Every finding on record at Avir at Magnolia

Based on observations, interviews, and record reviews, the facility failed to ensure that alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations are made to the abuse coordinator for two (Resident #1 and Resident #2) of five residents reviewed for abuse. The facility failed to notify the abuse and neglect coordinator (ADM) of the alleged abuse by CNA A towards Resident #1 and Resident #2 so it could be investigated and handled appropriately to ensure the residents' safety. The noncompliance was identified as PNC. The IJ began on 09/26/2025 and ended on 10/13/2025. The facility had corrected the noncompliance before the survey began on 10/14/2025. These failures could place residents at risk of abuse, neglect, trauma, and psychosocial harm. Findings included:Review of Resident #1's admission record, dated 10/14/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including depression (a mood disorder with persistent feelings of sadness and loss of interest), dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgment), epilepsy (a neurological disorder causing seizures), blindness in one eye (inability to see out of one eye), conductive hearing loss (when sound cannot reach the inner ear due to issues in the outer or middle ear) and cognitive communication deficit (a problem with communication caused by cognition rather than a language or speech deficit). Review of Resident #1's Quarterly MDS assessment, dated 08/27/2025, reflected a BIMS score of 07, indicating moderate cognitive impairment. Section GG (Functional Abilities) reflected she required substantial/maximal assistance for showering/bathe self.Review of Resident #1's care plan, dated 05/06/2025, reflected she was at risk for ADL self-care deficit with an intervention of providing assistance with ADLs/IADLs as needed. During an interview on 10/14/2025 at 12:20 PM, Resident #1 stated the facility and care provided to her was fine. Resident #1 stated no staff member had intentionally been mean to her or attempted to cause her harm. Resident #1 stated she felt safe in the facility.Review of Resident #2's admission record, dated 10/15/2025, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and most recent readmission on [DATE] with diagnoses including hemiplegia and hemiparesis (paralysis and weakness on one side of the body), dementia severe with mood disturbance (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgment causing behaviors), seizures, type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), depression (a mood disorder with persistent feelings of sadness and loss of interest), cerebral infarction (a blood clot blockage that impairs blood flow through the brain artery), dysphagia (difficulty swallowing), and cognitive communication deficit (a problem with communication caused by cognition rather than a language or speech deficit).Review of Resident #2's Quarterly MDS assessment, dated 08/21/2025, reflected a BIMS score of 06, indicating severe cognitive impairment. Section GG (Functional Abilities) reflected he was dependent on staff for toileting hygiene. Review of Resident #2's care plan, date initiated 07/23/2025, reflected he was at risk for harm: self-directed or other-directed with interventions that included: if resident poses a potential threat to injure self or others notify provider, utilize calming touch, and if safe, allow resident personal space. Review of Resident #2's care plan, dated 07/23/2025, reflected he was at risk for ADL self-care deficit with an intervention of providing assistance with ADLs/IADLs as needed.During an interview on 10/14/2025 at 1:04 PM, Resident #2 stated the care provided to him was alright. Resident #2 stated someone hurt him but was unable to provide a name or further information. Resident #2 then began asking for his mother.During a phone interview on 10/15/2025 at 09:23 AM, FM #2 stated Resident #2 had a history of physical abuse, though she was unsure of the details of the history of abuse. FM #2 stated Resident #2 is confused with short-term memory loss and some long-term memory loss. She stated she did not have any concerns related to staff taking care of Resident #2 and thought, when he stated someone hurt him, he was referring to his history of abuse prior to his admission to the facility. FM #2 stated Resident #2 had refused care and had increasing agitation but that started several months prior. She stated she didn't notice any changes in demeanor over the past couple of weeks. FM #2 stated she had no concerns for Resident #2's safety or the care provided to him. During a phone interview on 10/15/2025 at 11:24 AM, NA B stated she had worked at the facility for the past 5 months. She stated she witnessed, on an unknown date, CNA A place soap directly on Resident #1's face in a manner that would cause the soap to run directly into Resident #1's eyes. NA B stated CNA A then handed Resident #1 a washcloth with soap on it for Resident #1 to wipe her face and eyes with. NA B stated at that time she obtained a clean, dry washcloth and handed it to Resident #1. NA B stated she did not report the incident to the abuse coordinator (ADM) immediately. She stated that she had not noticed any changes in demeanor in Resident #1, but when NA B approached Resident #1 to give her a shower, Resident #1 will ask if NA B or the mean one is going to give her a shower. NA B stated, on an unknown date, she assisted CNA A and NA C with providing peri-care to Resident #2. NA B stated Resident #2 was in bed when she entered the room. NA B stated Resident #2 had a history of agitation and being combative, but that day was worse than normal for him. NA B stated that while she was placing a brief under Resident #2, he punched CNA A. NA B stated she suggested to CNA A moving the bed away from the wall and raising it up to make it easier to finish applying the brief to him. NA B stated after moving the bed, she was holding Resident #2's hand and it slipped from her grip. She stated Resident #2 then punched CNA A in the chest really hard while NA C was attempting to pull up Resident #2's pants. NA B stated CNA A reacted by lifting her knee and placing it across Resident #2's arm and chest pinning his arm to the bed. NA B stated CNA A used one hand to hold Resident #2's other arm that was not secured with her knee then placed her other hand around the front of Resident #2's throat. NA B stated Resident #2's face turned red, his voice became strained, and he kept repeating, stop, stop and then stated, just kill me already. NA B stated CNA A told Resident #2, mother f*****, I'm the boss here, I'm going to show you, you are not going to beat the f*** out of me. NA B stated after NA C secured Resident #2's brief and pulled up his pants, the bed was lowered, and all staff left the room. NA B stated at the time she was concerned for the safety of Resident #2 and was in shock at the events she witnessed when leaving the room. NA B stated she did not report the witnessed incident to the abuse coordinator (ADM) immediately. NA B stated she checked on Resident #2 later that shift and he was calmer. NA B stated he had no changes in his demeanor since she witnessed the incident and she thought he had forgotten about the incident. NA B stated she did not report the incidents immediately to the abuse coordinator because she feared CNA A. She stated CNA A bragged about how she had her FM beat people up and how CNA A had her FM come up to the facility to fight someone. NA B stated she was trained to report all suspicions of abuse to the abuse coordinator right away. NA B listed relevant examples and types of abuse. NA B stated she should have reported both incidents immediately to the abuse coordinator. NA B stated she talked to the ADM on 09/23/2025 about CNA A but did not mention either incident. NA B stated she reported both incidents to the ADM on 09/26/2025. NA B confirmed that they are to report all allegations to ADM immediately.During a phone interview on 10/15/2025 at 01:49 PM, CNA A stated she had worked at the facility for about a year. She stated she was currently suspended pending an investigation involving her and 2 separate incidents of abuse. CNA A stated she had been trained on abuse and neglect. She stated she had not showered Resident #1 in close to 2 months. CNA A stated Resident #1 always requested a dry washcloth that she then placed over her face after getting in the shower. CNA A stated Resident #1 would not take a shower without the dry washcloth on her face. CNA A denied ever putting soap directly on Resident #1's face or putting soap on a washcloth for Resident #1 to wash her face. CNA A stated Resident #1 needed assistance with washing her hair, back and waist down. She stated Resident #1 washed the remainder of her body herself. CNA A stated she was informed the second incident involved her putting her knee across Resident #2's chest, physically restraining him, and cussing at him. CNA A stated on 09/18/2025 she had worked with Resident #2, and he was more combative than usual. She stated Resident #2 had feces all over his bed, brief, clothes and body. CNA A stated she was paired with NA C to work that day. CNA A stated was providing peri-care to Resident #2, with the assistance of NA C, Resident #2 hit her right hip with a closed fist. CNA stated that she requested NA C find another staff member to assist with completing peri-care. NA C left room and returned with NA B. CNA A stated that she then held Resident #2's arms while he was positioned on his right side while NA B performed peri-care. She stated they then turned Resident #2, and he hit CNA A in the stomach. CNA A stated they were able to finish peri-care, put a sheet under him, and secure his brief. CNA A stated she notified the nurse working that day that Resident #2 was combative during peri-care. CNA A stated Resident #2 would frequently cuss at staff when he was receiving care. CNA A denied Resident #2 told her to stop while performing care to him that day. CNA A stated she completed her shift that day, including providing pericare for Resident #2 and getting him up into his wheelchair prior to leaving for the day. She stated when she got him up into his wheelchair, he was calm and cooperative. CNA A was informed by the ADM that one of the allegations was she placed her knee on Resident #2's chest and held his hands. CNA A stated There is no way. I am 5 foot. She stated that when the bed is raised to provide pericare she could not lift her leg high enough to put her knee on Resident #2's chest while he was in bed. CNA A stated she was trained in handling combative residents. She stated she was trained to give them space, allow them time to calm down, and reapproach, but she stated she could not leave Resident #2 covered in his own feces. CNA A denied all allegations related to abuse.During a phone interview on 10/15/2025 at 2:29 PM, FM #1 stated he had no concerns with staff, or the care provided at the facility for Resident #1. He stated that he had not noticed a change in Resident #1's demeanor over the last couple of months. He stated that Resident #1 has a cell phone and sends him texts often. He stated that Resident #1 had not talked to or texted him with any concerns related to the way staff treat her, or the care provided to her. FM #1 stated that any concerns he had brought up to management had been addressed appropriately in a timely manner. FM #1 stated he felt Resident #1 was safe in the facility and he was satisfied with the care provided to her. Interview on 10/15/2025 at 2:51 PM, NA D stated she works on the secured unit and trained on abuse. NA D is giving examples of abuse and further stated that all abuse is reported to ADM.Interview on 10/15/2025 at 3:01 PM, RN A stated she is a charge nurse, Last in-serviced on Friday (10/10/25) related to ANE. Topics included: what is abuse, definition of ANE, report ANE to ADM. Interview on 10/15/2025 at 3:23 PM, CNA B stated she is also a med aide. CNA B stated she was last trained on ANE and in-serviced last week. CNA B stated the topics included: signs of ANE, what to do if witnessed, who to speak with or hear about it.Interview on 10/15/2025 at 3:23 PM, RN B Worked here for 6 to 7 years. RN B stated she was trained on ANE and last in-serviced last week. RN A stated the topics included: to report any concerns or suspicion of abuse to the ADM immediately, such as yelling, neglect, not changing the resident, hitting. RN B stated the negative effects are residents being withdrawn, stop eating, decline in condition, bruising. RN B stated she never witnessed any form of abuse in the facility and feels the residents are safe here. RN B stated she has 2 family members living here and can comfortably report any allegations of ANE. During a phone interview on 10/15/2025 at 4:09 PM, NA C stated she had worked at the facility since July 2025. She stated she had been trained on abuse and neglect. NA C stated she was trained to report any suspected or witnessed abuse to the abuse coordinator (ADM) immediately. NA C was able to provide an explanation of appropriate types and examples of abuse and neglect. NA C stated on an unknown date in August 2025 she witnessed CNA A in the shower room with Resident #1. She stated CNA A put soap directly on Resident #1's forehead. NA C stated Resident #1 then started yelling my eyes, they are burning. She stated that CNA A waited about a minute before using the shower head to roughly rinse Resident #1 face and eyes. She stated that Resident #1 calmed down after her face and eyes were rinsed. NA C stated that later that (unknown) day Resident #1 complained of irritation to her eyes. She stated she did not report the incident to anyone that day because she was scared of CNA A. NA C stated she had not noticed a change in demeanor for Resident #1 since the day of the incident. NA C stated on an unknown date while working with CNA A she was assisting with providing pericare to Resident #2 because he was being combative. She stated she requested NA B to assist as well due to Resident #2's behaviors. NA C stated she and NA B transferred Resident #2 into bed. NA C stated Resident #2 became combative after transferring to bed. She stated while she was holding Resident #2 arm to prevent him from hitting another staff member her grip slipped, and CNA A grabbed both of Resident #2's arms while he was laying on his back. NA C stated CNA A then crossed Resident #2's arms and held his hand with her on the resident's upper chest where the collarbones meet. NA C stated that CNA A then placed her left knee on Resident #2's chest at the bottom of his ribs. NA C stated CNA A asked Resident #2 who's the boss now to which Resident #2 responded stop, you are as his face was turning red. NA C stated CNA A then immediately released Resident #2 and left room. NA C stated the bed was raised to her waist level at the time of the events. NA C stated she continued to provide care to Resident #2 for the remainder of the day. NA C stated she had not witnessed Resident #2 be combative since that day. NA C stated she did not report the incident that day because the ADM was not in her office and NA C did not have the ADM phone number to call her. She stated she did not feel comfortable talking to the charge nurse or the ADON that day about the incident because CNA A was friends with them. NA C stated she talked to the ADM about the incident the next day. NA C stated she was scared of CNA A because CNA A is known to go after someone if they report her. She stated other staff members are no longer talking to her because she reported CNA A. She stated CNA A has also been known to threaten to hurt people in the past. NA C stated she would immediately report the incident to the ADM if she were to witness any abuse, neglect, or exploitation occurring. Observation on 10/16/2025 at 09:33 AM, revealed Resident #1 in the shower room getting in her shower chair with assistance from staff. Resident #1 did not appear to exhibit any anxiety or emotional distress while in the shower. During a phone interview on 10/16/2025 at 10:36 AM, the MD stated he was notified of the allegations related to Resident #2 while performing his scheduled rounds but could not recall the allegations related to Resident #1. He stated Resident #2 was being followed by the psychiatrist due to aggressive behaviors. He stated Resident #2 was difficult and pretty aggressive. MD stated he performed an assessment on Resident #2 and did not observe any abnormal bruising. He stated he had not noticed a change in Resident #2's demeanor over the previous 2 weeks. The MD stated Resident #1 had a history of dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgment) with some disorientation. The MD stated he felt all the residents were safe at the facility. He stated the facility had enough staff providing care to the residents when he did his rounds. He stated he had not witnessed any abuse or neglect at the facility. The MD stated he had good communication with the staff in the facility.During an interview on 10/16/2025 at 11:39 AM, the DON stated she had worked at the facility for 4 years but had only been in the DON position since 10/2/2025. She stated she had been trained on abuse, neglect, and exploitation. The DON stated she expected staff to report any concerns related to abuse, neglect or exploitation immediately to the abuse coordinator (ADM). The DON stated not reporting the incident immediately to the ADM could affect the investigation and the outcome of the investigation, especially if you have a resident with cognitive issues and staff turnover. The DON stated she had never witnessed any abuse