to resident-resident altercations, content including reporting procedures, interventions, and documentation procedures. Initiated 4/15/22 at 6am completed at 945 am. Total attendees 27. 14. Staff who were not on duty will be notified, to come to the facility for education by the DON/designee. No staff will be allowed to work on the floor until education has been completed for items #13, #14a, #14b, #14c, 15a, and 15b . Administrator, DON, and MDS Coordinator will monitor for employee completion of required edu [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent abuse for 4 of 11 residents (Resident #s 1, 2, 4, and 5) reviewed for supervision. 1. The facility staff did not provide supervision to prevent Resident #1 from sexually abusing Resident #2 on 04/11/22. Resident #2 wandered into Resident #1's room. Resident #2 was heard yelling. Resident #1 was found behind Resident #2, his hand on her shoulder, holding his partially erect penis while thrusting toward Resident #2. Residents #1 and #2's briefs were down. 2. The facility staff did not separate and supervise Resident #5 to prevent his continued verbal and physical abuse of Resident #4. On 04/9/22 Resident #4 was found hovering over Resident #5 yelling at him. The NA B opened the door to see what was happening and then closed the door and called for the nurse. NA B left Resident #5 in imminent harm. An Immediate Jeopardy (IJ) situation was identified on 04/14/22 at 3:00 p.m. While the IJ was removed on 04/15/22, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, emotional distress, and death. Findings included: 1. Record review of face sheet dated 04/13/22, indicated Resident #1 was a [AGE] year-old male, admitted on [DATE] and his diagnoses included adjustment disorder (emotional or behavioral reaction to a stressful event or change in a person's life), [CONDITION(S)] (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), cognitive communication deficit (difficulty with thinking and how someone uses language), and [CONDITION(S)] (a serious mental disorder in which people interpret reality abnormally). Record review of MDS dated [DATE], indicated Resident #1's BIMS score was 7 (severe cognitive impairment), he wandered every 1-3 days, ambulated with a walker. There were no behaviors noted. Record review of Resident #1's care plan dated 04/11/22 indicated he displayed socially inappropriate behavior and inappropriate sexual gesture with a female resident. Interventions included 15-minute monitoring and sent out to behavioral hospital for evaluation and treatment. There was no previous care plan for sexually inappropriate behavior available for review. Record review of face sheet dated 04/13/22, indicated Resident #2 was a [AGE] year-old female, admitted on [DATE], and her diagnoses included Alzheimer's (a progressive neurologic disorder that causes the brain to shrink (atrophy) and brain cells to die) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of MDS dated [DATE] indicated Resident #2 had a BIMS score of 2 (severe cognitive impairment), wandered daily, and ambulated without assistance. Record review of care plan dated 12/30/21 indicated Resident #2 required placement on the secure unit due to wandering and significant safety awareness due to dementia. Interventions included assist with location of room with verbal cures, notify physician if behavior increases (1/18/22- in and out of other residents' rooms, at times will take things out of other residents' rooms, 2/6/22 altercation with another resident, 2/11/22 attempted to take another residents walker, 4/11/22 victim of inappropriate sexual gesture). The care plan did not address supervision. Observation conducted on 04/14/22 with the Administrator, DON and ADON, who verified the identity of the staff and residents, of the facility's two separate camera recordings on 04/08/22 from 7:30 a.m. through 8:30 a.m. indicated: At 8:09 a.m. there were no aides on the hall, Resident #2 wandered on hall and then back into her room. Camera error exact time unknown-CNA F went into another resident's room while CNA C was in the shower room. At 8:13 a.m. Resident #2 wandered into the hall, then into a resident room next to the shower room. At 8:14 a.m., CNA C out of shower to get a wheelchair and then back into shower room. At 8:16 a.m., CNA C opened the shower door and took a resident in a wheelchair out of the shower. CNA C walked past the resident room next to the shower room. CNA C walked into Resident #1's room, escorted Resident #2 out of Resident #1's room and walks back toward Resident #2's room at the opposite end of the hall. At 8:19 a.m. CNA F comes out of other residents' room. Record review of nurse note dated 04/11/22 at 4:08 p.m., completed by LVN D, indicated CNA C heard Resident #2 scream no don't do that when she entered the room. The door was open and she witnessed Resident #1 standing behind Resident #2. Resident #1 was holding on to Resident #2 with one hand, his pants were down and he was exposed. Resident #2's pants were down and she was exposed. Record review of nurse note dated 04/11/22 at 4:18 p.m., completed by the DON, indicated CNA C exited the shower room at approximately 8:15 a.m. and heard Resident #2's raised voice coming Resident #1's room. CNA C entered the room and noted Resident #2 had his pants down and was standing behind Resident #2. Resident #1 had his penis in his hand and was saying 'get it, get it'. Resident #2's incontinence protective wear and pants were down. CNA C separated Resident #1 and #2 and immediately removed Resident #2 from the room. DON and Treatment nurse examined Resident #2 in her room and did not notice any redness or drainage to rectal or perineal/vaginal area. Resident #2 was calm at the time of the examination. No injuries noted. The physician was notified and new orders to send Resident #1 to behavioral hospital for evaluation and treatment. The administrator was notified. Resident #2's daughter was notified. Psych services was notified. Record review of NP E's visit report dated 04/11/22 indicated Resident #1 denied any inappropriate behaviors occurred. Resident #1's BIMS was assessed and scored at 15. Record review of Resident #1's behavior monitoring from 01/01/22 through 04/08/22 indicated no behaviors were documented. Record review of Resident #2 behavior monitoring from 01/01/22 through 04/08/22 indicated there were 79 incidents of wandering into other residents' rooms and the nurse was notified. During an interview on 04/13/22 at 8:35 a.m. the Administrator said CNA C came out of the shower room and heard Resident #2 say 'stop'. She said the door was open and she saw Resident #1 standing behind Resident #2. She said both residents' pants and briefs were down. She said Resident #1 had his penis in his hand. She said Resident #2 was assessed and it was not determined she was penetrated. She said psych services was contacted and increased Resident #1's [MEDICATION(S)] (an antidepressant medication). She said Resident #1 denied the allegations. She said Resident #1's last BIMS score was a 7 but he was re-assessed and it was 15. She said Resident #1 had previous sexually inappropriate behaviors and would masturbate on the porch. She said he was easily re-directed. During an interview on 04/13/22 at 9:10 a.m., CNA C said she was previously trained on abuse and neglect prevention. She said approximately 2 or 3 weeks prior she had previously caught Resident #1 with another resident sitting on his bed. She said Resident #1 was standing between the other resident's legs as she was sitting on his bed. She said both residents were fully dressed. She said Resident #1 stepped back and said he was trying to help the other resident. She said she thought she told LVN G of the incident. She said the most recent incident occurred after breakfast at approximately 8:15 a.m. She said was in the shower room when heard Resident #2 scream No don't do that no no no. She said she brought the other resident out of the shower room and walked to Resident #1's room. She said both Resident #1 and Resident #2's pants were down. She said Resident #1 had his penis in his hand and was holding Resident #2's left shoulder as he was telling Resident #1 to get it, get it as he was thrusting. She said Resident #1 sat down on his bed when he walked into the room. She said Resident #2 was crying. She said she dressed Resident #2 and walked her out of the room. She said she and CNA F were working the secure unit together. She said they had cell phones to call the nurse if there as an emergency. During an interview on 04/13/22 at 9:47 a.m., the DON said she had heard of the incident of another resident being in Resident #1's room but she was not told the incident was sexual. During an interview on 04/13/22 at 11:35 a.m., LVN I said she had witnessed an incident approximately 2 - 3 months prior where another resident had taken off her clothes in her room and her roommate had opened the door as Resident #1 walked by. She said he stopped and stared, and when asked why he did that he said because he could. She said she had heard of the incident where he stood over the same resident while she sat on his bed. During an interview on 04/13/22 at 11:53 a.m., LVN G said she had not noticed Resident #1 having inappropriate sexual behaviors. She said Resident #1 did stare at the resident that was found sitting on his bed. During an interview on 04/14/22 at 10:15 a.m., the DON said she was not able to locate LVN A, NA B, or CNA C's training for sexually inappropriate behaviors or resident abuse. During an interview on 04/14/22 at 1:30 p.m., the Administrator said she was not aware of any previous incidents related to inappropriate sexual