occurring at the facility. She stated she felt the residents were safe at the facility. The DON stated CNA A had worked in the facility for approximately the past 2 years though most of that was working through a staffing agency. She stated the facility stopped using the staffing agency and CNA A decided to apply for a full-time job with the facility. The DON stated she felt CNA A was a good CNA and provided really good patient care and the DON would frequently recommend CNA A to orient and train other staff members. The DON stated she never had any indication CNA A was disliked by anyone or that CNA A would instigate drama or conflict until recently when an issue outside of work on social media appeared involving some staff. She stated she was not sure of the entire details of the social media post, only that another staff member, who no longer worked at the facility, felt threatened by CNA A's FM after making a random post on [social media] that did not even have anything to do with work. The DON stated she was unsure what day CNA A worked last. The DON stated NA B had worked at the facility for the past few months and was a little resistant to learning and training. She stated she changed her approach to training NA B and NA B was more receptive to critique and learning. She stated she was unaware of any other allegations made by NA B. The DON stated she knew NA B and NA C received the training related to abuse, neglect and exploitation but was unsure if they received any additional training.During an interview on 10/16/2025 at 1:41 PM, the ADM stated she had worked at the facility for the past 8 years and she was also the abuse coordinator. She stated she had received training on abuse, neglect and exploitation. The ADM stated the definition of abuse was the intentional infringement of adverse effects that produces a negative outcome. She stated she expected staff to report any concerns or suspicions of abuse to her immediately. The ADM stated if she is not in her office then she expected staff to call her phone. She stated she gave out her phone number to all staff members time and time again and her phone number was posted in the employee break room. The ADM denied ever witnessing any form of abuse in the facility and felt the residents were safe. The ADM stated she was also an RN, and she would monitor for abuse by performing frequent rounds and even going into a resident's room to assist the CNAs with providing care to the residents. The ADM stated she monitored allegations of abuse by repeatedly going back to the resident to monitor, observe, and talk in long conversations with the resident listed in the allegation. The ADM stated she would also go with staff or the wound care provider to perform skin assessments after an incident. The ADM stated she was notified on 09/26/2025 at 2:00 PM by NA B about allegations of abuse to Resident #1 and Resident #2 by CNA A. The ADM stated she was informed by NA B that CNA A purposefully allowed soap to go into Resident #1's eyes during a shower and was slow to react and physically restrained Resident #2 with her body while providing pericare in his bed. The ADM stated at that time she collected a brief statement from NA B, but NA B was unable to provide a date or time for either one of the incidents that occurred. The ADM stated she asked NA B why she did not report the incident immediately to her like she had been trained to do. The ADM stated, NA B reported she was scared of CNA A due to a [social media] post from another, previously employed, staff member in which CNA A's FM threatened to bust out the previous staff member's windows. The ADM stated she had seen the social media comments under the social media's post threatening violence, but she never saw the actual social media post, and the language used in the comments was slang and she was unable to understand what was being said. The ADM stated CNA A did not make a comment on the social media post. The ADM stated she immediately started her investigation, a quick assessment of Resident #2's chest and neck and no abnormalities were noted and a quick assessment of Resident #1. The ADM stated she spoke with NA C related to allegations on 09/26/2025 around 03:00 PM and received her statement. The ADM denied receiving any reports prior to 09/26/2025 with allegations of abuse involving CNA A from NA C. She stated that NA C stated she was scared of CNA A due to a previous incident of cyber-bullying on social media involving a staff member that no longer worked at the facility. The ADM stated she suspended CNA A on 09/26/2025 at around 4:00 PM and collected her statement later through a text message. She stated she provided 1:1 in-service with NA B and NA C related to reporting expectations. The ADM stated she received further detailed witness statements from NA B and NA C on 10/2/2025 and both NAs continued to state they did not report the concerns for abuse immediately after the witnessed incident due to fear of CNA A. The ADM stated she spoke with another staff member during her investigation that wished to remain anonymous that stated NA C told her she really did not witness the alleged abuse by CNA A, but NA B had convinced her to make the report. The ADM stated she did not confront NA C with the statement because she did not want to breach the trust of the other staff member. She stated that she felt the other staff member was impartial to all other staff. The ADM stated she in-serviced all staff about cyber-bullying. She stated she terminated CNA A on 10/13/2025 due to concerns with cyber-bullying. She stated after talking with the anonymous staff member, looking at the bed height in relation to the length of CNA A's legs, the safety surveys and both Resident #1 and Resident #2 repeatedly stating no one at the facility had hurt them, her findings were unfounded for the allegation of abuse. The ADM stated she provided in-services on abuse, reporting guidelines for abuse, and sensitivity training to all staff. She stated she also implemented for two staff members to assist Resident #2 any time patient care is provided. A telephone interview with the PNP was attempted on 10/26/2025 at 05:22 PM. A voicemail was left requesting a return phone call. A returned phone call was not received prior to exit. Review of CNA A's employee file, on 10/17/2025, reflected a background check had been performed and revealed no convictions that would make CNA A unemployable. Review of CNA's employee file reflected the facility also performed and EMR and NAR search and no concerns were revealed. CNA A's hire date was officially 03/01/2025. Review reflected CNA A received training on Abuse, Neglect, and Exploitation as well as Texas Senate [NAME] 9 on 07/01/2025. Review of CNA A's employee file reflected CNA A's last day worked was 09/26/2025 and she was terminated on 10/13/2025 with reason for termination listed as allegation of abuse with no circled next to Had the employee received any prior warning?.Review of facility in-services reflected in-services dated 03/02/2025, 03/04/2025 and 03/16/2025 related to Abuse, Neglect, and Exploitation with CNA A's signature which indicated her attendance to the in-services.Review of NA B's witness statement reflected the following: On 09/26/2025 [NA B] states [CNA A] put soap in [Resident #1]'s eyes that was on a washcloth when she was washing her face and placed her hands on [Resident #2]'s chest to hold him down when they were providing him care and signed by NA B.Review of facility records reflected Safe surveys were conducted from a date range of 9/26/2025 to 10/4/2025, no findings. Review of NA B's witness statement, dated 10/02/2025, reflected the following: [CNA A], and [NA C], were changing [Resident #2]. [NA C] had called because they needed help. I was watching him being changed and he was being combative. I joined in to help and we were able to turn him toward the wall. I put the brief on him and we turned him back to the other side so I could do the tab on his brief. He started hitting and he kicked me in the arm, (no bruising) and he hit [CNA A] in the chest. He hit her hard. [CNA A] started cursing but I don't think it was at him. After that I decided to pull the bed out and I was on the right arm and [CNA A] was on the other arm. He was able to get his arm loose from me and he hit [CNA A] again. I grabbed his arm back gently and [CNA A] had her knee on his chest and her right arm was holding him and her left arm was at the bottom of his neck and his face began to turn red. [Resident #2] was saying stop it over and over again. [CNA A] was calling him bad names and [CNA A] was telling him mother****** I am the boss and she would beat the s*** out him. [Resident #2] then got off him and he did not fight anymore after that.[Resident #1] had asked me to take her in the shower room and we put her in the shower chair. [Resident #1] asked for a wash rag and [CNA A] squirted the soap in her face and it got into her eyes. [Resident #1] kept say my eyes; you got soap in my eyes and then [Resident #1] asked me for a wash rag and I went and go the wash rag. Before I gave it to [Resident #1], [CNA A] put more soap on the wash rag and [CNA A] took the wash rag and washed her face with it. After she took the wash rag and did her face [Resident #1] kept saying wash rag, wash rag and I said to [CNA A] that she just wants a wash rag. [CNA A] did not say anything to me. I gave the wash rag to [Resident #1]. [CNA A] was rinsing [Resident #1]'s body. I left the shower room after that. This happened about two and a half weeks ago. I was worried to report because I was scared of the posts on [social media]. Signed by NA B. Review of NA C's undated witness statement reflected the following: [NA B] and I were assisting [CNA A] changing [Resident #2] and he was being very combative so [CNA A] took one of her arms and held onto his arm and then her other arm was on his chest. [Resident #2] was asking for [CNA A] to stop. I think she was using her body to hold him. [NA B] and I were watching [CNA A] because we were new when she was caring for [Resident #2]. [Resident #2] did not want to transfer and [CNA A] was picking at him like taking her fingers and putting them on his body. [Resident #2] can pivot on one leg and [CNA A] was getting him up and she transferred him onto the bed out of his wheelchair. [Resident #2] was aggressive and [CNA A] was taking her fingers and placing them on different parts of his face. [Resident #2] continued to be very combative. [Resident #2]'s hands were folded and she took her hands and placed them on top of his hands. She kept her hands there until [Resident #2] said ok you win you are the boss. She stopped.When I went to school I was taught that you do not put soap on a washcloth when you are washing a resident's face. [CNA A] took the soap bottle and poured soap on [Resident #1]s hair and it ran into her eyes and she let the soap stay like this for a full minute. After the minute was up she took the sprayer and sprayed towards her face. [Resident #1] took the water and used it and washed the soap off of her face.I feel [CNA A] is a good aide. She needs some training on compassion. Signed by NA C.Review of NA C's witness statement, dated 10/02/2025, reflected the following: Addendum to statement:[CNA A] was cussing but I am not sure what she was cussing about. She was just cussing. [Resident #2] was very angry and fighting us when we were trying to change him. We always have two people and both of us have to try to care for him. He is combative everytime we try to change him and we have to hold him down. I feel he gets worse at night but also in the mornings he is very very bad. On this day I think he was worse than most days. When we were trying to hold him he was very strong and kept getting away from us. Wherever we were holding him he was able to get away from us. [CNA A] had her knee on [Resident #2] to hold him down to. We have to get him up and he will not try to get out of bed if he up[sic?]. If he is up he is calm. Signed by NA C.Review of unsigned, undated, witness statement reflected the following: On September 18, 2025, [CNA A] stated she remembered the day when they had trouble with [Resident #2] and the day was Thursday and [LVN E] was the nurse. In the beginning [NA C] and she were cleaning up [Resident #2]. They had raised the bed to [CNA A]'s hip which was approximately 23 inches above the floor. With the bed raised to hip level it would be 25 inches from the ground. [Resident #2] was being combative, and [CNA A] stated they texted [NA B] to come and help them. When [NA B] came to the room [CNA A] stated [NA B] was holding [Resident #2]'s hands and [NA C] was trying to keep him from kicking [NA B] and herself. [CNA A] and [NA B] switched positions because [NA B] could not turn his upper body. [NA B] stated she got both hands and held them on his left shoulder with one hand and turned him with the hand[sic?] while [NA B] finished cleaning the BM from his right side which was difficult since they had him turned on this right side facing the wall. [NA C] was holding his leg and [CNA A] stated they struggled to push the sheets under him and then they turned him on his bed. They were able to get his brief on and then they were only able to put a draw sheet under him. [CNA A] stated they then positioned him in the bed so that he could eat breakfast and then they all walked out. [CNA A] stated she remembered that day clearly because [Resident #2] had never been that combative before or hit her like that before.Per [CNA A] via text Review of in-service dated 09/27/2025, with subject Abuse/Neglect/Abuse Prevention coordinator is [ADM] and her cell is [###-###-####]. If not at the facility notify her on her cell for any allegations of abuse/neglect/exploitation. When a resident is combative walk away from the resident and go and get your charge nurse. Sometimes a resident will get care from someone else. Also remember the change in personality is the disease process reflected 36 of the 98 staff members attended the in-service.Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 2001 and last revised 09/2022, reflected the following: .1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion m

Based on interview and record review, the facility failed to ensure the residents had the right to be free from physical abuse and neglect for two (Resident #1 and Resident #2) of five residents reviewed for abuse and neglect. 1. The facility failed to ensure Resident #1 was not physically abused by CNA A, on an unknown date, and witnessed by NA B and NA C, when CNA A put soap in Resident #1's eyes in the shower room.2. The facility failed to ensure Resident #2 was not physically abused by CNA A, on an unknown date, and witnessed by NA B and NA C, when CNA A physically restrained Resident #2 in his room while providing peri-care. The noncompliance was identified as PNC. The IJ began on 09/26/2025 and ended on 10/13/2025. The facility had corrected the noncompliance before the survey began on 10/14/2025. These failures placed residents at risk of abuse, neglect, trauma, and psychosocial harm.Findings included:Review of Resident #1's admission record, dated 10/14/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including depression (a mood disorder with persistent feelings of sadness and loss of interest), dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgment), epilepsy (a neurological disorder causing seizures), blindness in one eye (inability to see out of one eye), conductive hearing loss (when sound cannot reach the inner ear due to issues in the outer or middle ear) and cognitive communication deficit (a problem with communication caused by cognition rather than a language or speech deficit). Review of Resident #1's Quarterly MDS assessment, dated 08/27/2025, reflected a BIMS score of 07, indicating moderate cognitive impairment. Section GG (Functional Abilities) reflected she required substantial/maximal assistance for showering/bathe self.Review of Resident #1's care plan, dated 05/06/2025, reflected she was at risk for ADL self-care deficit with an intervention of providing assistance with ADLs/IADLs as needed. During an interview on 10/14/2025 at 12:20 PM, Resident #1 stated the facility and care provided to her was fine. Resident #1 stated no staff member had intentionally been mean to her or attempted to cause her harm. Resident #1 stated she felt safe in the facility.Review of Resident #2's admission record, dated 10/15/2025, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and most recent readmission on [DATE] with diagnoses including hemiplegia and hemiparesis (paralysis and weakness on one side of the body), dementia severe with mood disturbance (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgment causing behaviors), seizures, type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), depression (a mood disorder with persistent feelings of sadness and loss of interest), cerebral infarction (a blood clot blockage that impairs blood flow through the brain artery), dysphagia (difficulty swallowing), and cognitive communication deficit (a problem with communication caused by cognition rather than a language or speech deficit).Review of Resident #2's Quarterly MDS assessment, dated 08/21/2025, reflected a BIMS score of 06, indicating severe cognitive impairment. Section GG (Functional Abilities) reflected he was dependent on staff for toileting hygiene. Review of Resident #2's care plan, date initiated 07/23/2025, reflected he was at risk for harm: self-directed or other-directed with interventions that included: if resident poses a potential threat to injure