behavior. She said she was not aware LVN A, NA B, or CNA C were not trained. She said she became the new Administrator in January 2022 and was not aware staff was not trained. She said she and the DON or designee were responsible for ensuring staff was trained. During an interview on 04/14/22 at 1:54 p.m., the DON said both aides on the secure unit should not be providing resident care at the same time. She said one of the aides was supposed to monitor and supervise the other residents and the hall to ensure residents do not wander or to be able to intervene for resident safety. She said she was not able to locate training records to indicate the staff had been trained. She said she or designee were responsible for ensuring staff was trained. She could not say why the staff were not trained or she could not locate the training records. During an interview on 04/14/22 at 2:05 p.m., CNA F said a resident came out of his room and the resident required incontinent care. She said she went into the shower room to gather supplies. She said CNA C was almost finished showering a different resident so she left the shower room and assisted the other resident with his incontinent care. She said she did not see Resident #2 wandering in the hall. She said had been working for 2 months and did not recall specific training related to monitoring the residents prior to the incident on 04/08/22. During an interview on 04/15/22 at 3:34 p.m. the administrator and DON said they had re-inserviced and educated three staff on 04/13/22 working on hall 300 to have one staff monitoring and the other staff providing care. They said staff were also trained to request help when they need to take care of residents and they were monitoring the hall. The DON said she was not able locate any staff training records that contained the names of the staff that worked during the incident. She said NA B was not a certified aide and there was no record she was trained regarding resident to resident aggression. During an interview on 04/15/22 at 4:14 p.m., Psych NP J said he received a call from the facility the morning of the incident with Residents #1 and #2. He said he had worked with Resident #1 for many years. He said Resident #1 had multiple hypersexual behaviors in the past that included exposing himself to others and masturbating. He said he had just recently started seeing Resident #2 as she was wandering and stealing items from other residents' rooms. He said staff have to monitor, intervene, and divert residents' behaviors. 2. Record review of face sheet dated 04/04/22 indicated Resident #4 was a [AGE] year-old male who was admitted on [DATE]. His diagnoses included [CONDITION(S)] (a serious mental disorder in which people interpret reality abnormally), dementia with behaviors, delusional disorders (serious mental illness - called a [CONDITION(S)]- in which a person cannot tell what is real from what is imagined), and anxiety (a feeling of fear, dread, and uneasiness). Record review of MDS dated [DATE] indicated Resident #4 had severe cognitive impairment and wandered every 1 to 3 days. There were no behaviors documented. Record review of care plan dated 10/08/21 indicated Resident #4 had a history of physical aggressive behavior. Interventions included social services to evaluate and visit, activities staff to visit and provide diversional activities, talk in a calm voice when behavior is disruptive, and remove from public area when behavior is disruptive and unacceptable. Record review of care plan dated 04/09/22 indicated Resident #4 exhibited aggressive behavior noted by staff standing over another resident and yelling, threatening and physical aggression directed at staff trying to diffuse the situation. Interventions included placing Resident #4 in an area for frequent observation social services to evaluate and visit, activities staff to visit and provide diversional activities, talk in a calm voice when behavior is disruptive, and remove from public area when behavior is disruptive and unacceptable, and sent to behavior hospital for evaluation/treatment. There was no care plan to address verbal and physical aggression towards his roommate that occurred on 03/19/22. Record review of Resident #4's behavior monitoring from 01/01/22 through 04/09/22 indicated on 04/05/22 CNA C noted verbal behaviors directed at others included threatening others, screaming/yelling at others, and cursing at others-nurse notified. There were no additional dates completed. Record review of nurse note dated 03/19/22 at 2:22 p.m., completed by LVN L, indicated LVN L heard shouting from Resident #4's room. LVN L observed Resident #4 shouting aggressively as he stood over Resident #5. Resident #4 was redirected to the dining room and offered snacks. Resident #4 refused snacks. LVN L notified CNAs to be on alert for any aggressive behavior towards other residents. Resident #5 had no apparent injuries and denied pain. Record review of a face sheet dated 04/04/22 indicated Resident #5 was a [AGE] year-old male, admitted on [DATE], and his diagnoses included catatonic [CONDITION(S)] (rare severe mental disorder characterized by striking motor behavior, typically involving either significant reductions in voluntary movement or [CONDITION(S)] and agitation), vascular dementia with behavioral disturbances (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), paranoid [CONDITION(S)] (characterized by predominantly positive symptoms of [CONDITION(S)], including delusions and hallucinations), major depressive disorder (serious mood disorder), and anxiety. Record review of an MDS dated [DATE] indicated Resident #5 had severe cognitive impairment. Wandered every 1 to 3 days. There were no physical or verbal behaviors noted. Record review of Resident Incident Report dated 04/09/22 at 5:25 a.m. and completed by LVN A indicated NA B entered Resident #4 and Resident #5's room and found Resident #4 bent over Resident #5. Resident #4 was yelling at Resident #5. LVN A separated the residents. Resident #4 sat at the foot of his bed. LVN A sat on the floor by the foot of his bed. LVN A reached down to assist Resident #4 from the floor and Resident #4 swung his fist and struck LVN A's upper right arm. Resident #4 yelled he was going to kill LVN A. Resident #5 was moved to a different room. During an interview on 04/13/22 at 2:08 p.m., NA B said she heard voices and yelling and went to Residents #4 and #5's room. She said she opened the door and saw Resident #4 standing over Resident #5 while Resident #5 lay in his bed. She said she shut the door and told the other staff to get LVN A. She said she did not know why she did not intervene. She said she was not a certified aide and was not trained on behaviors. She said she was not trained on how to redirect residents. She said LVN A came to the room and directed Resident #4 to his bed. She said Resident #4 went toward his bed and said, I'll [OBSCENITY] ing kill you. She said CNA K was on shift with her. Record review of CNA K's undated statement included in the ongoing facility's investigation indicated CNA C told her she heard shouting and rumbling in the room and for her (CNA K) to go and get LVN A. LVN A opened the door and LVN A, CNA C and CNA K walked into Resident #4 and Resident #5's room. Resident #4 was standing over Resident #5 hitting him and cursing at him. LVN A was able to get Resident #4 off Resident #5. Resident #4 started to swing and curse at LVN A. Resident #4 fell on the floor as he swung. LVN A directed CNA K to get LVN I. LVN I tried to talk to Resident #4 and he started cursing at LVN A and picked up a shoe. LVN A moved Resident #5 to another room. All staff left Resident #4's room for their safety. During an interview on 04/13/22 at 4:27 p.m., LVN A said he was not trained on dementia for the secure unit. He said he was not aware of any specific care plans for Resident #4. He said there were other incidents of Resident #4 yelling at Resident #5 but he was able to redirect him. He said if resident #4 was not able to see' Resident #5 then he would calm down. He said he did not do a nurse note or an incident report. He could not say why he did not document the incident. He said the most recent incident, Resident #4 was screaming at the top of his lungs at Resident #5. He said Resident #4 continued to yell at Resident #5 when he (LVN A) got between the residents. He said Resident #5 said Resident #4 hit him in the back. He said Resident #5 did not have any marks on his back. He said Resident #4 was pretty traumatized for the next day or two. Record review of nurse note dated 04/09/22 at 10:47 a.m., completed by LVN A, indicated LVN A was called to Resident #4 and Resident #5's room at 5:25 a.m. LVN A found Resident #4 standing over Resident #5, yelling. LVN A directed Resident #4 to sit on his bed but he sat on the floor. LVN A attempted to help him up but Resident #4 hit LVN A on the right upper arm and started to yell he was going to kill LVN A. LVN A moved Resident #5 to another room for safety. Resident #5 stated Resident #4 hit him in the back. There was no visible injury. Resident #5 was resting in a safe bed. Notified on-call ADON, and the ADON notified the DON. DON stated she was going to send Resident #4 to a behavioral hospital. During an interview on 04/13/22 at 8:35 a.m. the Administrator said she was not aware of any previous incidents between Residents #4 and #5. She said she was new to the facility as of January 2022 and no one reported anything during the morning meetings. She said they were roommates. She said Resident #4 was found standing over Resident #5. She said Resident #4 was recently put on [MEDICATION(S)] (antipsychotic medicine) for talking to