self or others notify provider, utilize calming touch, and if safe, allow resident personal space. Review of Resident #2's care plan, dated 07/23/2025, reflected he was at risk for ADL self-care deficit with an intervention of providing assistance with ADLs/IADLs as needed.During an interview on 10/14/2025 at 1:04 PM, Resident #2 stated the care provided to him was alright. Resident #2 stated someone hurt him but was unable to provide a name or further information. Resident #2 then began asking for his mother.During a phone interview on 10/15/2025 at 09:23 AM, FM #2 stated Resident #2 had a history of physical abuse, though she was unsure of the details of the history of abuse. FM #2 stated Resident #2 is confused with short-term memory loss and some long-term memory loss. She stated she did not have any concerns related to staff taking care of Resident #2 and thought, when he stated someone hurt him, he was referring to his history of abuse prior to his admission to the facility. FM #2 stated Resident #2 had refused care and had increasing agitation but that started several months prior. She stated she didn't notice any changes in demeanor over the past couple of weeks. FM #2 stated she had no concerns for Resident #2's safety or the care provided to him. During a phone interview on 10/15/2025 at 11:24 AM, NA B stated she had worked at the facility for the past 5 months. She stated she witnessed, on an unknown date, CNA A place soap directly on Resident #1's face in a manner that would cause the soap to run directly into Resident #1's eyes. NA B stated CNA A then handed Resident #1 a washcloth with soap on it for Resident #1 to wipe her face and eyes with. NA B stated at that time she obtained a clean, dry washcloth and handed it to Resident #1. NA B stated she did not report the incident to the abuse coordinator (ADM) immediately. She stated that she had not noticed any changes in demeanor in Resident #1, but when NA B approached Resident #1 to give her a shower, Resident #1 will ask if NA B or the mean one is going to give her a shower. NA B stated, on an unknown date, she assisted CNA A and NA C with providing pericare to Resident #2. NA B stated Resident #2 was in bed when she entered the room. NA B stated Resident #2 had a history of agitation and being combative, but that day was worse than normal for him. NA B stated that while she was placing a brief under Resident #2, he punched CNA A. NA B stated she suggested to CNA A moving the bed away from the wall and raising it up to make it easier to finish applying the brief to him. NA B stated after moving the bed, she was holding Resident #2's hand and it slipped from her grip. She stated Resident #2 then punched CNA A in the chest really hard while NA C was attempting to pull up Resident #2's pants. NA B stated CNA A reacted by lifting her knee and placing it across Resident #2's arm and chest pinning his arm to the bed. NA B stated CNA A used one hand to hold Resident #2's other arm that was not secured with her knee then placed her other hand around the front of Resident #2's throat. NA B stated Resident #2's face turned red, his voice became strained, and he kept repeating, stop, stop and then stated, just kill me already. NA B stated CNA A told Resident #2, mother f*****, I'm the boss here, I'm going to show you, you are not going to beat the f*** out of me. NA B stated after NA C secured Resident #2's brief and pulled up his pants, the bed was lowered, and all staff left the room. NA B stated at the time she was concerned for the safety of Resident #2 and was in shock at the events she witnessed when leaving the room. NA B stated she did not report the witnessed incident to the abuse coordinator (ADM) immediately. NA B stated she checked on Resident #2 later that shift and he was calmer. NA B stated he had no changes in his demeanor since she witnessed the incident and she thought he had forgotten about the incident. NA B stated she did not report the incidents immediately to the abuse coordinator because she feared CNA A. She stated CNA A bragged about how she had her FM beat people up and how CNA A had her FM come up to the facility to fight someone. NA B stated she was trained to report all suspicions of abuse to the abuse coordinator right away. NA B listed relevant examples and types of abuse. NA B stated she should have reported both incidents immediately to the abuse coordinator. NA B stated she talked to the ADM on 09/23/2025 about CNA A but did not mention either incident. NA B stated she reported both incidents to the ADM on 09/26/2025. NA B confirmed that they are to report all allegations to ADM immediately.During a phone interview on 10/15/2025 at 01:49 PM, CNA A stated she had worked at the facility for about a year. She stated she was currently suspended pending an investigation involving her and 2 separate incidents of abuse. CNA A stated she had been trained on abuse and neglect. She stated she had not showered Resident #1 in close to 2 months. CNA A stated Resident #1 always requested a dry washcloth that she then placed over her face after getting in the shower. CNA A stated Resident #1 would not take a shower without the dry washcloth on her face. CNA A denied ever putting soap directly on Resident #1's face or putting soap on a washcloth for Resident #1 to wash her face. CNA A stated Resident #1 needed assistance with washing her hair, back and waist down. She stated Resident #1 washed the remainder of her body herself. CNA A stated she was informed the second incident involved her putting her knee across Resident #2's chest, physically restraining him, and cussing at him. CNA A stated on 09/18/2025 she had worked with Resident #2, and he was more combative than usual. She stated Resident #2 had feces all over his bed, brief, clothes and body. CNA A stated she was paired with NA C to work that day. CNA A stated she was providing peri-care to Resident #2, with the assistance of NA C, Resident #2 hit her right hip with a closed fist. CNA stated that she requested NA C find another staff member to assist with completing peri-care. NA C left room and returned with NA B. CNA A stated that she then held Resident #2's arms while he was positioned on his right side while NA B performed peri-care. She stated they then turned Resident #2, and he hit CNA A in the stomach. CNA A stated they were able to finish peri-care, put a sheet under him, and secure his brief. CNA A stated she notified the nurse working that day that Resident #2 was combative during peri-care. CNA A stated Resident #2 would frequently cuss at staff when he was receiving care. CNA A denied Resident #2 told her to stop while performing care to him that day. CNA A stated she completed her shift that day, including providing peri-care for Resident #2 and getting him up into his wheelchair prior to leaving for the day. She stated when she got him up into his wheelchair, he was calm and cooperative. CNA A was informed by the ADM that one of the allegations was she placed her knee on Resident #2's chest and held his hands. CNA A stated There is no way. I am 5 foot. She stated that when the bed is raised to provide peri-care she could not lift her leg high enough to put her knee on Resident #2's chest while he was in bed. CNA A stated she was trained in handling combative residents. She stated she was trained to give them space, allow them time to calm down, and reapproach, but she stated she could not leave Resident #2 covered in his own feces. CNA A denied all allegations related to abuse.During a phone interview on 10/15/2025 at 2:29 PM, FM #1 stated he had no concerns with staff, or the care provided at the facility for Resident #1. He stated that he had not noticed a change in Resident #1's demeanor over the last couple of months. He stated that Resident #1 has a cell phone and sends him texts often. He stated that Resident #1 had not talked to or texted him with any concerns related to the way staff treat her, or the care provided to her. FM #1 stated that any concerns he had brought up to management had been addressed appropriately in a timely manner. FM #1 stated he felt Resident #1 was safe in the facility and he was satisfied with the care provided to her. Interview on 10/15/2025 at 2:51 PM, NA D stated she works on the secured unit and trained on abuse. NA D is giving examples of abuse and further stated that all abuse is reported to ADM.Interview on 10/15/2025 at 3:01 PM, RN A stated she is a charge nurse, Last in-serviced on Friday (10/10/25) related to ANE. Topics included: what is abuse, definition of ANE, report ANE to ADM. Interview on 10/15/2025 at 3:23 PM, CNA B stated she is also a med aide. CNA B stated she was last trained on ANE and in-serviced last week. CNA B stated the topics included: signs of ANE, what to do if witnessed, who to speak with or hear about it.Interview on 10/15/2025 at 3:23 PM, RN B Worked here for 6 to 7 years. RN B stated she was trained on ANE and last in-serviced last week. RN A stated the topics included: to report any concerns or suspicion of abuse to the ADM immediately, such as yelling, neglect, not changing the resident, hitting. RN B stated the negative effects are residents being withdrawn, stop eating, decline in condition, bruising. RN B stated she never witnessed any form of abuse in the facility and feels the residents are safe here. RN B stated she has 2 family members living here and can comfortably report any allegations of ANE. During a phone interview on 10/15/2025 at 4:09 PM, NA C stated she had worked at the facility since July 2025. She stated she had been trained on abuse and neglect. NA C stated she was trained to report any suspected or witnessed abuse to the abuse coordinator (ADM) immediately. NA C was able to provide an explanation of appropriate types and examples of abuse and neglect. NA C stated on an unknown date in August 2025 she witnessed CNA A in the shower room with Resident #1. She stated CNA A put soap directly on Resident #1's forehead. NA C stated Resident #1 then started yelling my eyes, they are burning. She stated that CNA A waited about a minute before using the shower head to roughly rinse Resident #1 face and eyes. She stated that Resident #1 calmed down after her face and eyes were rinsed. NA C stated that later that (unknown) day Resident #1 complained of irritation to her eyes. She stated she did not report the incident to anyone that day because she was scared of CNA A. NA C stated she had not noticed a change in demeanor for Resident #1 since the day of the incident. NA C stated on an unknown date while working with CNA A she was assisting with providing pericare to Resident #2 because he was being combative. She stated she requested NA B to assist as well due to Resident #2's behaviors. NA C stated she and NA B transferred Resident #2 into bed. NA C stated Resident #2 became combative after transferring to bed. She stated while she was holding Resident #2 arm to prevent him from hitting another staff member her grip slipped, and CNA A grabbed both of Resident #2's arms while he was laying on his back. NA C stated CNA A then crossed Resident #2's arms and held his hand with her on the resident's upper chest where the collarbones meet. NA C stated that CNA A then placed her left knee on Resident #2's chest at the bottom of his ribs. NA C stated CNA A asked Resident #2 who's the boss now to which Resident #2 responded stop, you are as his face was turning red. NA C stated CNA A then immediately released Resident #2 and left room. NA C stated the bed was raised to her waist level at the time of the events. NA C stated she continued to provide care to Resident #2 for the remainder of the day. NA C stated she had not witnessed Resident #2 be combative since that day. NA C stated she did not report the incident that day because the ADM was not in her office and NA C did not have the ADM phone number to call her. She stated she did not feel comfortable talking to the charge nurse or the ADON that day about the incident because CNA A was friends with them. NA C stated she talked to the ADM about the incident the next day. NA C stated she was scared of CNA A because CNA A is known to go after someone if they report her. She stated other staff members are no longer talking to her because she reported CNA A. She stated CNA A has also been known to threaten to hurt people in the past. NA C stated she would immediately report the incident to the ADM if she were to witness any abuse, neglect, or exploitation occurring.Observation on 10/16/2025 at 09:33 AM, revealed Resident #1 in the shower room getting in her shower chair with assistance from staff. Resident #1 did not appear to exhibit any anxiety or emotional distress while in the shower. During a phone interview on 10/16/2025 at 10:36 AM, the MD stated he was notified of the allegations related to Resident #2 while performing his scheduled rounds but could not recall the allegations related to Resident #1. He stated Resident #2 was being followed by the psychiatrist due to aggressive behaviors. He stated Resident #2 was difficult and pretty aggressive. MD stated he performed an assessment on Resident #2 and did not observe any abnormal bruising. He stated he had not noticed a change in Resident #2's demeanor over the previous 2 weeks. The MD stated Resident #1 had a history of dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgment) with some disorientation. The MD stated he felt all the residents were safe at the facility. He stated the facility had enough staff providing care to the residents when he did his rounds. He stated he had not witnessed any abuse or neglect at the facility. The MD stated he had good communication with the staff in the facility.During an interview on 10/16/2025 at 11:39 AM, the DON stated she had worked at the facility for 4 years but had only been in the DON position since 10/2/2025. She stated she had been trained on abuse, neglect, and exploitation. The DON stated she expected staff to report any concerns related to abuse, neglect or exploitation immediately to the abuse coordinator (ADM). The DON stated not reporting the incident immediately to the ADM could affect the investigation and the outcome of the investigation, especially if you have a resident with cognitive issues and staff turnover. The DON stated she had never witnessed any abuse occurring at the facility. She stated she felt the residents were safe at the facility. The DON stated CNA A had worked in the facility for approximately the past 2 years though most of that was working through a staffing agency. She stated the facility stopped using the staffing agency and CNA A decided to apply for a full-time job with the facility. The DON stated she felt CNA A was a good CNA and provided really good patient care and the DON would frequently recommend CNA A to orient and train other staff members. The DON stated she never had any indication CNA A was disliked by anyone or that CNA A would instigate drama or conflict until recently when an issue outside of work on social media appeared involving some staff. She stated she was not sure of the entire details of the social media post, only that another staff member, who no longer worked at the facility, felt threatened by CNA A's FM after making a random post on [social media] that did not even have anything to do with work. The DON stated she was unsure what day CNA A worked last. The DON stated NA B had worked at the facility for the past few months and was a little resistant to learning and training. She stated she changed her approach to training NA B and NA B was more receptive to critique and learning. She stated she was unaware of any other allegations made by NA B. The DON stated she knew NA B and NA C received the training related to abuse, neglect and exploitation but was unsure if they received any additional training. During an interview on 10/16/2025 at 1:41 PM, the ADM stated she had worked at the facility for the past 8 years and she was also the abuse coordinator. She stated she had received training on abuse, neglect and exploitation. The ADM stated the definition of abuse was the intentional infringement of adverse effects that produces a negative outcome. She stated she expected staff to report any concerns or suspicions of abuse to her immediately. The ADM stated if she is not in her office then she expected staff to call her phone. She stated she gave out her phone number to all staff members time and time again and her phone number was posted in the employee break room. The ADM denied ever witnessing any form of abuse in the facility and felt the residents were safe. The ADM stated she was also an RN, and she would monitor for abuse by performing frequent rounds and even going into a resident's room to assist the CNAs with providing care to the residents. The ADM stated she monitored allegations of abuse by repeatedly going back to the resident to monitor, observe, and talk in long conversations with the resident listed in the allegation. The ADM stated she would also go with staff or the wound care provider to perform skin assessments after an incident. The ADM stated she was notified on 09/26/2025 at 2:00 PM by NA B about allegations of abuse to Resident #1 and Resident #2 by CNA A. The ADM stated she was informed by NA B that CNA A purposefully allowed soap to go into Resident #1's eyes during a shower and was slow to react and physically restrained Resident #2 with her body while providing pericare in his bed. The ADM stated at that time she collected a brief statement from NA B, but NA B was unable to provide a date or time for either one of the incidents that occurred. The ADM stated she asked NA B why she did not report the incident immediately to her like she had been trained to do. The ADM stated, NA B reported she was scared of CNA A due to a [social media] post from another, previously employed, staff member in which CNA A's FM threatened to bust out the previous staff member's windows. The ADM stated she had seen the social media comments under the social media's post threatening violence, but she never saw the actual social media post, and the language used in the comments was slang and she was unable to understand what was being said. The ADM stated CNA A did not make a comment on the social media post. The ADM stated she immediately started her investigation, a quick assessment of Resident #2's chest and neck and no abnormalities were noted and a quick assessment of Resident #1. The ADM stated she spoke with NA C related to allegations on 09/26/2025 around 03:00 PM and received her statement. The ADM denied receiving any reports prior to 09/26/2025 with allegations of abuse involving CNA A from NA C. She stated that NA C stated she was scared of CNA A due to a previous incident of cyber-bullying on social media involving a staff member that no longer worked at the facility. The ADM stated she suspended CNA A on 09/26/2025 at around 4:00 PM and collected her statement later through a text message. She stated she provided 1:1 in-service with NA B and NA C related to reporting expectations. The ADM stated she received further detailed witness statements from NA B and NA C on 10/2/2025 and both NAs continued to state they did not report the concerns for abuse immediately after the witnessed incident due to fear of CNA A. The ADM stated she spoke with another staff member during her investigation that wished to remain anonymous that stated NA C told her she really did not witness the alleged abuse by CNA A, but NA B had convinced her to make the report. The ADM stated she did not confront NA C with the statement because she did not want to breach the trust of the other staff member. She stated that she felt the other staff member was impartial to all other staff. The ADM stated she in-serviced all staff about cyber-bullying. She stated she terminated CNA A on 10/14/2025 due to concerns with cyber-bullying. She stated after talking with the anonymous staff member, looking at the bed height in relation to the length of CNA A's legs, the safety surveys and both Resident #1 and Resident #2 repeatedly stating no one at the facility had hurt them, her findings were unfounded for the allegation of abuse. The ADM stated she provided in-services on abuse, reporting guidelines for abuse, and sensitivity training to all staff. She stated she also implemented for two staff members to assist Resident #2 any time patient care is provided. A telephone interview with the PNP was attempted on 10/26/2025 at 05:22 PM. A voicemail was left requesting a return phone call. A returned phone call was not received prior to exit. Review of CNA A's employee file, on 10/17/2025, reflected a background check had been performed and revealed no convictions that would make CNA A unemployable. Review of CNA's employee file reflected the facility also performed and EMR and NAR search and no concerns were revealed. CNA A's hire date was officially 03/01/2025. Review reflected CNA A received training on Abuse, Neglect, and Exploitation as well as Texas Senate [NAME] 9 on 07/01/2025. Review of CNA A's employee file reflected CNA A's last day worked was 09/26/2025 and was terminated on 10/13/2025 with reason for termination listed as allegation of abuse with no circled next to Had the employee received any prior warning?.Review of facility in-services reflected in-services dated 03/02/2025, 03/04/2025 and 03/16/2025 related to Abuse, Neglect, and Exploitation with CNA A's signature which indicated her attendance to the in-services.Review of facility records reflected Safe surveys were conducted from a date range of 9/26/2025 to 10/4/2025, no findings. Review of NA B's witness statement reflected the following: On 09/26/2025 [NA B] states [CNA A] put soap in [Resident #1]'s eyes that was on a washcloth when she was washing her face and placed her hands on [Resident #2]'s chest to hold him down when they were providing him care and signed by NA B.Review of NA B's witness statement, dated 10/02/2025, reflected the following: [CNA A], and [NA C], were changing [Resident #2]. [NA C] had called because they needed help. I was watching him being changed and he was being combative. I joined in to help and we were able to turn him toward the wall. I put the brief on him and we turned him back to the other side so I could do the tab on his brief. He started hitting and he kicked me in the arm, (no bruising) and he hit [CNA A] in the chest. He hit her hard. [CNA A] started cursing but I don't think it was at him. After that I decided to pull the bed out and I was on the right arm and [CNA A] was on the other arm. He was able to get his arm loose from me and he hit [CNA A] again. I grabbed his arm back gently and [CNA A] had her knee on his chest and her right arm was holding him and her left arm was at the bottom of his neck and his face began to turn red. [Resident #2] was saying stop it over and over again. [CNA A] was calling him bad names and [CNA A] was telling him mother****** I am the boss and she would beat the s*** out him. [Resident #2] then got off him and he did not fight anymore after that.[Resident #1] had asked me to take her in the shower room and we put her in the shower chair. [Resident #1] asked for a wash rag and [CNA A] squirted the soap in her face and it got into her eyes. [Resident #1] kept say my eyes; you got soap in my eyes and then [Resident #1] asked me for a wash rag and I went and go the wash rag. Before I gave it to [Resident #1], [CNA A] put more soap on the wash rag and [CNA A] took the wash rag and washed her face with it. After she took the wash rag and did her face [Resident #1] kept saying wash rag, wash rag and I said to [CNA A] that she just wants a wash rag. [CNA A] did not say anything to me. I gave the wash rag to [Resident #1]. [CNA A] was rinsing [Resident #1]'s body. I left the shower room after that. This happened about two and a half weeks ago. I was worried to report because I was scared of the posts on [social media]. Signed by NA B.Review of NA C's undated witness statement reflected the following: [NA B] and I were assisting [CNA A] changing [Resident #2] and he was being very combative so [CNA A] took one of her arms and held onto his arm and then her other arm was on his chest. [Resident #2] was asking for [CNA A] to stop. I think she was using her body to hold him.[NA B] and I were watching [CNA A] because we were new when she was caring for [Resident #2]. [Resident #2] did not want to transfer and [CNA A] was picking at him like taking her fingers and putting them on his body. [Resident #2] can pivot on one leg and [CNA A] was getting him up and she transferred him onto the bed out of his wheelchair. [Resident #2] was aggressive and [CNA A] was taking her fingers and placing them on different parts of his face. [Resident #2] continued to be very combative. [Resident #2]'s hands were folded and she took her hands and placed them on top of his hands. She kept her hands there until [Resident #2] said ok you win you are the boss. She stopped.When I went to school I was taught that you do not put soap on a washcloth when you are washing a resident's face. [CNA A] took the soap bottle and poured soap on [Resident #1]s hair and it ran into her eyes and she let the soap stay like this for a full minute. After the minute was up she took the sprayer and sprayed towards her face. [Resident #1] took the water and used it and washed the soap off of her face.I feel [CNA A] is a good aide. She needs some training on compassion. Signed by NA C.Review of NA C's witness statement, dated 10/02/2025, reflected the following: Addendum to statement:[CNA A] was cussing but I am not sure what she was cussing about. She was just cussing. [Resident #2] was very angry and fighting us when we were trying to change him. We always have two people and both of us have to try to care for him. He is combative everytime we try to change him and we have to hold him down. I feel he gets worse at night but also in the mornings he is very very bad. On this day I think he was worse than most days. When we were trying to hold him he was very strong and kept getting away from us. Wherever we were holding him he was able to get away from us. [CNA A] had her knee on [Resident #2] to hold him down to. We have to get him up and he will not try to get out of bed if he up[sic?]. If he is up he is calm. Signed by NA C.Review of unsigned, undated, witness statement reflected the following: On September 18, 2025, [CNA A] stated she remembered the day when they had trouble with [Resident #2] and the day was Thursday and [LVN E] was the nurse. In the beginning [NA C] and she were cleaning up [Resident #2]. They had raised the bed to [CNA A]'s hip which was approximately 23 inches above the floor. With the bed raised to hip level it would be 25 inches from the ground. [Resident #2] was being combative, and [CNA A] stated they texted [NA B] to come and help them. When [NA B] came to the room [CNA A] stated [NA B] was holding [Resident #2]'s hands and [NA C] was trying to keep him from kicking [NA B] and herself. [CNA A] and [NA B] switched positions because [NA B] could not turn his upper body. [NA B] stated she got both hands and held them on his left shoulder with one hand and turned him with the hand[sic?] while [NA B] finished cleaning the BM from his right side which was difficult since they had him turned on this right side facing the wall. [NA C] was holding his leg and [CNA A] stated they struggled to push the sheets under him and then they turned him on his bed. They were able to get his brief on and then they were only able to put a draw sheet under him. [CNA A] stated they then positioned him in the bed so that he could eat breakfast and then they all walked out. [CNA A] stated she remembered that day clearly because [Resident #2] had never been that combative before or hit her like that before.Per [CNA A] via textReview of in-service dated 09/27/2025, with subject Abuse/Neglect/Abuse Prevention coordinator is [ADM] and her cell is [###-###-####]. If not at the facility notify her on her cell for any allegations of abuse/neglect/exploitation. When a resident is combative walk away from the resident and go and get your charge nurse. Sometimes a resident will get care from someone else. Also remember the change in personality is the disease process reflected 36 of the 98 staff members attended the in-service. Review of the facility policy titled Identifying Types of Abuse, dated 2001 and revised September 2022, reflected the following: Policy StatementAs part of the abuse prevention strategy, volunteers, employees and contractors

Based on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated and report the report the results of all investigations to the state survey agency within five working days of the incident for two of five residents (Resident #1 and Resident #2) reviewed for abuse and neglect. The facility failed to thoroughly investigate two allegations of abuse regarding Resident #1 and Resident #2 to identify a timeframe of when alleged abuse occurred and failed to notify the local law enforcement. This deficient practice placed residents at risk of abuse due to not having a thorough investigation done for facility reported incidents. Findings included:Review of Resident #1's admission record, dated 10/14/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including depression (a mood disorder with persistent feelings of sadness and loss of interest), dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgment), epilepsy (a neurological disorder causing seizures), blindness in one eye (inability to see out of one eye), conductive hearing loss (when sound cannot reach the inner ear due to issues in the outer or middle ear) and cognitive communication deficit (a problem with communication caused by cognition rather than a language or speech deficit). Review of Resident #1's Quarterly MDS assessment, dated 08/27/2025, reflected a BIMS score of 07, indicating moderate cognitive impairment. Section GG (Functional Abilities) reflected she required substantial/maximal assistance for showering/bathe self.Review of Resident #1's care plan, dated 05/06/2025, reflected she was at risk for ADL self-care deficit with an intervention of providing assistance with ADLs/IADLs as needed. During an interview on 10/14/2025 at 12:20 PM, Resident #1 stated the facility and care provided to her was fine. Resident #1 stated no staff member had intentionally been mean to her or attempted to cause her harm. Resident #1 stated she felt safe in the facility.Review of Resident #2's admission record, dated 10/15/2025, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and most recent readmission on [DATE] with diagnoses including hemiplegia and hemiparesis (paralysis and weakness on one side of the body), dementia severe with mood disturbance (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgment causing behaviors), seizures, type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), depression (a mood disorder with persistent feelings of sadness and loss of interest), cerebral infarction (a blood clot blockage that impairs blood flow through the brain artery), dysphagia (difficulty swallowing), and cognitive communication deficit (a problem with communication caused by cognition rather than a language or speech deficit).Review of Resident #2's Quarterly MDS assessment, dated 08/21/2025, reflected a BIMS score of 06, indicating severe cognitive impairment. Section GG (Functional Abilities) reflected he was dependent on staff for toileting hygiene. Review of Resident #2's care plan, date initiated 07/23/2025, reflected he was at risk for harm: self-directed or other-directed with interventions that included: if resident poses a potential threat to injure self or others notify provider, utilize calming touch, and if safe, allow resident personal space. Review of Resident #2's care plan, dated 07/23/2025, reflected he was at risk for ADL self-care deficit with an intervention of providing assistance with ADLs/IADLs as needed.Review of facility's self-reporting template, dated 06/26/2025, reflected NA B alleged on an unknown date and time CNA A put soap in Resident #1's eyes and on an unknown date and time CNA A placed her hands on Resident #2's chest to hold him down while providing care. The template also reflected the local law enforcement was not notified.Review of facility's Provider Investigation Report, signed on 10/02/2025, reflected Incident Date: Unknown and Time of Incident: __:__ o a.m. o p.m. The report also reflected that the police were notified but there was no case number or documentation provided. During an interview on 10/14/2025 at 1:04 PM, Resident #2 stated the care provided to him was alright. Resident #2 stated someone hurt him but was unable to provide a name or further information. Resident #2 then began asking for his mother.During a phone interview on 10/15/2025 at 09:23 AM, FM #2 stated Resident #2 had a history of physical abuse, though she was unsure of the details of the history of abuse. FM #2 stated Resident #2 is confused with short-term memory loss and some long-term memory loss. She stated she did not have any concerns related to staff taking care of Resident #2 and thought, when he stated someone hurt him, he was referring to his history of abuse prior to his admission to the facility. FM #2 stated Resident #2 had refused care and had increasing agitation but that started several months prior. She stated she didn't notice any changes in demeanor over the past couple of weeks. FM #2 stated she had no concerns for Resident #2's safety or the care provided to him. During a phone interview on 10/15/2025 at 11:24 AM, NA B stated she had worked at the facility for the past 5 months. She stated she witnessed, on an unknown date, CNA A place soap directly on Resident #1's face in a manner that would cause the soap to run directly into Resident #1's eyes. NA B stated CNA A then handed Resident #1 a washcloth with soap on it for Resident #1 to wipe her face and eyes with. NA B stated at that time she obtained a clean, dry washcloth and handed it to Resident #1. NA B stated she did not report the incident to the abuse coordinator (ADM) immediately. She stated that she has not noticed any changes in demeanor in Resident #1, but when NA B approaches Resident #1 to give her a shower, Resident #1 will ask if NA B or the mean one is going to give her a shower. NA B stated, on an unknown date, she assisted CNA A and NA C with providing peri-care to Resident #2. NA B stated Resident #2 was in bed when she entered the room. NA B stated Resident #2 had a history of agitation and being combative, but that day was worse than normal for him. NA B stated that while she was placing a brief under Resident #2, he punched CNA A. NA B stated she suggested to CNA A moving the bed away from the wall and raising it up to make it easier to finish applying the brief to him. NA B stated after moving the bed, she was holding Resident #2's hand and it slipped from her grip. She stated Resident #2 then punched CNA A in the chest really hard while NA C was attempting to pull up Resident #2's pants. NA B stated CNA A reacted by lifting her knee and placing it across Resident #2's arm and chest pinning his arm to the bed. NA B stated CNA A used one hand to