inanimate objects. She said he was put on 1-1 staffing with 15-minute monitoring and sent to a behavior hospital for evaluation and treatment. During an interview on 04/14/22 at 1:54 p.m., The DON said she would have separated Residents #4 and #5 and they would not have continued as roommates if she was made aware of the previous incidents. She said no one told her of the previous incidents and nothing was reported during morning meeting. During an interview on 04/14/22 at 2:08 p.m., NA B said she realized after she shut the door of Residents #4 and #5 room that she had left Resident #5 in danger. She said she stood right outside of the door until LVN A arrived and intervened. During an interview on 04/15/22 at 3:34 p.m. the administrator and DON said NA B should have intervened and not shut the door. The DON said NA B was a new aide and she needed more experience and training. They said staff were also trained to request help when they need to take care of residents. The DON said LVN A should have documented the prior incident and notified the administrator (the abuse coordinator and/or designee). The DON said she was not able locate staff training records that contained the names of the staff that worked during the incident. During an interview on 04/15/22 at 4:14 p.m., psych NP J said he was not made aware of previous incidents of aggression from Resident #4. He said he would have addressed the aggressions and recommended Residents #4 and #5 be separated and not continued their status as roommates. Record review of In-Service Training Report dated 09/21/21 indicated the topic was safety monitoring-Hall-3: Hall-3 staff are to have safety monitoring of hall at all times. Staff may take turns, being safety monitor. Observe for potential abuse behaviors, wandering, and/or falls and attempt to prevent altercations and incidents. The in-service did not include the names of the LVN A, NA B, CNA C, or CNA K. Record review of the facility's Safety and Supervision of Residents policy dated 2001 indicated Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision .5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently; .Systems Approach to Safety .2. Resident supervision is a core component of the systems approach to safety. The type and frequency of the resident supervision is determined by the individual resident's assessed needs .Resident Risks and Environment Hazards .risk factors and environmental hazards include: .d. unsafe wandering; . Record review of the facility's Behavioral Assessment, Intervention and Monitoring policy dated 2001 indicated .8. Interventions and approaches will be based on detailed assessment of physical, psychological and behavioral symptoms and their underlying causes.interventions will be adjusted based on the impact on behavior and other symptoms . The facility was notified of the Immediate Jeopardy on 04/14/22 at 3:00 p.m. and the administrator was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 04/15/22 at 1:55 p.m. and reflected the following: Facility failed to prevent Resident #1 from sexually abusing Resident #2. On 4/11/22 Resident #2 was heard yelling please don't no no no Resident #1 was found behind Resident #2 , his pants down and his hand on her shoulder . Resident #1 had a partially erect penis and was thrusting toward resident #2. Resident #2's brief was down. Approximately 2-3 weeks earlier Resident #3 was found sitting on Resident #1's bed. He was standing between her legs hovering over her. Both were fully clothed. There were no interventions put in place. Facility failed to prevent Resident #4 from verbally and physically abusing Resident #5. On 3/19/22 Resident #4 was seen standing over Resident #5, while Resident #5 was in bed, yelling aggressively at him. No interventions were put in place at the time. On 4/9/22 Resident #4 was found hovering over Resident #5 yelling at him. The nurse aide opened the door to see what was happening and then closed the door and called for the nurse. She did not intervene and separate the Residents. She had not been trained on dealing with behaviors. Please accept the following plan of removal: 1. Notify V.P. of Clinical Operations of immediate Jeopardy status - On site 4/14/22 @ 3 pm 2. Notify Regional Director of operations of Immediate Jeopardy status - Onsite 4/14/22@ 3 pm. 3. Notify facility Medical Director of Immediate Jeopardy status- Notified via phone by ADON -4/14/22@ 4pm. 4. Resident #1 was immediately placed on 1:1 monitoring beginning @ 8:30 am on 4/11/22. Attending MD /Designee and responsible party were notified. Medication orders were received. He remained on 1:1 monitoring until transferred to a Behavioral Hospital @3:30 pm on 4/11/22. He remains at the Behavioral Hospital at time of this report. 5. Resident #2 was assessed by facility licensed nursing staff on 4/11/22@ 8:21 am with no visible injuries noted. She was calm. Attending MD /Designee and responsible party were notified. Responsible party later called facility and requested she be sent out for exam .MD/Designee were notified of family's request and order received to send to ER for evaluation and examination. She was transferred to a hospital on 4/11/22 @ 8:30 pm. She returned to the facility on [DATE] @ 3 am. Verbal report was received from nurse at Hospital indicating no abrasions, tears or injuries on physical exam, specimens were collected during exam and are pending completion by forensics lab. She has been noted to be in pleasant mood and in no immediate distress or discomfort noted. 6. Resident #3 has been assessed on numerous occasions for the past 3 weeks with no noted skin issues or obvious discomfort observed. 7. Resident #4 was placed on 15-minute interval monitoring beginning 4/9/22 @ 6am. Attending MD/Designee were notified. Order received to transfer to behavioral hospital. Resident remained on 15-minute monitoring until transferred to Behavioral Hospital on 4/9/22 @4:45 pm. He remains at a Behavioral Hospital at the time of this report. 8. Resident #5 was assessed by licensed nursing staff on 4/9/22 with no injuries noted. He was placed on 15-minute monitoring beginning 4/9/22 @ 6 am and monitoring was discontinued on 4/12/22@ 7am with no further incidents noted. 9. Residents who reside on the secure unit have had skin assessments completed by licensed nursing staff treatment nurse for any unidentified concerns with none identified. Initiated 4/13/22 @t 11 am and Completed 4/13/22 @ 3:30 pm by Treatment Nurse. 10. Residents who reside on the secure unit were evaluated for any physical aggressive behaviors with none identified. Initiated 4/14/22@ approx. 4:30 pm and Completed 4/14/22@ 5:30 pm by ADON. Care plans for Residents #1, 2 , 4 & 5 were updated to reflect identified event and interventions were reviewed . 11. Facility staff were provided education by DON/Designee on: 11a) Inappropriate Resident to Resident touching. Reporting procedures discussed. Initiated 4/13/22@ 12:30 pm, Follow up sessions @2:30 pm and 6pm Completed @ 6:30pm on 4/13/22 Total attendees on 4/13/22-51 Subsequent sessions on 4/14 /22@beginning @ 10am, Completed @ 10:30 am on 4/14/22 -Total attendees 11. Follow up sessions conducted @ 4/15/22 beginning @ 6am completed by 9am. Total Attendees 29. 11b) Supervision and Monitoring of Hall 3/Secure Unit. Content discussed and procedures discussed to facilitate monitoring of unit. Staff were educated that one staff would be monitoring Residents and the hallway on Hall 3 while care is being delivered by the other staff member. Staff were instructed to take turns with these roles and to notify the nurse if additional monitoring assistance is needed. Initiated 4/13/22@ 11am, Follow up sessions @ 2:30 pm. and 6:00 pm. Completed @ 6:30 pm on 4/13/22. Total attendees 50 Subsequent sessions on 4/14/22@ 10 am, Completed@ 10 :30 am. 12 attendees Follow up sessions beginning 4/15/22 @ 6 am completed @ 945 am. Total attendees 29. 11c) Abuse -Content Abuse Coordinator - contact #s and the facility Abuse Prohibition Guideline. Initiated 4/13/22@10:30 am, Follow up sessions @2:30 pm and 6 pm. Completed @ 6:30 pm on 4/13/22. Total attendees 63 Subsequent sessions 4/14/22 beginning @10 am, Completed @ 10:30 am on 4/14/22- 17 attendees Follow up sessions on 4/15/22 beginning at 6am completed at 945 am. Total attendees 29. 12. Facility staff were provided education by DON/Designee on: 12a) Behavior Assessment, Intervention and Monitoring - content included facility policy. Initiated 4/14/22@ 5:30 pm, Completed @ 5:50 pm on 4/14/22 Attendees 32. Follow up session on 4/15/22 beginning at 6 am completed by 945 am. Total attendees 22. 12b) Unmanageable Residents - content included facility policy. Initiated 4/14/22@ 5:30 pm Completed @ 6:00 pm on 4/14/22 Attendees 35 Follow up sessions on 4/15/22 beginning at 6 am completed at 945 am. Total attendees 29. 13. Facility were provided education by DON/Designee on resident to resident-resident altercations, content including reporting procedures, interventions and documentation procedures. Initiated 4/15/22 at 6am completed at 945 am. Total attendees 27. 14. Staff who were not on duty will be notified, to come to the facility for education by the DON/designee. No staff will be allowed to work on the floor until education has been completed for items #13, #14a, #14b, #14c, 15a, and 15b . Administrator ,DON, and MDS Coordinator will monitor for employee completion of required education topics . Administrator, DON, MDS Coordinator and HR Director will conduct audits of current facility employees and indicate completion dates for required education . Staff are being notified to report to facility for education completion via phone and texts. Notifications started on 4/14/22 @ 3:30 pm and are continuing on 4/15/22. Administrator, DON and MDS Coordinator will continue to audit , notify, and provide education items until all employees have completed the requirement . 