hold Resident #2's other arm that was not secured with her knee then placed her other hand around the front of Resident #2's throat. NA B stated Resident #2's face turned red, his voice became strained, and he kept repeating, stop, stop and then stated, just kill me already. NA B stated CNA A told Resident #2, mother f*****, I'm the boss here, I'm going to show you, you are not going to beat the f*** out of me. NA B stated after NA C secured Resident #2's brief and pulled up his pants, the bed was lowered, and all staff left the room. NA B stated at the time she was concerned for the safety of Resident #2 and was in shock at the events she witnessed when leaving the room. NA B stated she did not report the witnessed incident to the abuse coordinator (ADM) immediately. NA B stated she checked on Resident #2 later that shift and he was calmer. NA B stated had no changes in his demeanor since she witnessed the incident and she thought he had forgotten about the incident. NA B stated she did not report the incidents immediately to the abuse coordinator because she feared CNA A. She stated CNA A bragged about how she had her FM beat people up and how CNA A has had her FM come up to the facility to fight someone. NA B stated she was trained to report all suspicions of abuse to the abuse coordinator right away. NA B listed relevant examples and types of abuse. NA B stated she should have reported both incidents immediately to the abuse coordinator. NA B stated she talked to the ADM on 09/23/2025 about CNA A but did not mention either incident. NA B stated she reported both incidents to the ADM on 09/26/2025.During a phone interview on 10/15/2025 at 01:49 PM, CNA A stated she had worked at the facility for about a year. She stated she was currently suspended pending an investigation involving her and 2 separate incidents of abuse. CNA A stated she had been trained on abuse and neglect. She stated she had not showered Resident #1 in close to 2 months. CNA A stated Resident #1 always requested a dry washcloth that she then placed over her face after getting in the shower. CNA A stated Resident #1 would not take a shower without the dry washcloth on her face. CNA A denied ever putting soap directly on Resident #1's face or putting soap on a washcloth for Resident #1 to wash her face. CNA A stated Resident #1 needed assistance with washing her hair, back and waist down. She stated Resident #1 washed the remainder of her body herself. CNA A stated she was informed the second incident involved her putting her knee across Resident #2's chest, physically restraining him, and cussing at him. CNA A stated on 09/18/2025 she had worked with Resident #2, and he was more combative than usual. She stated Resident #2 had feces all over his bed, brief, clothes and body. CNA A stated she was paired with NA C to work that day. CNA A stated while she was providing peri-care to Resident #2, with the assistance of NA C, Resident #2 hit her right hip with a closed fist. CNA stated that she requested NA C find another staff member to assist with completing peri-care. NA C left room and returned with NA B. CNA A stated that she then held Resident #2's arms while he was positioned on his right side while NA B performed peri-care. She stated they then turned Resident #2, and he hit CNA A in the stomach. CNA A stated they were able to finish peri-care, put a sheet under him, and secure his brief. CNA A stated she notified the nurse working that day that Resident #2 was combative during peri-care. CNA A stated Resident #2 would frequently cuss at staff when he was receiving care. CNA A denied Resident #2 told her to stop while performing care to him that day. CNA A stated she completed her shift that day, including providing peri-care for Resident #2 and getting him up into his wheelchair prior to leaving for the day. She stated when she got him up into his wheelchair, he was calm and cooperative. CNA A was informed by the ADM that one of the allegations was she placed her knee on Resident #2's chest and held his hands. CNA A stated There is no way. I am 5 foot. She stated that when the bed is raised to provide peri-care she could not lift her leg high enough to put her knee on Resident #2's chest while he was in bed. CNA A stated she was trained in handling combative residents. She stated she was trained to give them space, allow them time to calm down, and reapproach, but she stated she could not leave Resident #2 covered in his own feces. CNA A denied all allegations related to abuse.During a phone interview on 10/15/2025 at 2:29 PM, FM #1 stated he had no concerns with staff, or the care provided at the facility. He stated that he had not noticed a change in Resident #1's demeanor over the last couple of months. He stated that Resident #1 has a cell phone and sends him texts often. He stated that Resident #1 has not talked to or texted him with any concerns related to the way staff treat her, or the care provided to her. FM #1 stated that any concerns he had brought up to management had been addressed appropriately in a timely manner. FM #1 stated he felt Resident #1 was safe in the facility and he was satisfied with the care provided to her. During a phone interview on 10/15/2025 at 4:09 PM, NA C stated she had worked at the facility since July 2025. She stated she had been trained on abuse and neglect. NA C stated she was trained to report any suspected or witnessed abuse to the abuse coordinator (ADM) immediately. NA C was able to provide an explanation of appropriate types and examples of abuse and neglect. NA C stated on an unknown date in August 2025 she witnessed CNA A in the shower room with Resident #1. She stated CNA A put soap directly on Resident #1's forehead. NA C stated Resident #1 then started yelling my eyes, they are burning. She stated that CNA A waiting about a minute before using the shower head to roughly rinse Resident #1 face and eyes. She stated that Resident #1 calmed down after her face and eyes were rinsed. NA C stated that later that (unknown) day Resident #1 complained of irritation to her eyes. She stated she did not report the incident to anyone that day because she was scared of CNA A. NA C stated she had not noticed a change in demeanor for Resident #1 since the day of the incident. NA C stated on an unknown date while working with CNA A she was assisting with providing peri-care to Resident #2 because he was being combative. She stated she requested NA B to assist as well due to Resident #2's behaviors. NA C stated she and NA B transferred Resident #2 into bed. NA C stated Resident #2 became combative after transferring to bed. She stated while she was holding Resident #2 arm to prevent him from hitting another staff member her grip slipped, and CNA A grabbed both of Resident #2's arms while he was laying on his back. NA C stated CNA A then crossed Resident #2's arms and held his hand with her on the resident's upper chest where the collarbones meet. NA C stated that CNA A then placed her left knee on Resident #2's chest at the bottom of his ribs. NA C stated CNA A asked Resident #2 who's the boss now to which Resident #2 responded stop, you are as his face was turning red. NA C stated CNA A then immediately released Resident #2 and left room. NA C stated the bed was raised to her waist level at the time of the events. NA C stated she continued to provide care to Resident #2 for the remainder of the day. NA C stated she had not witnessed Resident #2 be combative since that day. NA C stated she did not report the incident that day because the ADM was not in her office and NA C did not have the ADM phone number to call her. She stated she did not feel comfortable talking to the charge nurse or the ADON that day about the incident because CNA A was friends with them. NA C stated she talked to the ADM about the incident the next day. NA C stated she was scared of CNA A because CNA A is known to go after someone if they report her. She stated other staff members are no longer talking to her because she reported CNA A. She stated CNA A has also been known to threaten to hurt people in the past. NA C stated she would immediately report the incident to the ADM if she were to witness any abuse, neglect, or exploitation occurring. Observation on 10/16/2025 at 09:33 AM, revealed Resident #1 in the shower room getting in her shower chair with assistance from staff. Resident #1 did not appear to exhibit any anxiety or emotional distress while in the shower. During a phone interview on 10/16/2025 at 10:36 AM, MD stated he was notified of the allegations related to Resident #2 while performing his scheduled rounds but could not recall the allegations related to Resident #1. He stated Resident #2 was being followed by the psychiatrist due to aggressive behaviors. He stated Resident #2 was difficult and pretty aggressive. MD stated he performed an assessment on Resident #2 and did not observe any abnormal bruising. He stated he had not noticed a change in Resident #2's demeanor over the previous 2 weeks. MD stated Resident #1 had a history of dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgment) with some disorientation. MD stated he felt all the residents were safe at the facility. He stated the facility had enough staff providing care to the residents when he did his rounds. He stated he had not witnessed any abuse or neglect at the facility. MD stated he had good communication with the staff in the facility.During an interview on 10/16/2025 at 11:39 AM, the DON stated she had worked at the facility for 4 years but had only been in the DON position since 10/2/2025. She stated she had been trained on abuse, neglect, and exploitation. The DON stated she expected staff to report any concerns related to abuse, neglect or exploitation immediately to the abuse coordinator (ADM). The DON stated not reporting the incident immediately to the ADM could affect the investigation and the outcome of the investigation, especially if you have a resident with cognitive issues and staff turnover. The DON stated she had never witnessed any abuse occurring at the facility. She stated she felt the residents were safe at the facility. The DON stated CNA A had worked in the facility for approximately the past 2 years though most of that was working through a staffing agency. She stated the facility stopped using the staffing agency and CNA A decided to apply for a full-time job with the facility. The DON stated she felt CNA A was a good CNA and provided really good patient care and the DON would frequently recommend CNA A to orient and train other staff members. The DON stated she never had any indication CNA A was disliked by anyone or that CNA A would instigate drama or conflict until recently when an issue outside of work on social media appeared involving some staff. She stated she was not sure of the entire details of the social media post, only that another staff member, who no longer worked at the facility, felt threatened by CNA A's FM after making a random post on [social media] that did not even have anything to do with work. The DON stated she was unsure what day CNA A worked last. The DON stated NA B had worked at the facility for the past few months and was a little resistant to learning and training. She stated she changed her approach to training NA B and NA B was more receptive to critique and learning. She stated she was unaware of any other allegations made by NA B. The DON stated she knew NA B and NA C received the training related to abuse, neglect and exploitation but was unsure if they received any additional training.During an interview on 10/16/2025 at 1:41 PM, the ADM stated she had worked at the facility for the past 8 years and she was also the abuse coordinator. She stated she had received training on abuse, neglect and exploitation. The ADM stated the definition of abuse was the intentional infringement of adverse effects that produces a negative outcome. She stated she expected staff to report any concerns or suspicions of abuse to her immediately. The ADM stated if she is not in her office then she expected staff to call her phone. She stated she gave out her phone number to all staff members time and time again and her phone number was posted in the employee break room. The ADM denied ever witnessing any form of abuse in the facility and felt the residents were safe. The ADM stated she was also a RN, and she would monitor for abuse by performing frequent rounds and even going into a resident's room to assist the CNAs with providing care to the residents. The ADM stated she monitored allegations of abuse by repeatedly going back to the resident to monitor, observe, and talk in long conversations with the resident listed in the allegation. The ADM stated she would also go with staff or the wound care provider to perform skin assessments after an incident. The ADM stated she was notified on 09/26/2025 at 2:00 PM by NA B about allegations of abuse to Resident #1 and Resident #2 by CNA A. The ADM stated she was informed by NA B that CNA A purposefully allowed soap to go into Resident #1's eyes during a shower and was slow to react and physically restrained Resident #2 with her body while providing pericare in his bed. The ADM stated at that time she collected a brief statement from NA B, but NA B was unable to provide a date or time for either one of the incidents that occurred. The ADM stated she asked NA B why she did not report the incident immediately to her like she had been trained to do. The ADM stated, NA B reported she was scared of CNA A due to a [social media] post from another, previously employed, staff member in which CNA A's FM threatened to bust out the previous staff member's windows. The ADM stated she had seen the social media comments under the social media's post threatening violence, but she never saw the actual social media post, and the language used in the comments was slang and she was unable to understand what was being said. The ADM stated CNA A did not make a comment on the social media post. The ADM stated she immediately started her investigation, a quick assessment of Resident #2's chest and neck and no abnormalities were noted and a quick assessment of Resident #1. The ADM stated she spoke with NA C related to allegations on 09/26/2025 around 03:00 PM and received her statement. The ADM denied receiving any reports prior to 09/26/2025 with allegations of abuse involving CNA A from NA C. She stated that NA C stated she was scared of CNA A due to a previous incident of cyber-bullying on social media involving a staff member that no longer worked at the facility. The ADM stated she suspended CNA A on 09/26/2025 at around 4:00 PM and collected her statement later through a text message. She stated she provided 1:1 in-service with NA B and NA C related to reporting expectations. The ADM stated she received further detailed witness statements from NA B and NA C on 10/2/2025 and both NAs continued to state they did not report the concerns for abuse immediately after the witnessed incident due to fear of CNA A. The ADM stated she made a call to the police department to report the incident on 10/04/2025 but received no case number or follow-up. She stated the one of the regional compliance staff took the investigation report to the police department on 10/14/2025 and received the call for service number CFS-25-12418. The ADM stated after her investigation she was unable to determine the date and time of either alleged incident. The ADM stated she spoke with another staff member during her investigation that wished to remain anonymous. The ADM stated that the anonymous staff member stated NA C told her she really did not witness the alleged abuse by CNA A, but NA B had convinced her to make the report. The ADM stated she did not confront NA C with the statement because she did not want to breach the trust of the other staff member. She stated that she felt the other staff member was impartial to all other staff. The ADM stated she in-serviced all staff about cyber-bullying. She stated after talking with the anonymous staff member, looking at the bed height in relation to the length of CNA A's legs, the safety surveys and both Resident #1 and Resident #2 repeatedly stating no one at the facility had hurt them, her findings were unfounded for the allegation of abuse. The ADM stated she terminated CNA A on 10/13/2025 due to allegations of abuse even though the investigation was unfounded. She stated with the previous concerns related to social media she did not want that tension returning to the facility. The ADM stated she provided in-services on abuse, reporting guidelines for abuse, and sensitivity training to all staff. She stated she also implemented for two staff members to assist Resident #2 any time patient care is provided. The ADM also stated she had set up an in-service to be performed by the local law enforcement related to cyber-bullying that was scheduled to occur the following week. A telephone interview with PNP was attempted on 10/26/2025 at 05:22 PM. A voicemail was left requesting a return phone call. A returned phone call was not received prior to exit. Review of CNA A's employee file, on 10/17/2025, reflected a background check had been performed and revealed no convictions that would make CNA A unemployable. Review of CNA's employee file reflected the facility also performed and EMR and NAR search and no concerns were revealed. CNA A's hire date was officially 03/01/2025. Review reflected CNA A received training on Abuse, Neglect, and Exploitation as well as Texas Senate [NAME] 9 on 07/01/2025. Review of CNA A's employee file reflected CNA A was terminated on 10/13/2025 with reason for termination listed as allegation of abuse with no circled next to Had the employee received any prior warning?.Review of facility in-services reflected in-services dated 03/02/2025, 03/04/2025 and 03/16/2025 related to Abuse, Neglect, and Exploitation with CNA A's signature which indicated her attendance to the in-services.Review of NA B's witness statement reflected the following: On 09/26/2025 [NA B] states [CNA A] put soap in [Resident #1]'s eyes that was on a washcloth when she was washing her face and placed her hands on [Resident #2]'s chest to hold him down when they were providing him care and signed by NA B.Review of NA B's witness statement, dated 10/02/2025, reflected the following: [CNA A], and [NA C], were changing [Resident #2]. [NA C] had called because they needed help. I was watching him being changed and he was being combative. I joined in to help and we were able to turn him toward the wall. I put the brief on him and we turned him back to the other side so I could do the tab on his brief. He started hitting and he kicked me in the arm, (no bruising) and he hit [CNA A] in the chest. He hit her hard. [CNA A] started cursing but I don't think it was at him. After that I decided to pull the bed out and I was on the right arm and [CNA A] was on the other arm. He was able to get his arm loose from me and he hit [CNA A] again. I grabbed his arm back gently and [CNA A] had her knee on his chest and her right arm was holding him and her left arm was at the bottom of his neck and his face began to turn red. [Resident #2] was saying stop it over and over again. [CNA A] was calling him bad names and [CNA A] was telling him mother****** I am the boss and she would beat the s*** out him. [Resident #2] then got off him and he did not fight anymore after that.