15. Safe surveys were conducted for Residents on the secure unit and reside in the facility general population area with no safety or abuse concerns identified. Initiated 4/13/22 @ 4:00 per Social Worker and Completed 4/14/22@8:20 pm per facility Administrator . 10 Residents interviewed. 16. Compliance will be monitored through: 16a) Review of 24-Hour Reports, A/I Reports and Medical record review by Nursing Management and Administrator during Clinical meetings with corrective actions taken for identified concerns. The DON and administrator will conduct clinical meetings 3 x weekly and this will be an ongoing process. 16b) Findings will submitted to the facility QAPI Committee for review and additional Audits and corrective actions if indicated. 17. Facility Administrator and the DON were provided education on compliance and monitoring procedures by V.P. Of Clinical Operations. Monitoring of the facility's plan or removal occurred on 04/15/22 and included the following: Observations, interviews, and record reviews were conducted on 04/15/22 from 12:00 p.m. through 4:35 p.m. and included 9 residents, 6 nurses including charge nurses, treatment nurse, MDS nurse, 6 certified nurse aides, activity director, activity coordinator, BOM, housekeeping, dietary staff, and the ADON and DON that were on duty during this time. Staff were able to identify inappropriate resident to resident touching and reporting procedures. Staff provided appropriate resident supervision and redirection. There were no observed concerns. Staff were able to disc [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents was provided for 1 of 4 Residents (Resident #1) reviewed for accidents. Resident #1 was transferred to and from the wheelchair without using a Hoyer lift resulting in a fractured right leg. This failure could place residents at risk for improper care, injury, pain, and decreased quality of life. Findings included: Record review of Resident #1's face sheet dated 4/6/22, indicated Resident #1 was [AGE] years old and admitted on [DATE]. Resident #1's diagnoses included: unspecified fracture of right femur (thigh bone), [CONDITION(S)] (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), and [CONDITION(S)] (a disease in which the immune system eats away at the protective covering of nerves). Record review of Resident #1's MDS dated [DATE] indicated Resident #1 was cognitively intact. No transfers occurred in the assessment period. Record review of Resident #1's care plan dated 4/16/21 and reviewed 12/30/21 indicated Resident #1 required a Hoyer lift (a mobility tool used to help residents with mobility challenges get out of bed) for all transfers due to poor trunk/limb control secondary to [CONDITION(S)]. Record review of a progress noted dated 3/2/22 at 10:54 p.m., completed by LVN A, indicated Resident #1 complained of right knee pain. Resident #1 told her she felt her knee pop while CNAs were repositioning her in bed. There was no bruising or swelling noted at the time. The Resident's leg was elevated on a pillow and the resident was given pain medication. Record review of an incident report dated 3/3/22, completed by LVN H, indicated Resident #1 reported she was lifted by two CNAs when one of the CNAs stumbled trying to lift her out of her electric wheelchair without a lift pad. The resident indicated she landed in bed and the CNAs fell over on her leg causing pain. LVN H documented Resident #1 had a bruise and swelling to the right knee. Record review of an x-ray report dated 3/3/22 indicated Resident #1 had mild arthritic changes of the knee with acute distal femur fracture. During an observation and interview on 04/06/22 at 12:02 p.m., Resident #1 was in her bed with her right leg elevated and she was eating her lunch. She said she did not want to get out of bed. She said CNA F transferred her from her bed to her wheelchair and did not know why she did not use the Hoyer lift to transfer her. She said she told CNA F to put her down, but CNA F wrapped her arms around her (Resident #1) and transferred her to the wheelchair. She said when she was put back in bed that evening, the staff did not use a Hoyer lift. She said her knee popped when she was transferred to the bed. She said she had some pain and received pain medication. She said the staff always used the Hoyer lift when she was being transferred. She said she did not know why the staff transferred her without the Hoyer lift that day. During observation rounds on 4/6/22 from 12:02 p.m. to 2:30 p.m. Resident #2 and #3 were up in their wheelchairs and had lift pads underneath them. There were no opportunities for observations of Hoyer lift transfer during the investigation. During an interview on 04/06/22 at 12:24 p.m., LVN A said staff were not supposed to transfer or lift residents who required a Hoyer lift without using the Hoyer lift. She said she was called to Resident #1's room by CNA G on 3/2/22 around 8:30 p.m. She saw there was no lift pad under Resident #1. She went to get one and took it back to the room. She said Resident #1 repeatedly kept saying she wanted to get to bed. She said rather than trying to put the Hoyer lift pad underneath Resident #1, CNA G and CNA I each got opposite sides of Resident #1 and transferred her to bed. She said Resident #1 fell on to her side. She said when CNA G and CNA I laid Resident #1 on her back, Resident #1 said her knee had popped. She said Resident #1 did not complain of pain initially and she thought it was because she had administered a pain pill at 6:00 p.m. She said staff received training on Hoyer lifts and transfers prior to the incident and immediately after the incident. She said she checked on Resident #1 throughout the night and she did not complain of any pain. Record review of an Employee Counseling Form dated 3/4/22 indicated CNA F told the DON she could not get to a Hoyer lift on Hall 2 because it was lunch time, and the other Hoyer lift's wheel was stuck. Resident #1 was demanding to get up before lunch time. CNA F indicated the CNA on Hall 1 was not available to help her, so she transferred Resident #1 without difficulty and did not put a Hoyer pad underneath her. Attempted to call CNA F on 4/6/22 at 12:50 p.m. regarding the incident involving Resident #1's incident. A message was left for her to call. During an interview on 4/6/22 at 1:59 p.m., CNA G said she was teaching another CNA how to use the Hoyer lift. She said Resident #1 was supposed to have a Hoyer lift for all transfers. CNA G said Resident #1 did not have a lift pad under her. Resident #1 told her the aide in the morning gave her a bear hug and transferred her. CNA G said she went to get the nurse because Resident #1 did not have the pad under her for the Hoyer lift. CNA G said she and CNA I did a 2-person transfer to put Resident #1 in bed. She said Resident #1 kept telling them to just get her back in bed. She said when they transferred her the Resident wound up face down and they had to reposition her. She said when they repositioned her, they heard a pop. CNA G said she does not know who said someone fell on Resident #1. She said nobody fell on the resident. CNA G said she did not feel comfortable transferring Resident #1 without the Hoyer lift. She said looking back they probably should have put the lift pad under her while she was in her wheelchair. During an interview on 4/6/22 at 2:31 p.m., LVN H said Resident #1 told her about her knee hurting and then told her she had been transferred without the Hoyer lift. She said she was not working the night of the incident. During an interview on 4/11/22 at 3:39 p.m., CNA I said she was asked to help transfer Resident #1 back to bed because she did not have the lift pad under her. She said Resident #1 was supposed to be transferred with the Hoyer lift. CNA I said she grabbed the upper part of her body and CNA G grabbed her lower body. When they got her in bed, she had to be repositioned because she had rolled onto her face. She said she thought she heard a pop when they repositioned her in bed. During an interview on 4/6/22 at 9:21 a.m., the DON said on the morning of 3/2/22 CNA F body lifted Resident #1 from her bed to her wheelchair. CNA F told the DON it was around lunch time and the lunch carts were on the hall so she could not get to the Hoyer lift and could not find any co-workers to assist her with a transfer so she made the decision to transfer Resident #1 because the Resident can pressure staff. The DON said that evening the staff were going to put Resident #1 back to bed and there was no lift pad underneath her. The CNAs got the nurse and they decided to do a 2-person transfer. When they got her in bed and were repositioning her, they heard a pop. She said Resident #1 opted not to have surgery for the fracture. She said Resident #1 should have been transferred with the Hoyer lift and the evening aides should have put the pad under her for the transfer. Record review of the facility's Safe Lifting and Movement of Residents policy revised October 2009 indicated In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility use appropriate techniques and devices to lift and move residents . 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of resident shall be eliminated when feasible .5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. During the exit conference on 4/06/22 at 4:20 p.m., the Administrator and the DON were asked for any additional information related to care plans. No additional information was provided.

Based on interview and record review the facility failed to ensure the advance directive was provided to EMT personnel upon transfer for 1 of 5 residents reviewed for advanced directives. (Resident #1) The facility did not send the completed Out of Hospital Do Not Resuscitate (OOH-DNR) form for Resident #1 when she was transferred to the hospital on [DATE]. Resident #1 received artificial ventilation, cardiopulmonary resuscitation, and advanced airway management against her wishes. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk of not having end of life choices respected. The findings included: Physician orders [REDACTED].#1 was admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The orders included hospice services and a code status of Do Not Resuscitate. A care plan dated [DATE] indicated Resident #1 was a DNR, with approaches including Should [MEDICAL CONDITION] occur and/or breathing independently cease, staff will allow a natural death. The care plan indicated Resident #1 was receiving hospice services. The most recent care plan conference summary dated [DATE] indicated Resident #1 was a DNR Code Status. An OOH-DNR dated [DATE] indicated Resident #1 directed cardiopulmonary resuscitation (CPR), transcutaneous cardiac pacing, defibrillation, advanced airway management, and artificial ventilation not be initiated or maintained. The form indicated the following: This document or a copy thereof must accompany the person during his/her medical transport. emergency room visit notes dated [DATE] at 6:32 a.m., indicated Resident #1 arrived at the emergency department on [DATE] at 6:06 a.m. with apnea and a weak thready [MEDICAL CONDITION] (irregular, fast) pulse. The note indicated Resident #1 arrived by ambulance and was receiving artificial ventilation via a bag valve mask. The note indicated the facility did not provide any DNR/DNI paperwork and reaffirmed with the emergency department multiple times the resident was a full code. The note indicated Resident #1 was aggressively managed with intubation and IV blood pressure medication, but lost a pulse at 6:25 a.m. The note indicated advanced cardiovascular life support and CPR were started and resident had a return of circulation, but remained intubated. The note indicated Resident #1's power of attorney called the emergency department and indicated the resident had a DNR/DNI. emergency room visit notes dated [DATE] at 7:00 a.m., indicated the physician had a round table discussion with Resident #1's family and the decision was made to respect the resident's wishes and extubate her in the emergency department. The note indicated Resident #1 expired in the emergency department at 10:32 a.m. A nursing note dated [DATE] at 7:19 a.m., indicated at 4:45 a.m. LVN A found Resident #1 lying in bed with her eyes open and unresponsive to verbal and physical stimuli. The noted indicated LVN A was unable to obtain 02 saturation (measuring oxygen in the blood) or blood pressure and Resident #1 had a respiratory rate of 40 and a heartrate of 115 beats per minute. The note indicated LVN A found no signed DNR in Resident #1's medical chart and called EMS. The note indicated LVN A told EMS Resident #1 did not have a signed DNR in her medical chart. The note indicated LVN A notified Resident #1's responsible party who told her Resident #1 was on hospice and had a DNR status. The note indicated LVN A told the responsible party there was no signed DNR on the medical chart and Resident #1 was transferred to the hospital and was being treated as a full code. During an interview on [DATE] at 9:10 a.m., the administrator said the nursing notes on [DATE] indicated Resident #1 became unresponsive and the nurse was unable to locate the DNR document in resident's chart and notified EMS of needed transport to the hospital. The administrator said the facility failed to have a copy of Resident #1's OOH-DNR in her medical record and the DNR record was not readily accessible to staff. During an interview on [DATE] at 9:15 a.m., the SW said Resident #1's OOH-DNR was not in her medical record on [DATE]. She said the OOH-DNR was later located in Resident #1's hospice chart. The SW said she performed an audit of all resident's charts for DNR records to ensure all medical charts identified the resident's code status and had appropriate documentation and did not find any other issues. During an interview on [DATE] at 9:25 a.m., the MDS coordinator said when a resident had a DNR status a red sheet would be placed in front of the resident's medical record and a signed OOH-DNR would be placed behind the red sheet. She said nurses are to look for both the red sheet and the signed OOH-DNR when sending a resident to the hospital. During an interview on [DATE] at 9:25 a.m., the ADON said the DNR document was not in Resident #1's medical chart on [DATE]. She said the DNR document was in Resident #1's hospice chart. She said it was the facilities protocol for the nurse to check the front of the chart for the documents needed before initiating CPR. If the documents are not in place, the resident is considered a full code status. All staff had been inserviced on this. During an interview on [DATE] at 10:37 a.m., a RN at the local hospital said Resident #1 arrived at the emergency department on [DATE] with respiratory difficulty. He said Resident #1 did not arrive with any documents indicating she had a DNR status and was intubated in the emergency department. The RN the family arrived and indicated Resident #1 had a DNR status and requested no life saving measures. The RN said the family signed the appropriate paperwork and Resident #1 was extubated and expired in the emergency department. An in-service dated [DATE] titled Advance Directives/DNR/Full Code indicated upon admission the SW would place a signed DNR order, signed DNR document and a red DNR paper in front of the chart of the all residents that had a DNR status. The in-service indicated the MDS nurse would address DNR status in the care plan. The in-service indicated nurses would check the chart for the code status of a resident immediately when resident declined or was unresponsive prior to initiating CPR. An in-service dated [DATE] titled Hospice indicated a hospice information sheet had been place in front of the charts of residents receiving hospice services. The in-service indicated the face sheet contained information regarding how to contact hospice and to call hospice with any and all problems for residents receiving services. Record review of 4 resident charts indicated 4 of 4 had appropriate paperwork in the front of the chart to indicate code status. Resident's #2 and #5 charts had a red sheet of paper with DNR documents in the front of the chart. Resident's #3 and #4 charts had a green sheet of paper in the front of t the chart that indicated a full code status. Review of the facility's policy Do Not Resuscitate Order reflected the following, 3. Should the resident be transferred to the hospital, a photocopy of the DNR order form must be provided to the EMT personnel transporting the resident to the hospital.