[Resident #1] had asked me to take her in the shower room and we put her in the shower chair. [Resident #1] asked for a wash rag and [CNA A] squirted the soap in her face and it got into her eyes. [Resident #1] kept say my eyes; you got soap in my eyes and then [Resident #1] asked me for a wash rag and I went and go the wash rag. Before I gave it to [Resident #1], [CNA A] put more soap on the wash rag and [CNA A] took the wash rag and washed her face with it. After she took the wash rag and did her face [Resident #1] kept saying wash rag, wash rag and I said to [CNA A] that she just wants a wash rag. [CNA A] did not say anything to me. I gave the wash rag to [Resident #1]. [CNA A] was rinsing [Resident #1]'s body. I left the shower room after that. This happened about two and a half weeks ago. I was worried to report because I was scared of the posts on [social media]. Signed by NA B. Review of NA C's undated witness statement reflected the following: [NA B] and I were assisting [CNA A] changing [Resident #2] and he was being very combative so [CNA A] took one of her arms and held onto his arm and then her other arm was on his chest. [Resident #2] was asking for [CNA A] to stop. I think she was using her body to hold him. [NA B] and I were watching [CNA A] because we were new when she was caring for [Resident #2]. [Resident #2] did not want to transfer and [CNA A] was picking at him like taking her fingers and putting them on his body. [Resident #2] can pivot on one leg and [CNA A] was getting him up and she transferred him onto the bed out of his wheelchair. [Resident #2] was aggressive and [CNA A] was taking her fingers and placing them on different parts of his face. [Resident #2] continued to be very combative. [Resident #2]'s hands were folded and she took her hands and placed them on top of his hands. She kept her hands there until [Resident #2] said ok you win you are the boss. She stopped.When I went to school I was taught that you do not put soap on a washcloth when you are washing a resident's face. [CNA A] took the soap bottle and poured soap on [Resident #1]s hair and it ran into her eyes and she let the soap stay like this for a full minute. After the minute was up she took the sprayer and sprayed towards her face. [Resident #1] took the water and used it and washed the soap off of her face.I feel [CNA A] is a good aide. She needs some training on compassion. Signed by NA C.Review of NA C's witness statement, dated 10/02/2025, reflected the following: Addendum to statement:[CNA A] was cussing but I am not sure what she was cussing about. She was just cussing. [Resident #2] was very angry and fighting us when we were trying to change him. We always have two people and both of us have to try to care for him. He is combative everytime we try to change him and we have to hold him down. I feel he gets worse at night but also in the mornings he is very very bad. On this day I think he was worse than most days. When we were trying to hold him he was very strong and kept getting away from us. Wherever we were holding him he was able to get away from us. [CNA A] had her knee on [Resident #2] to hold him down to. We have to get him up and he will not try to get out of bed if he up[sic?]. If he is up he is calm. Signed by NA C.Review of unsigned, undated, witness statement reflected the following: On September 18, 2025, [CNA A] stated she remembered the day when they had trouble with [Resident #2] and the day was Thursday and [LVN E] was the nurse. In the beginning [NA C] and she were cleaning up [Resident #2]. They had raised the bed to [CNA A]'s hip which was approximately 23 inches above the floor. With the bed raised to hip level it would be 25 inches from the ground. [Resident #2] was being combative, and [CNA A] stated they texted [NA B] to come and help them. When [NA B] came to the room [CNA A] stated [NA B] was holding [Resident #2]'s hands and [NA C] was trying to keep him from kicking [NA B] and herself. [CNA A] and [NA B] switched positions because [NA B] could not turn his upper body. [NA B] stated she got both hands and held them on his left shoulder with one hand and turned him with the hand[sic?] while [NA B] finished cleaning the BM from his right side which was difficult since they had him turned on this right side facing the wall. [NA C] was holding his leg and [CNA A] stated they struggled to push the sheets under him and then they turned him on his bed. They were able to get his brief on and then they were only able to put a draw sheet under him. [CNA A] stated they then positioned him in the bed so that he could eat breakfast and then they all walked out. [CNA A] stated she remembered that day clearly because [Resident #2] had never been that combative before or hit her like that before. Per [CNA A] via textDuring phone interview on 10/16/2025 at 01:25 PM, A representative from the local police department stated the police department received a call to service on 10/14/2025 at 01:26 PM from the facility related to a staff member abused a resident but no further information was provided regarding the staff member's name or the resident's name. She stated the call to service was cancelled on 10/14/2025 at 01:29 PM. She stated that no investigation by the police department was conducted. Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 2001 and last revised 09/2022, reflected the following: Policy StatementAll reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findi

Based on observation, interview, and record review, the facility failed to 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 4 (Resident #7, Resident #75, Resident #49 and Resident #2) of 8 residents reviewed for infection control practices, in that: The facility failed to:1. Ensure CNA E changed dirty gloves when handling clean items while providing peri care to Resident #7 and Resident #75.2. Ensure MA D sanitized blood pressure monitor in between Resident #49 and Resident #2 while obtaining blood pressure. 3. Ensure MA D had not stored her orange juice in use, in the med cart at the facility. This failure could place residents at risk for healthcare associated cross-contamination and infections. Findings included:Review of Resident #7's face sheet dated 08/27/25 reflected an [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including unsteadiness on feet, cognitive communication deficit, weakness, need for assistance with personal care, dementia, muscle weakness, lack of coordination and hypertension. Review of Resident #7's quarterly MDS assessment, dated 08/07/25 reflected he rarely /never understood a BIMS interview questions, indicating a severely impaired cognition. Review of Resident #7's care plan dated 08/07/25 reflected he had functional & mixed bladder incontinence r/t immobility, cognitive deficit. The relevant intervention was cleaning peri-area with each incontinence episode. Review of Resident #75's face sheet dated 08/27/25 reflected an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including urinary tract infection, acute respiratory failure, chronic pain, muscle weakness, lack of coordination, severe sepsis (life threatening reaction to an infection), end stage renal disease and need for assistance with personal care. Review of Resident #75's initial MDS assessment dated [DATE] reflected a BIMS score of 10, indicating moderately impaired cognition. Review of Resident #75's care plan dated 08/07/25 reflected she had functional bladder incontinence r/t Confusion, Impaired Mobility, Physical limitations. The relevant intervention was checking every two hours and wash, rinse, and dry perineum. During an observation on 08/27/25 at 1:10pm CNA E was providing peri care for Resident #7. CNA E put on gloves after washing her hands. After that she opened the brief and cleaned Resident #7's front and back with wet wipes dispensed directly from the packet. In that process she handled the whole wipe packet with the soiled gloves. During an observation on 08/27/25 at 2:20pm CNA E was providing peri care for Resident #75. She performed peri care by cleaning Resident #75's front and back with wet wipes dispensed directly from the whole packet. In that process she handled the wipe packet containing clean wipes, with the soiled gloves. CNA E had not changed her gloves before handling the clean wet wipe packet while providing peri care to Resident #7 and Resident#75. After the completion of peri care she saved the contaminated wipe packets containing wet wipes in Resident #7 and Resident #75's rooms for future use (as stated by CNA E). During an interview on 08/27/25 at 2:45pm CNA E stated she was a CNA for many years and was diligent in following infection control protocol. When the surveyor walked through the entire process CNA E pointed out that she had not changed the soiled gloves before handling the clean packet containing wet wipes. She stated her negligence contaminated the whole packet of wipes. CNA E stated she was risking spreading diseases by handling a clean packet with contaminated gloves. CNA E stated she could not remember any in services on peri care in the recent past. Review of Resident #49's face sheet dated 08/26/25 reflected an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertension, pain, abnormal weight loss, unsteadiness on feet, lack of coordination, muscle wasting, vitamin D deficiency, heart disease, muscle weakness, and lack of coordination. Review of Resident #49's quarterly MDS assessment, dated 08/08/25 reflected a BIMS score of 9 indicating her cognition was moderately impaired. Review of Resident #49's care plan dated 04/22/25 reflected she had hypertension, and a relevant intervention was evaluating blood pressure. Review of Resident # 49's medication order revealed: Lisinopril 5 mg tablet: Give 1 tablet orally in the morning related to essential (primary) hypertension. Hold if BP <115/55 or HR <55. -Start Date- 07/09/2025. Review of Resident #2's face sheet dated 08/26/25 reflected an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, vitamin d deficiency, hypertension, congestive heart failure, orthostatic hypotension ( sudden drop in blood pressure when standing up), and muscle weakness. Review of Resident #2's annual MDS assessment, dated 06/30/25 reflected a BIMS score of 9 indicating her cognition was moderately impaired. Review of Resident #2's care plan dated 04/22/25 reflected she had hypertension, and a relevant intervention was monitoring blood pressure and administer medication as ordered. Review of Resident #2's medication order revealed: Midodrine HCl Oral Tablet 2.5 MG (Midodrine HCl): Give 1 tablet by mouth every morning and at bedtime for hypotension. Hold for SBP > 130. -Start Date- 05/16/2025. During an observation on 08/26/25 at 9:45am MA D failed to sanitize the wrist blood pressure monitor before using it on Resident #49 and in between Resident #2 and Resident #49. MA D took the blood pressure of Resident #49 with a wrist blood pressure monitor without sanitizing it. After administering the medications to Resident #49 she moved on to Resident #2 and used the same blood pressure monitor on her without sanitizing it. MA D did not sanitize the monitor after the use on Resident #2 until the investigator pointed it out. After the completion of administering medications to Resident #2, MA D opened the third drawer of her med cart and pulled out a bottle of orange juice and drank directly from it with lips contact. After drinking two sips she capped the bottle and placed it back in the same drawer. During an interview on 08/26/25 at 10:35am, MA D stated the orange juice was her personal item and stored in the drawer so that she could drink while administering medications to the residents. When the surveyor asked about the appropriateness of storing personal belongings in the med cart, MA D stated storing orange juice was against the infection control protocol at the facility and she should not have stored it in the med cart. She stated storing orange juice in the med cart and drinking from it could cause cross contamination, resulting in spreading contagious diseases at the facility. MA D stated not sanitizing blood pressure cuffs in between the residents also could cause spreading of diseases among residents, staff, and visitors. She stated she was aware of the impact on residents if she did not follow the infection control protocol as it was necessary to minimize spreading diseases from one resident to another. MA D stated she received trainings on infection control occasionally however no in-services received were specifically on sanitizing medical equipment or restricting personal belongings in the med cart. During an interview on 08/28/25 at 2:25pm the DON stated CNA E should not have handled the wet wipe packet with soiled gloves. He stated CNA E was supposed to throw away the contaminated wet wipe packet instead of saving it for future use, when she realized that the packet was contaminated. The DON said his expectation was the staff sanitized all medical equipment in between residents including blood pressure cuffs. The DON said no staff at the facility should handle clean items with dirty hands or gloves. He added, staff had to change their contaminated gloves before handling clean items. He stated personal belongings were not allowed in the med cart for infection control reasons. The DON stated he identified deficiencies in infection control practices by observation during routine rounds in the facility. He stated if any deficiencies were observed the related staff would be retrained and in serviced. The DON stated he could not remember exactly when the staff received in services on infection control as he started working at the facility only a few months ago and was in the process of fixing the issues one by one. Review of the in-service records from 05/01/25 to 08/28/25 revealed there were separate in services on 06/10/25 on hand hygiene and using gloves during nursing care. Record review of the facility's policy Handwashing / Hand hygiene Revised in October 2023 reflected: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Indications for Hand Hygiene1. Hand hygiene is indicated:2. immediately before touching a resident.3. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device).4. after contact with blood, body fluids, or contaminated surfaces.5. after touching a resident.6. after touching the resident's environment.7. before moving from work on a soiled body site to a clean body site on the same resident; and8. immediately after glove removal.1. Use an alcohol-based hand rub containing at least 60% alcohol for most clinical situations.2. Wash hands with soap and water:9. when hands are visibly soiled; and10. after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile. Record review of facility policy Perineal Care revised in February 2018 reflected: The purpose of this procedure is to provide cleanliness and comfort to resident, to prevent infections and skin irritation, and to observe the resident's skin condition .. Wash hands. Wear gloves and follow Standard Precautions if contact with blood or body fluids is likely. 3. If resident is heavily soiled with feces, turn resident on side and clean away feces with tissue, wipes, or incontinent brief. Discard soiled gloves along with the soiled brief and/or wipes in trash bag. Cover the resident, provide safety measures, and wash hands with soap and water. Record review of facility policy Medication Labelling and Storage revised in February 2023 reflected: .2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Record review of facility policy standard precautions revised in September 2022 reflected:.Reusable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed.Gloves are changed as necessary during the care of a resident to prevent cross contamination from one body site to another (from moving from a dirty site to a clean site.)