Based on interview and record review, the facility failed to ensure residents received adequate supervision and assistance was provided to prevent injury for 1 of 5 residents reviewed for accidents. (Resident #1) The facility did not prevent Resident #1 from falling during a Hoyer lift transfer. A strap on the Hoyer lift was not secured and came off, causing the resident to fall and sustain a neck fracture and ear laceration. This failure could place residents who required transfers with Hoyer lift at risk for injury, discomfort, and decreased quality of care. Findings included: The MDS dated [DATE] indicated Resident #1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The MDS further indicated Resident #1 was cognitively intact; was dependent for transfers and required the physical assistance of at least two staff for transfers, and he utilized a wheelchair for mobility. A care plan dated 12/08/18 indicated Resident #1 required the use of a Hoyer lift for safe transfers with the assistance of at least 2 staff members, with a goal of no harm would be sustained during transfers, staff would use the Hoyer lift for all transfers, and place left pad securely in place to prevent pinching or bruising during transfers. A nursing note dated 04/14/19 indicated Resident #1 fell from the Hoyer lift while two CNAs were transferring the resident from his bed to his wheelchair. The note indicated Resident #1 had a 2-inch skin tear to his right elbow with abrasion, and a tear on his right ear from the middle outer ear to outer inner ear, and [MEDICAL CONDITION] and a swollen abrasion to the lower area under the resident's right ear lobe. No other injuries were noted, and there were no complaints of pain. The resident remained on the floor in a fallen position until EMS arrived. Family and physician notified. During an interview on 04/24/19 at 1:34 p.m. CNA C said on 4/14/19, the day of the incident, she hooked up the sling to transfer Resident #1 from his bed to his wheelchair and she was called away by another resident. She said CNA A and CNA B took over transferring Resident #1. She said the strap was not broken and she did not know how the strap came off the arm of the Hoyer lift. She said the DON inspected the sling and tried to replicate the event to see how the sling strap came off the Hoyer lift, but could not determine how the strap came off. She said she was trained on Hoyer lift transfers prior to the incident. During an interview on 04/24/19 at 9:50 a.m., CNA A said Resident #1 fell from the Hoyer lift as she assisted him in the transfer from his bed to his wheelchair. She said the Hoyer lift and sling were in working condition at the time of the incident. She said the straps on the lift were not torn or broken. She said the strap came off the Hoyer lift. She said she was trained on Hoyer lift transfers prior to the incident. During an interview on 04/24/19 at 9:53 a.m. CNA B said Resident #1 fell from the Hoyer lift as she assisted him to transfer from his bed to his wheelchair. She said the Hoyer lift and sling were in working condition at the time of the incident. She said the straps on the lift were not torn or broken. She said while she assisted CNA A with the transfer, she heard a loud snap and the strap came off the Hoyer lift. She said she was trained on Hoyer lift transfers prior to the incident. The hospital dischage summary dated 04/18/19 indicated Resident #1's [DIAGNOSES REDACTED]. Resident #1's physician orders [REDACTED]. During an interview on 04/24/19 at 9:10 a.m., the ADON said Resident #1 was receiving [MEDICAL TREATMENT] treatment out of the facility and not available for interview. She said Resident #1's ear laceration required transfer to an out of town hospital for repair. During an interview on 04/24/19 at 1:00 p.m. the Director of Rehabilitation said he conducted one-on- one training with CNA C on 04/17/17. He said he conducted training on a regular basis, but had not yet completed one-on-one training with CNA A or CNA B, but the CNAs were checked off on using the Hoyer lift during their orientation. He said the sling strap could not slip off the arm of the Hoyer lift unless the strap broke or was not secured on the Hoyer lift. During an interview on 04/24/19 at 1:20 p.m., the administrator said the DON investigated the incident, and he reviewed the details. He said he did not have the sling that was used to transfer Resident #1. He said he inspected all the slings in the facility and there were no slings with broken straps. He said a staff one-on-one training was pending for all staff on Hoyer lift transfers and skills check by the therapy staff. The facility investigation report dated 04/15/19 indicated Resident #1 fell because the strap detached from the hook on the Hoyer lift arm. The facility inspected the Hoyer lift and all slings. New slings were ordered to replace any slings with wear and tear. The report indicated therapy staff were going to complete a one-on-one skills check for each staff. The Abuse Prohibition Guideline policy dated (YEAR) indicated Neglect includes but is not limited to failure to provide goods and services necessary to avoid physical harm . The sling instructions (undated) page 14 indicated place straps over the hooks of the swivel bar. Match the corresponding colors on each side of the sling for an even lift of the patient.

Based on observation, interview and record review, the facility failed to implement their written policies and procedures that prohibit and prevent neglect for 1 of 9 residents reviewed for neglect. (Resident #1) The facility did not report an allegation of neglect, immediately, but not later than 2 hours, to the state agency when Resident #1 sustained a fracture to her left leg during a transfer when the staff neglected to use a mechancial lift as required to transfer the resident. This failure could place 5 residents requiring the assistance of a Hoyer lift/mechanical lift and two staff for transfer at risk of abuse, injuries, and decreased self-worth. Findings included: An Abuse Prohibition Guideline dated (YEAR), defined neglect as failure to provide goods and services necessary to avoid physical harm and indicated Any employee who becomes aware of an allegation of abuse, neglect or misappropriation of resident property, shall report the incident to a supervisor, DON or Administrator immediately and to the state agency in accordance with state law. Physician orders [REDACTED].#1 was a [AGE] year-old female, re-admitted [DATE], with [DIAGNOSES REDACTED]. A care plan dated 11/09/17 indicated Resident #1 required the use of a mechanical lift for safe transfers with the assist of at least 2 staff members and noted staff was to use a mechanical lift for all transfers. The most recent MDS dated [DATE] indicated Resident #1 had clear speech, was understood by others, understands others. Resident #1 was cognitively intact and required extensive (two or more) persons physical assistance with bed mobility and transfers. During an interview on 07/24/18 at 3:30 p.m., Resident #1 said on 06/25/18 the aide told her the mechanical lift was broken and she and another aide would physically lift Resident #1 to her bed. Resident #1 said she told the aides she was scared to be transferred without the lift. She said the two aides were positioned under each of Resident #1's arms. Resident #1 said the aides lifted and turned her, and her left leg twisted and made a popping sound. Resident #1 said she told the aides to stop. She said she was hollering and her leg hurt. Resident #1 said she wished they would have had 3 staff to assist with the transfer. She said she was scared the staff would drop her. She said she told the nurse her leg hurt and described how the aides made her leg pop. During an interview on 07/25/17 at 11:57 a.m., CNA A said on 6/25/18, she could not find the mechanical lift and CNA B suggested a manual lift without the mechanical lift. CNA A said CNA B said the charge nurse said they could do a manual lift. CNA A said her feet became tangled with Resident #1's feet and she heard Resident #1's leg pop. She said she told CNA B to stop the transfer, but CNA A continued with the transfer until Resident #1 was in her bed. During an interview on 07/25/18 at 12:14 p.m., CNA B said on 6/25/18, Resident #1 said to go ahead and transfer her without the mechanical lift. CNA B said she did not tell LVN A they manually transferred Resident #1. She said, Resident #1 said her leg popped and hurt when we put her in the bed. CNA B said she told LVN A about the resident's complaint of pain. She said the facility did not have a working mechanical lift when she and CNA A transferred Resident #1 from her wheelchair to her bed. During an interview on 07/24/18 at 3:10 p.m., LVN A said on 06/26/18 CNA A and CNA B told her Resident #1 wanted to go to bed and did not want to wait for the mechanical lift. She said she told the aides to wait and she would check the battery on the lift to ensure it was charged. She said she went to Resident #1's room and found the resident was already in bed. LVN A said Resident #1 asked LVN A if her leg was supposed to pop. LVN A said Resident #1 told her the aides lowered the bed, lifted her out of the wheelchair and onto the bed. LVN A said she talked to the aides and was told Resident #1 did not complain of her leg popping or any pain during the transfer. LVN A said she assessed Resident #1 and there was no swelling or redness. She said she notified the physician when the CNAs reported the resident's leg popped when they transferred her. The physician ordered an x-ray. She said she found out Resident #1's leg was fractured when she returned to work the next day. An x-ray report for Resident #1 dated 06/26/18 indicated her bones were osteoporotic, and noted she had a fractured thigh bone, near the knee. During an interview on 07/24/18 at 11:15 a.m., the DON said two staff are required to assist with transfers for residents who require a mechanical lift. She said the facility's rented mechanical lift and the back-up battery on the newer mechanical lift were both picked up by the supply company. She said the newer mechanical lift ran out of battery and the facility's old mechanical lift had to be plugged in for charging. She said on 06/26/18, Resident #1 indicated she did not want to wait for the mechanical lift to charge and the aides had to lift the resident to bed. She said Resident #1 requested the staff lift her to her bed. During an observation on 07/24/18 at 11:00 a.m., the facility's mechanical lift was in working condition and had a charged battery. On 07/27/18 at 3:10 p.m. the DON indicated 5 residents required a Hoyer/mechanical lift for transfers.