Based on observations, interviews, and record reviews the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen.The facility failed to ensure food was properly labeled and dated. The facility failed to maintain proper kitchen sanitation when [NAME] B, did not follow proper hand hygiene protocols.These deficient practices could place residents who were served from the kitchen at risk for health complications and foodborne illnesses. Finding included:Observations of the kitchen on 8/26/25, at 8:51am revealed four Chocolate flavored Creme Pies located in a second spare refrigerator located in the kitchen area that were not labeled or dated. Observations of [NAME] B, on 8/27/2025, at 10:25pm performing puree meal preparation revealed the [NAME] did not wash her hands to start the puree process. The [NAME] then began the food preparation process without wearing gloves. She added eight scoops of tamale pie bread to the food processor but forgot the tomato juice in the refrigerator to the left of her. Immediately after retrieving the tomato juice from the refrigerator the [NAME] did not wash her hands or don new gloves. [NAME] B handled multiple utensils which included a scoop, spatula, and a large spoon throughout the preparation without washing her hands in between. After preparing pureed beans, [NAME] B licked her finger to remove the excess beans. It was also observed that she failed to adequately wash and sanitize the pan after each pureed dish, and only rinsed out the blender cup instead in a nearby sink behind her. She stated she could not go in the area where the dishwasher was located, but did not say why she was not able to go to other area. An Interview with the Kitchen Manager, on 8/27/2025, at 2:06pm, revealed that the Manager was last in serviced on hand hygiene on 08/14/2025. The Kitchen Manager stated if staff did not properly sanitize their hands and wear gloves while preparing food residents could become sick. The Manager also said all items in the kitchen should be labeled and dated after opened. An Interview with Head [NAME] B, on 8/28/2025, at 10:00am, revealed that she has been trained on hand hygiene and labeling and dating foods. She stated if they did not use proper hand hygiene or label and date food correctly this could have a negative effect on residents by causing them to become sick.Record Review of the Food Receiving and Storage Policy Revised November 2022, revealed refrigerated foods are labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded.Record Review of the Handwashing/Hand Hygiene Policy Revised October 2023 revealed the facility considers hand hygiene the primary means to prevent the spread of healthcare associated infections. Policy Interpretation and Implementation. Administrative Practices to Promote Hand Hygiene 1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing thetransmission of healthcare-associated infections.2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread ofinfections to other personnel, residents, and visitors.3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub) are readilyaccessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol-basedhand-rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflow throughoutthe facility.4. Personnel are educated regarding ways to prevent contact dermatitis and other skin irritation, and providedwith supplies that support healthy hand skin.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 4 of 10 residents (Resident #2, Resident #25, Resident #40, and Resident #66) reviewed for rights. The facility failed to ensure CNA D and HK F knocked on Resident #2, Resident #25, and Resident #40's doors when going into the residents' rooms. The facility failed to provide Resident #66 with a privacy bag for his catheter. These failures could place residents at risk of feeling like their privacy was being invaded or could have a negative psychosocial, psychosocial harm and emotional distress. Findings included: Resident #2 Record review of Resident #2's Face Sheet dated 08/26/2025 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included obstructive pulmonary disease (chronic progressive lung disease), hyperthyroidism (excessive production of thyroid hormones), type 2 diabetes mellitus with hyperglycemia (high blood sugar), morbid obesity, hyperlipidemia (high cholesterol), insomnia (difficulty sleeping), hypertension (high blood pressure), heart failure, respiratory failure, constipation, muscle wasting, muscle weakness, and cognitive communication deficit (problems with communication). Record review of Resident #2's Annual MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of 09 indicating moderate cognitive impairment. Resident #25 Review of Resident #25's Face Sheet dated 08/26/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #25's diagnoses included hemiplegia and hemiparesis following cerebral infraction affecting left non dominant side (paralysis and weakness on left side after stroke), dementia (memory, thinking, difficulty), viral hepatitis C (a bloodborne virus that causes liver inflammation), type 2 diabetes mellitus with other specified complications (high blood sugar), hyperlipidemia (high cholesterol), glaucoma (eye disease), hypertension (high blood pressure), and cerebral infraction (stroke). Record review of Resident #25's Quarterly MDS assessment dated [DATE] revealed Resident #25 had a BIMS score of 99 indicating Resident #25 was unable to complete the BIMS. Resident #40 Record review of Resident #40's Face Sheet dated 08/26/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #40's diagnoses included hypertension (high blood pressure), trigeminal neuralgia (severe facial pain), lack of coordination, need for assistance with personal care, high risk of sexual behavior, eating disorder, metabolic encephalopathy (brain disease), muscle wasting, muscle weakness, difficulty in walking, and tobacco use. Record review of Resident #40's Quarterly MDS assessment dated [DATE] revealed Resident #40 had a BIMS score of 09 indicating moderate cognitive impairment. Resident #66 Record review of Resident # 66's face sheet dated 08/27/2025 revealed this was a [AGE] years old male who was admitted to the facility 06/15/2025 (original admission date 11/14/2024) and diagnosed with hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following cerebral infarction affecting right dominant side. Hyperkalemia (high level of calcium in the blood). Pneumonia. Chronic kidney disease, stage 4 (severe). Cognitive communication deficit. Mild cognitive impairment. Depression. Anemia. Difficulty in walking. Luck of coordination. Type 2 Diabetes mellitus without complications. Vitamin deficiency. Hyponatremia (low sodium level in the blood). Essential hypertension (high blood pressure). Chronic kidney disease. Neuromuscular dysfunction (impairment of nerves and muscles) of bladder. Benign prostatic hyperplasia (increased cell production in a normal tissue) with lower urinary tract symptoms. Pain. Record review Resident # 66's MDS assessment dated [DATE] reflected BIMS score of 11=indicating moderate cognitive impairment. Record review Resident # 66's care plane (undated) revealed there were no order to provide him with urinary drainage bag covers or dignity bags. Record review Resident # 66's physician orders revealed there were no orders to keep the urinary drainage bag concealed. Observation of hall 100 on 08/26/2025 at 9:36am revealed that CNA D did not knock on Resident #2's door before entering the room. Observation of hall 100 on 08/26/2025 at 9:53am revealed CNA D did not knock on Resident #40's door before entering the room. Observation on 08/26/2025 at 10:06 AM revealed Resident # 66's urinary drainage bags were lying on both sides of the Resident #66 while he was lying in his bed. The drainage bags were not covered; both bags were filled with yellow color urine. The door to Resident #66' room was open. The urinary drainage bags could not be seeing from outside. The Resident #66 had a roommate, and the urinary drainage bags were visible to his roommate. Observation of 100 hall on 08/26/2025 at 12:35pm revealed that HK F did not knock on Resident #25's door before entering. Observation of Resident #66 on 08/27/2025 at 09:22 AM revealed Resident # 66's urinary drainage bags were lying on both sides of him while he was in bed. Both urinary drainage bags were uncovered and was filled with yellow color urine. The door to Resident #66' room was open. The urinary drainage bags could be seeing from outside. The Resident #66 had a roommate, and the urinary drainage bags were visible to his roommate. Observation on 08/27/2025 at 10:12 AM revealed Resident # 66's POA placed his urinary drainage bags were placed into ACE's two pockets apron. The apron with the urinary drainage bags was secured around Resident # 66's neck and the drainage bags were positioned on the Resident # 66's chest. Observation on 08/28/2025 approximately at 08:40 AM revealed Resident # 66's drainage bags were lying on both sides of the Resident's # 66 while he was lying in his bed. The drainage bag positioned on his right side was covered with a bed sheet, urinary drainage bag on his left side was not covered, the urinary drainage bag was filled with yellow color urine. The door to Resident #66' room was open. The urinary drainage bags could not be seeing from outside. The Resident #66 had a roommate, and the urinary drainage bags were not visible to his roommate. During an interview with Resident #25 on 08/26/2025 at 1:31pm revealed he would not respond to any questions from the surveyor. In an interview and observation with the Resident # 66's FM who was his POA representative on 08/27/2025 at 09:23 AM, she stated that the facility did not provide Resident #66 with any bags to hide his urinary drainage bags. She thought that facility would provide one, but they never did so the Resident # 66's family member purchased an apron from a store. The FM pulled out the apron from Resident #66's dresser; This small apron had printed letters ACE with two pockets. The FM secured the apron around her neck to show where the apron was placed when Resident # 66's family member takes him to his appointments and procedures. The FM said that she wished that Resident # 66 were provided with specialized bags to hide his urinary drainage bags. During an interview with Resident #40 on 08/27/2025 at 1:41pm revealed that staff do not knock most of the time. He said he would prefer staff knock all the time because there were times, he would be butt naked and it would give him time to put a sheet on. During an interview with Resident #2 on 08/27/2025 at 1:47pm revealed that staff do not knock all the time. She said she would prefer for staff to knock all the time, so she knows they were coming in. During an interview with CNA D on 08/27/2025 at 2:53pm revealed she had been trained on resident rights. She said the policy for knocking was that staff must knock every time a staff member wanted to go into the resident's room. She said that the facility was their home, and it was disrespectful for staff not to knock before entering. She said the resident may feel violated because the room was their space, the resident's home. She said it might scare the resident if someone just walked in. She said that no one monitored to ensure staff were knocking. She said she did not realize she just walked into the residents' rooms. She also said that she needed to pay more attention. During an interview with HK F on 08/27/2025 at 1:56pm revealed that she had been trained on resident rights. She said the policy for knocking was that all staff were supposed to knock in the resident's door before entering. She said staff were to knock for the resident's privacy. She said that everyone was supposed to always knock before going into the resident's room. She said if staff did not knock then the resident may feel like they did not have any privacy. She said that staff did not have to knock on the resident's door in an emergency. She said she did not know who monitored to ensure staff were knocking. She said that she probably did not knock on the resident's door because it was open. She also said she still should have knocked on the resident's door. In an interview with DON on 08/28/2025 approximately at 8:35 AM he stated that that if the urinary drainage bags were not covered, it was a dignity thing. The DON could not recall when the facility's staff had in-service trainings on treating residents with dignity. In an interview with NCNA E on 08/28/2025 at 09:04 AM she stated that the urinary drainage bags need to be hidden for privacy. She stated that she was working there about 2-3 months, but she could not recall any trainings provided there on resident rights or dignity. In an interview with 08/28/2025 09:13 AM with LVN B she stated that urinary drainage bags must be covered. She stated that the facility has in service trainings constantly but could not recall when last time the staff had in-service training on dignity issues related to urinary drainage bags. An interview with the DON on 08/28/2025 at 2:17 p.m., revealed he and staff had been trained on resident rights. He said the policy was that staff were to knock on the resident's door before entering the resident's room. He said that staff were to always knock before entering the resident's room. He said staff did not have to knock if it was a medical emergency. He also said that if staff did not knock on the door the resident may feel uncomfortable if someone just walked into their room. He said that he and the ADM was responsible for monitoring to ensure staff were knocking. He said that him and the ADM monitored knocking by doing compliance rounds. He said he had no idea why staff were not knocking. An interview with the ADM on 08/28/2025 at 2:51 p.m., revealed that she and staff had been trained on resident rights. She said the policy was to knock on the door and wait for the resident to respond. She said that it was important for staff to knock on the residents' door for their privacy. She said the resident may feel like their privacy was being invaded. She said the only time staff did not need to knock on the resident's door was in the event of an emergency. She said that the facility did not monitor knocking and said that the facility needed to monitor. She said she staff have all been told and were just not doing what they had been taught. Record review of the Dignity Policy revised 02/2021 revealed residents are treated with dignity and respect at all times. Staff are expected to knock and request permission before entering residents' rooms. Record review of the revised facility's policy from February 2021 states: Demeaning practices and standards of care that compromise dignity is prohibited. Staff are expected to promote dignity and assist residents; for example: helping the resident to keep urinary catheter bags covered. Record review of the facility's In-service report on 08/28/2025 approximately at 14:40 PM revealed that there was no in-service training recorded for covering the urinary drainage bag.

Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 (Resident #66 and Resident #8) of 4 residents reviewed for catheter care. The facility failed to ensure Resident #66 and Resident #8's catheters' drainage bag positioned lower than Resident's urinary bladder to prevent urine from flowing back into the kidneys and urinary bladder. This failure could place residents at risk of UTI and other serious infections.Findings included: Record review of Resident # 66's face sheet dated 8/27/25 revealed a [AGE] year-old male who was admitted to the facility originally on 11/14/24 and re admitted on [DATE]. His diagnoses were hemiplegia and hemiparesis (paralysis on one side of the body), acute respiratory failure, chronic kidney disease, difficulty in walking, muscle weakness, lack of coordination, need for assistance with personal care, type 2 diabetes mellitus , neuromuscular dysfunction of bladder (impaired nerves and muscles that control bladder function) , and benign prostatic hyperplasia(enlargement of prostate gland) with lower urinary tract symptoms. Record review Resident#66's initial MDS assessment dated [DATE] reflected a BIMS score of 11 indicating moderate cognitive impairment. Record review Resident#66's care plan dated 07/21/25 revealed he had indwelling Suprapubic.Catheter (catheter tube inserted through small incision in the lower abdomen into the kidney/urinary bladder). The positioning of the urinary drainage bags was not included in the in the interventions in the care plan. During an observation on 08/26/2025 at 10:06 AM, on 08/27/25 at 9:22AM and on 08/28/25 at 08:40AM it was revealed Resident # 66's urinary drainage bags were lying on both sides of Resident # 66 while he was lying in his bed. The drainage bags were filled with yellow color urinary. During an observation on 08/27/2025 at 10:12 AM Resident # 66's urinary drainage bags were placed into two pockets of an apron he was wearing. The urinary drainage bags were in the pockets and were positioned at the chest level (above the level of the kidneys of Resident # 66). During an interview on 08/27/2025 at 12:07 PM Resident # 66 stated his kidneys were all that he had left and if they went, he also would go. He was unable to explain further about his conditions. During an interview on 08/28/2025 at 09:13 AM LVN F stated the urinary drainage bags must be placed below the bladder level for the gravity drain, however Resident #66 requested to be placed at his side on the bed as that made him feel safer and more comfortable. Record review of Resident# 8's face sheet dated 08/27/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were Urinary tract infection, Chronic obstructive pyelonephritis (inflammation of kidneys due to urinary tract obstruction), hydronephrosis (swelling of kidneys due to urine backup), Chronic kidney disease, Neuromuscular disfunction of bladder, retention of urine, Pressure ulcer of left buttock, stage 4, Unsteadiness on feet. Mild cognitive impairment, Type 2 Diabetes mellitus, Chronic heart failure, Constipation, acute kidney failure and need for assistance with personal care. Review of Resident # 8's of quarterly MDS assessment, dated 07/15/25 revealed a BIMS score of 07 indicating severe cognitive impairment. Review of Resident # 8's care plan, dated 06/25/2025 revealed resident had foley catheter. The relevant intervention was to position catheter bag and tubing below the level of the bladder and away from her room's entrance door. During a wound care observation on 08/27/2025 at 2:28 PM, Resident #8 was lying in bed. LVN H entered Resident #8's room for wound care and the urinary drainage bag of Resident #8 was removed from the lower part of her bed by LVN H and placed on Resident's # 8's bed. During an interview on 08/27/2025 at 2:45 PM LVN H stated she started working at the facility about two weeks ago and had not received any specific training on catheter management. She stated she placed Resident # 8's urinary drainage bag on resident's bed during the wound care and that could cause the urine to flow back into Resident # 8's body. She stated back flow of external urine into the body could lead to varieties of infection to the resident. During an interview on 08/28/2025 at 10:36 AM the MD stated it was OK if the urinary drainage bags were positioned next to the resident on the bed as the pressure inside of the kidneys are higher and urine could not get back to the kidneys easily. When the surveyor asked what if the urinary drainage bags were full, and they were in bed, MD stated in that case, the urine from the bags could flow back to the kidneys risking residents with infections. During an interview on 08/28/2025 at 8:35 AM with DON stated the placement of Resident 66's urinary drainage bags were not important as Resident # 66 had nephrostomy catheter, and the urine drains directly from his kidneys. He stated it was impossible for Resident #66 to get infection as kidneys have no reservoirs for urine to back up there. He stated since Resident #8 had foley catheter, placement of urinary drainage bags below the bladder level was important for Resident #8. He said if the urinary drainage bag were placed above bladder, the urine could flow back, and it could put residents at risk for infection. The DON said the training on catheter management was an ongoing process and was unable to remember if he had conducted any in services on this issue. Record review of Inservice records since 05/01/25 revealed there were no in-services conducted on Urinary catheter care. Record review of facility's policy Catheter Care, Urinary revised in July 2024 reflected: . The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into urinary bladder.