Based on observation, interview, and record review, the facility failed to report all allegations involving neglect immediately to the administrator and state agency for 1 of 9 residents reviewed for neglect. (Resident #1) The facility did not report an allegation of neglect, immediately, but not later than 2 hours, to the state agency when Resident #1 sustained a fracture to her left leg during a transfer after the staff neglected to use a Hoyer lift (mechanical lift) to transfer the resident as per Resident #1's care plan. This failure could place 5 residents requiring the assistance of a mechanical lift and two staff for transfer at risk of abuse, injuries, and decreased self-worth. Findings included: Physician orders [REDACTED].#1 was a [AGE] year-old female, re-admitted [DATE], with [DIAGNOSES REDACTED]. A care plan dated 11/09/17 indicated Resident #1 required the use of a mechanical lift for safe transfers with the assist of at least 2 staff members and noted staff was to use a mechanical lift for all transfers. The most recent MDS dated [DATE] indicated Resident #1 had clear speech, was understood by others, understands others. Resident #1 was cognitively intact and required extensive (two or more) persons physical assistance with bed mobility and transfers. During an interview on 07/24/18 at 3:30 p.m., Resident #1 said on 06/25/18 the aide told her the mechanical lift was broken and she and another aide would physically lift Resident #1 to her bed. Resident #1 said she told the aides she was scared to be transferred without the lift. She said the two aides were positioned under each of Resident #1's arms. Resident #1 said the aides lifted and turned her, and her left leg twisted and made a popping sound. Resident #1 said she told the aides to stop. She said she was hollering and her leg hurt. Resident #1 said she wished they would have had 3 staff to assist with the transfer. She said she was scared the staff would drop her. She said she told the nurse her leg hurt and described how the aides made her leg pop. During an interview on 07/25/17 at 11:57 a.m., CNA A said on 06/25/18, she could not find the mechanical lift and CNA B suggested a manual lift without the mechanical lift. CNA A said CNA B said the charge nurse said they could do a manual lift. CNA A said her feet became tangled with Resident #1's feet and she heard Resident #1's leg pop. She said she told CNA B to stop the transfer, but CNA A continued with the transfer until Resident #1 was in her bed. During an interview on 07/25/18 at 12:14 p.m., CNA B said on 06/25/18, Resident #1 said to go ahead and transfer her without the mechanical lift. CNA B said she did not tell LVN A they manually transferred Resident #1. She said, Resident #1 said her leg popped and hurt when we put her in the bed. CNA B said she told LVN A about the resident's complaint of pain. She said the facility did not have a working mechanical lift when she and CNA A transferred Resident #1 from her wheelchair to her bed. During an interview on 07/24/18 at 3:10 p.m., LVN A said on 06/25/18 CNA A and CNA B told her Resident #1 wanted to go to bed and did not want to wait for the mechanical lift. She said she told the aides to wait and she would check the battery on the lift to ensure it was charged. She said she went to Resident #1's room and found the resident was already in bed. LVN A said Resident #1 asked LVN A if her leg was supposed to pop. LVN A said Resident #1 told her the aides lowered the bed, lifted her out of the wheelchair and onto the bed. LVN A said she talked to the aides and was told Resident #1 did not complain of her leg popping or any pain during the transfer. LVN A said she assessed Resident #1 and there was no swelling or redness. She said she notified the physician that the CNAs reported the resident's leg popped during a transfer, and the physician ordered an x-ray. She said she found out Resident #1's leg was fractured when she returned to work the next day. An x-ray report for Resident #1 dated 06/26/18 indicated her bones were osteoporotic, and noted she had a fractured thigh bone, near the knee. During an interview on 07/24/18 at 11:15 a.m., the DON said two staff are required to assist with transfers for residents who require a mechanical lift. She said the facility's rented mechanical lift and the back-up battery on the newer mechanical lift were both picked up by the supply company. She said the newer mechanical lift ran out of battery and the facility's old mechanical lift had to be plugged in for charging. She said on 06/25/18, Resident #1 indicated she did not want to wait for mechanical lift to charge and the aides had to lift the resident to bed. She said Resident #1 requested the staff lift her to her bed. During an observation on 07/24/18 at 11:00 a.m., the facility's mechanical lift was in working condition with a charged battery. During an interview on 07/25/18 at 1:30 p.m., the DON and Administrator indicated they did not report the incident as neglect because they knew Resident #1 had sustained a fractured leg during a manual transfer by CNA A and CNA B. They said they did not feel it was neglect due to the condition of Resident #1's bones and the [MEDICAL CONDITION] and LVN A and CNA A and CNA B said Resident #1 told them to transfer her without the Hoyer. The DON said she spoke Resident #1 on 06/26/18, the day after she was physically transferred, and Resident #1 said she did not say she wouldn't wait for the Hoyer. The DON and Administrator acknowledged Resident #1's care plan indicated she required all transfers by mechanical lift and at least 2 staff. An Abuse Prohibition Guideline dated (YEAR), defined neglect as failure to provide goods and services necessary to avoid physical harm and indicated Any employee who becomes aware of an allegation of abuse, neglect or misappropriation of resident property, shall report the incident to a supervisor, DON or Administrator immediately and to the state agency in accordance with state law. On 07/27/18 at 3:10 p.m. the DON indicated 5 residents required a Hoyer/mechanical lift for transfers.

Based interview and record review, the facility failed to ensure each resident received adequate assistive devices to prevent accidents for 1 of 9 residents reviewed for accidents. (Resident #1) Staff did not use a Hoyer lift (mechanical lift) as required to transfer Resident #1, resulting in a fracture to her left leg. This failure could place 5 residents who required the assistance of a mechanical lift at risk of injuries and decreased self-worth. Findings included: Physician orders [REDACTED].#1 was a [AGE] year-old female, re-admitted [DATE], with [DIAGNOSES REDACTED]. A care plan dated 11/09/17 indicated Resident #1 required the use of a mechanical lift for safe transfers with the assist of at least 2 staff members and noted staff was to use a mechanical lift for all transfers. The most recent MDS dated [DATE] indicated Resident #1 had clear speech, was understood by others, understands others. Resident #1 was cognitively intact and required extensive (two or more) persons physical assistance with bed mobility and transfers. During an interview on 07/24/18 at 3:30 p.m., Resident #1 said on 06/25/18 the aide told her the mechanical lift was broken and she and another aide would physically lift Resident #1 to her bed. Resident #1 said she told the aides she was scared to be transferred without the lift. She said the two aides were positioned under each of Resident #1's arms. Resident #1 said the aides lifted and turned her, and her left leg twisted and made a popping sound. Resident #1 said she told the aides to stop. She said she was hollering and her leg hurt. Resident #1 said she wished they would have had 3 staff to assist with the transfer. She said she was scared the staff would drop her. She said she told the nurse her leg hurt and described how the aides made her leg pop. During an interview on 07/25/17 at 11:57 a.m., CNA A said on 6/25/18, she could not find the mechanical lift and CNA B suggested a manual lift without the mechanical lift. CNA A said CNA B said the charge nurse said they could do a manual lift. CNA A said her feet became tangled with Resident #1's feet and she heard Resident #1's leg pop. She said she told CNA B to stop the transfer, but CNA A continued with the transfer until Resident #1 was in her bed. During an interview on 07/25/18 at 12:14 p.m., CNA B said on 6/25/18, Resident #1 said to go ahead and transfer her without the mechanical lift. CNA B said she did not tell LVN A they manually transferred Resident #1. She said, Resident #1 said her leg popped and hurt when we put her in the bed. CNA B said she told LVN A about the resident's complaint of pain. She said the facility did not have a working mechanical lift when she and CNA A transferred Resident #1 from her wheelchair to her bed. During an interview on 07/24/18 at 3:10 p.m., LVN A said on 06/25/18 CNA A and CNA B told her Resident #1 wanted to go to bed and did not want to wait for the mechanical lift. She said she told the aides to wait and she would check the battery on the lift to ensure it was charged. She said she went to Resident #1's room and found the resident was already in bed. Resident #1 asked LVN A if her leg was supposed to pop. LVN A said Resident #1 told her the aides lowered the bed, lifted her out of the wheelchair and onto the bed. LVN A said she talked to the aides and was told Resident #1 did not complain of her leg popping or any pain during the transfer. LVN A said she assessed Resident #1 and there was no swelling or redness. She said she notified the physician that the CNAs reported the resident's leg popped when they transferred her, and the physician ordered an x-ray. She said she found out Resident #1's leg was fractured when she returned to work the next day. An x-ray report for Resident #1 dated 06/26/18 her bones were osteoporotic, and noted she had a fractured thigh bone, near the knee. During an interview on 07/24/18 at 11:15 a.m., the DON said two staff are required to assist with transfers for residents who require a mechanical lift. She said the facility's rented mechanical lift and the back-up battery on the newer mechanical lift were both picked up by the supply company. She said the newer mechanical lift ran out of battery and the facility's old mechanical lift had to be plugged in for charging. She said on 06/25/18, Resident #1 indicated she did not want to wait for the mechanical lift to charge and the aides had to lift the resident to bed. She said Resident #1 requested the staff lift her to her bed. During an observation on 07/24/18 at 11:00 a.m., the facility's mechanical lift was in working condition with a charged battery. During an interview on 07/25/18 at 1:30 p.m., the DON and Administrator acknowledged Resident #1's care plan indicated she required all transfers by mechanical lift with assistance from least 2 staff. On 07/27/18 at 3:10 p.m. the DON indicated 5 residents required a Hoyer/mechanical lift for transfers.

Based on interview and record review, the facility failed to provide the necessary care and services for 5 residents reviewed for advanced directives who had requested CPR in the event of cardiac or respiratory arrest. Resident #1 was found not breathing and had no pulse. Chest compressions were begun by the LVN, but stopped. The resident expired at the facility. LVN A worked the remainder of the shift, came back to work the next day and remained on the working schedule. This failure created an Immediate Jeopardy situation. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at isolated with actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the 52 residents who were full code at risk for death. Findings included: Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 was alert and able to make decisions regarding his care. A care plan with an onset date of [DATE] indicated Resident #1 was a "full code," with approaches including: "Initiate CPR immediately in the event of [MEDICAL CONDITION]", and "Call EMS for hospital transfer." The most recent "Care Plan Conference Summary" dated [DATE] indicated Resident #1 was a full code. Nurse notes dated [DATE] indicated LVN A entered the Resident #1's room and the resident appeared unconscious. She initiated CPR but was unsuccessful. He had no pulse. During an interview on [DATE] at 10:58 a.m., LVN A said she knew Resident #1 was a "full code" because of the sheet in the front of his chart. She said on [DATE] about 9:15 p.m., CNA B told her Resident #1 was dead. She assessed the resident and he was not breathing and did not have a pulse. She began CPR, but said it was not successful and she stopped. She said she did not call the ambulance. She called the on-call nurse. During an interview on [DATE] at 11:07 a.m. the DON said LVN A worked on [DATE], the day after the incident and was to return Monday [DATE]. Nurse's notes dated [DATE] at 8:30 p.m. indicated resident was requesting water from the nurse. Nurse's notes dated [DATE] at 9:18 p.m., read as follows: "Enter rsdt (resident's) room- rsdt appears to be unconscious. CPR initiated, unsuccessful. No pulse no hearbeat from rdsdt." Nurse's nots dated [DATE] at 9:30 p.m. read as follows: "Called on-call phone. Spoke to (name deleted), called DON, spoke to (name deleted), called RP of rsdt, spoke to (name deleted)." The facility's staff sign in sheet dated [DATE] indicated LVN A worked 6 a.m. to 2 p.m. on that day. LVN A's written statement dated [DATE] indicated she completed two full cycles of chest compressions with no results. She then went to call the on call nurse. The DON told her to call the Justice of the Peace and the family. During an interview on [DATE] at 9:25 a.m., CNA B said on [DATE] at about 9:15 p.m., she saw Resident #1 from the doorway and his color did not look right. She went to check on him and noticed he was not breathing and he did not have a pulse. She went to get LVN A and told her she thought the resident was dead. The nurse walked to Resident #1's room. She said she never heard the nurse call a code or ask for help. During an interview on [DATE] at 6:20 a.m., the DON said when she first spoke to LVN A, she was told the LVN had not performed CPR. The DON reviewed the nurse notes and again questioned the LVN. The LVN told her, at that time, she had completed two rounds of CPR and stopped because there had been no response from the resident. LVN A's personnel file indicated she had been CPR certified on [DATE]. The facility's undated policy titled "Emergency Response to Respiratory or [MEDICAL CONDITION]," "Standard - Staff will respond with Emergency Cart and Perform CPR, for all "Full code" residents, until appropriate help arrives." The Texas Nursing Practice Act, effective [DATE], reads as follows: "(5) "Vocational nursing" means a directed scope of nursinig practice... The term does not include acts of medical diagnosis..." The Texas Board of Nursing Position Statement reads as follows: "LVNs must use clinical reasoning and established evidence-based policies, procedures or guidelines as the basis for decision making in nursing practice. LVNs are accountable and responsible for the quality of nursing care provided and must exercise prudent nursing judgment to ensure the standards of nursing practice are met at all times." and "The LVN, with a focus on patient safety, is required to function within the parameters of the legal scope of practice and in accordance with the federal, state, and local laws, rules, regulations and policies, procedures and guidelines of the employing health care institution or practice setting." The "Lippincott Manual of Nursing Practice" eighth edition, page 1143, under Cardiopulmonary Resuscitation, "Nursing Action" : "1. Determine unresponsiveness; tap or gently shake patient while shouting, "Are you okay?" 2. Activate emergency medical service (call local emergency telephone number or 911) if outside hospital." The next steps are to open airway, assess for breathing, perform rescue breathing if indicated, assess for heart beat and perform chest compressions if no heart beat is found. The administrator was notified on [DATE] at 12:25 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 12:55 p.m. and included: "- Surveyor cited Resident #1 as being affected by incident on [DATE] at 9:15 p.m. Incident resulted from LVN perpetrator not following policy and procedure for full code directive. - Residents under the care of LVN perpetrator have the potential to be affected. - Facility Intervention: (A) All licensed nursing staff in serviced on facility policy and procedure for full code residents on [DATE] and [DATE]. All in services given and future in services to licensed staff will be given before they take charge and will include hypothetical questions prompting verbal responses verifying their understanding. (B) Planned in service to all nursing staff on [DATE] explaining our policy and procedure. (C) LVN perpetrator terminated on [DATE]. - To ensure compliance QA committee will monitor this issue and make recommendations for corrective action. Administrator responsible for implementation and corrective actions." The surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the IJ by: Six LVNs and 4 CNAs were interviewed and were able to verbalize the policy regarding residents who were a full code. They each were able to state that if CPR was initiated, then it was to continue until help arrived. On [DATE] at 12:55 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at isolated actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The facility's "Physician order [REDACTED]."