Based on interviews, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 2 of 58 days (08/09/2025 and 08/10/2025) reviewed for RN coverage. The facility failed to ensure they had an RN scheduled on duty for 08/09/2026 and 08/10/2025 and failed to ensure the DON was not acting as the charge nurse when the facility had an average daily occupancy of more than 60 residents. This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment.Findings included: Review of the daily staffing for June 1, 2025, through August 28, 2025, reflected zero hours worked by an RN on the following days: 08/09/2025 and 08/10/2025. The census both days was over 60 residents. Record review of staff schedules dated 08/01/2025 through 08/31/2025 revealed that there was no RN who worked on 08/09/2025 and 08/10/2025. The DON was the only RN scheduled for 08/09/2025 and 08/10/2025. Record review of time punches for Nursing staff for August 2025 revealed no RN punched in for 08/09/2025 and 08/10/2025. During an interview with the ADON on 08/28/2025 at 1:13p.m., she said she had been trained on staffing. She said that she was responsible for doing the nursing schedule. She said that the facility was to have an RN scheduled 8 consecutive hours every day. She said it was important to have an RN for 8 hours a day because the RN's skill set was a bit more than an LVN's. She said an RN can pronounce a resident if they were to pass. She said that she never had a concern where there were not enough staff because if there was not enough staff, she would come in to work. She also said that the DON could cover the RN shift. She said usually if someone called in or there was a staff shortage, she would try to call someone in to work or if she could not find coverage, she would go in to cover. She said the facility did not have a lot of issues with not being able to cover staff shortages. She said that the facility did not use agency or temporary staff. She said that the facility always had RN coverage. She said the residents' needs have never gone unmet because the facility always had an RN. She said she did not know what could happen if there was not an RN because she said the LVN can do the same things except pronounce a resident who passed. She said that she was not sure why an RN did not work on 08/09/2025 and 08/10/2025. During an interview with the DON on 08/28/2025 at 2:28p.m., he said he had been trained on staffing. He said the ADON was responsible for the nursing scheduling. He said the facility should have an RN scheduled 8 hours a day, 7 days a week. He said that it was important for the facility to have an RN because they were smarter than an LVN. He also said it was important to have an RN to supervise the care in the facility. He said the ADM and DON monitored to ensure there was an RN scheduled for 8 hours a day. He said he had never had concerns there were not enough staff to meet the resident's needs. He said the facility managed call outs or unanticipated staff shortage by calling someone else in or him and the ADON came in to assist if needed. He said that it was very infrequent that the facility could not find coverage. He said the facility did not use agency or temporary staff. He said there was never a time an RN was not available to provide care at the facility. He said if there was no RN it could cause lack of supervision and professional judgement. He said he can change his days and come in on the weekend and be an RN if he had another RN cover him for the two days he missed during the week. He said he was working as the RN on 08/09/2025 and 08/10/2025 so the facility did have an RN. During an interview with the ADM on 08/28/2025 at 2:57p.m., she said that she had been trained on staffing. She said that the ADON was responsible for doing the nursing schedules. She said that the policy was that an RN should be scheduled for 8 hours a day. She said it was important to have an RN because the RN was needed to be able to make the proper decisions and some fell outside the LVN's scope of practice. She said the ADON, and the DON were responsible for ensuring that there was an RN scheduled or working every day. She said she had never been concerned that there were not enough staff to meet the resident's needs because the facility had additional people who would come in to work. She also said she would come in and work as a CNA if needed. She said if they had a staff shortage or call out the facility would call other staff to come in to work. She also said she had some nurses would come in and help when she needed them. She said the facility did not use temporary or agency staff. She said it was rare that the facility did not have an RN. She said she did not know how to answer when asked about the types of services or care not provided when an RN was not onsite. She said if there was not an RN the facility would not have a supervisor. She said that she thought there was no RN on 08/09/2025 and 08/10/2025 due to a scheduling error. She also said she was going to check into it. Record review of Staffing, Sufficient and Competent Nursing revised 08/2022 revealed our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. A charge nurse is a licensed nurse with designated responsibilities that may include staff supervision, emergency coordination, provider or physician support and direct resident care. The director of nursing services (DNS) may serve as the charge nurse only when the average daily occupancy of the facility is 60 or fewer residents. A registered nurse provides services at least eight (8) hours every 24 hours, seven (7) days a week.

Based on interview and record review, the facility admitted a resident with a mental disorder before the Stated mental health authority had determined she was appropriately placed for 1 of 1 resident (Resident #9) reviewed for PASARR screening. The MDS Coordinator failed to complete the PASARR screening process for Resident #9. This failure could place residents at risk of not receiving specialized services. Findings included: During an interview with Resident #9 on 08/28/2025 at 11:48am, was present in her room with her son who is also a resident. Resident #9 was lying in bed with her son's dog, she did not speak much, and her son did most of the talking. He stated they have been in facility for a while and have no complaint are issues, he stated they are very happy at facility and are happy to have someone to help them. Son stated that he is from California and has been here with Grandfather who is from Texas. Record review of Resident #9 admission record revealed the resident was admitted to the facility on [DATE], with diagnoses including schizoaffective disorder (bipolar type), insomnia, depression, and generalized anxiety disorder. Record review of the quarterly MDS assessment for Resident #9 completed on 06/19/2025, Section C, revealed a BIMS score of 12/15, indicating mild cognitive impairment. Section I (Active Diagnoses) Indicated no active diagnoses for Resident #9. Record review of the Care Plan, dated 06/22/2025, revealed Resident #9 has depression related to schizoaffective disorder, with goals to exhibit indicators of depression, anxiety, or sad mood less than daily by the review date. Record review of the PASRR documentation in Resident #9's electronic health dated 10/11/2023, from Texas Medicaid & HealthCare Partnership with the Subject: You are not eligible for PASRR specialized services. Record review of Resident #9's psychiatric evaluation and medication review dated 08/20/2025, revealed Resident #9's psychiatric history includes significant diagnoses. During the evaluation, the resident reported increased depression and anxiety due to the passing of her [family member], along with sleep difficulties, though appetite remained good. Observations noted agitation, anxiety, forgetfulness, and confusion. Record review on 08/28/2025, did not reveal a PASRR Level I Am screening report for Resident #9. During an interview and observation on 08/28/2025 at 1:35 PM, the MDSN, was able to give a breakdown of MDS process and explain that the PASRR must be submitted after the IDT meeting no later than 14 days. During an interview on 08/28/2025 at 2:18 PM, the DON stated that the PASRR evaluation was covered by the MDSN, he was not sure how long the facility had to submit the PASRR application. The DON stated that not submitting the PASRR application timely could cause the residents to miss benefits that would help them in therapy and on useful equipment. During an interview on 08/28/2025 at 2:53 PM, with ADM, the ADM stated she had been at facility for around 6 months. The ADM takes care of all training and thought the facility had 24 hours to submit the PASRR applications but stated she would research this information. The ADM stated if this information were not submitted within 24 hours the negative effective on residents would be the facility would not know what was wrong with resident and what service to provide to each resident. Review of facility PASRR policy dated 07/29/2025, reflects, The PASRR program aims to ensure that individuals with mental illness or intellectual disabilities receive appropriate care and services. It assesses whether the nursing home is the most suitable setting for the individual's needs. Procedure 2. Screening Process: a). Level I Am screening: This initial screening determines if the individual may have a mental illness or intellectual disability. It is generally completed by the nursing facility before admission.b). Level II Evaluation: If the Level I screening indicates potential mental illness or intellectual disability, a Level II evaluation is conducted. This comprehensive assessment is performed by a qualified mental health professional and evaluates the individual's needs and whether nursing home placement is appropriate. 3. Documentation: Facilities must maintain thorough documentation of the PASRR assessments, including the Level I and Level II evaluations, as well as the recommendations made.

Based on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 Residents (Resident #3) reviewed for care plans. The facility failed to care plan Resident #3's dialysis that he received 3 times a week from an external dialysis center. This failure could lead to residents on dialysis receiving improper care/treatment. Findings included: Review of Resident #3's face sheet dated 08/27/25 reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease, depression, dementia, muscle wasting, vitamin d deficiency, type 2 diabetes, and hypertension. Review of Resident #3's annual MDS assessment, dated 08/14/25 reflected a BIMS score of 9 indicating the cognition was moderately impaired. It indicated Resident #3 had dialysis as special treatment for the end stage renal disease. Review of Resident #3's care plan dated 08/20/25 revealed there was no care plan for dialysis that he was receiving for end stage renal disease. During an observation and interview on 08/27/25 at 3:10pm Resident #3 was in his wheelchair socializing with other residents in the hall at the entrance. He stated he was doing good at the facility and was taken care of by the staff. Resident #3 stated he was on dialysis on Monday, Wednesday, and Friday. He stated he received transportation to the dialysis center organized by the facility and had no immediate issues currently. During an interview on 08/28/25 at 2:30pm LVN F stated whenever she was on duty, she was the nurse who prepared the resident, before going out for dialysis. She stated Resident #3 goes to the dialysis center 3 days a week. LVN F said before sending out Resident #3 she ensured the ports (a surgically created connection that allows blood to be accessed during dialysis) were in good condition without any infection or any other complications. She stated every time before he left the facility, she would check his vitals to make sure there were no abnormal readings, also filled out all the forms and communication logs. LVN F said she did all the preparation work before sending the resident for dialysis from her years of experience in nursing and had not checked his care plan for dialysis yet. She stated she would refer the care plan or contact the physician if there were any issues or concern related to dialysis care. LVN F stated care plan was an important part of nursing care as it provides information about goals and interventions however, she had not checked Resident #3's dialysis care plan as there were no such complicated situation occurred so far. LVN F stated creating care plan was the duty of the MDS nurse. In an interview on 08/28/25 at 10:48 AM, the MDS nurse said she was responsible for completing MDS assessments and care plans. She said if a resident had an active problem that was addressed by the facility it should be in the MDS and then care planned appropriately. The MDS nurse stated the dialysis treatment of Resident #3 should have been incorporated into the care plan. She said it was an unintentional negligence from her however she added Resident #3's dialysis treatment to the care plan on 08/27/25, as soon the surveyor informed her about the absence of it. She stated care plan was an integral part of resident's care as it provides guidelines to the nursing staff about the presenting problems, goals, and interventions. Record review of facility's policy Comprehensive Care Plans, revised in October 2023, reflected: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents' rights, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments for 1 of 3 medication carts (100 hall) reviewed for medication storage. The facility failed to ensure the medication cart for 100 hall was locked when unattended by LVN A on 08/26/2025 at 12:37p.m. These failures could place residents at risk of harm due to unauthorized access and potential ingestion of medication, needles, and other biologicals. Findings included: Observation on 08/26/2025 at 12:37p.m., revealed the 100-hall medication cart was unlocked and unattended by a resident's room. LVN A was in a resident's room with the door closed and was out of sight of the medication cart. During an interview on 08/28/2025 at 12:09p.m., with LVN A, she stated she was responsible for the 100-hall medication cart on 08/26/2025. She said that she had been trained on medication storage for medication carts. She said the policy was that the medication cart was to be always locked when the nurse was away from the cart. She said if the medication cart were left unattended and unlocked the risk could be a resident or staff could get into the medication cart and take medications, needles or the wrong medications and can harm themselves. She said the DON monitored to ensure the medication carts were locked but ultimately it was the nurse's responsibility. She said the DON monitored through observations. She said she forgot to lock the cart because she was worried about a resident and was rushing. During an interview on 08/28/2025 at 2:25p.m. with the DON, he said he and nursing staff had been trained on medication storage in the medication carts. He said the policy for medication storage was that the medication cart was to be always locked when unattended. He said the nurse who was using the medication cart was responsible for locking the cart when leaving the cart unattended. He said that the risk of the medication cart being left unlocked and unattended could possibly be a resident getting in the drawers and taking something. He said the DON and ADM monitored to ensure the medication carts were locked. He said the DON and ADM monitored through compliance rounds. He said he did not know why LVN A left the 100-hall medication cart unlocked, except she was dealing with a resident. During an interview on 08/28/2025 at 02:54p.m. with the ADM, she stated she and nursing staff had been trained on medication storage in the medication carts. She said the policy for medication storage was that all medication carts were to be locked. She said the nurse or medication aide who was working on the medication cart was responsible for ensuring it was always locked when unattended. She said if the medication cart were not locked and was unattended a resident or employee could take some medications. She said the charge nurse and the DON were responsible for monitoring to ensure that the medication carts were locked. She said they monitored by making walking rounds. She said LVN A left the medication cart because she was in a hurry to tend to a resident and was not aware she left it unlocked. Review of Medication Labeling and Storage Policy revised 2/2001 revealed the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents and hazards.NA A failed to have another staff assist while providing a mechanical lift transfer for Resident #1 from chair to bed on 07/09/2025. Resident #1 fell out of the mechanical lift, fell to the floor hitting her head, was transferred to the ER and was diagnosed with a laceration to the back of her head that required staples. The noncompliance was identified as past noncompliance. The IJ began on 07/09/25 and ended on 07/10/25. The facility had corrected the noncompliance before the survey began.This deficient practice could place residents at risk for falls, injuries, hospitalization, and death.Findings included: Review of Resident #1's face sheet dated 07/23/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with readmission date of 01/05/2022. Resident #1's diagnoses included Alzheimer's disease with early onset (a progressive brain disorder that gradually destroys memory and thinking skills, eventually impacting a person's ability to carry out even the simplest tasks), lack of coordination, need for assistance with personal care, morbid obesity due to excess calories, cerebral infarction, unspecified (a condition that may occur at any time after causal condition. Cerebral infarction is a process that results in an area of necrotic (death tissues tissue) in the brain).Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS (is a mandatory tool used to screen and identify the cognitive condition of residents) could not be conducted, and staff interview indicated Resident #1 had both short and long-term memory problems. Section GG (Functional abilities) reflected impairment on both lower extremities. It was also reflected in section GG Resident #1 was dependent for transfer from Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). (Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.)Review of Resident #1's quarterly care plan, dated 07/10/25, reflected she had an ADL self-care performance deficit r/t immobility with an intervention of requiring a mechanical lift with 2 staff assistance for transfers.Review of Resident #1's incident report dated 07/09/2025 written by RN B reflected; Nursing Description: Called to room by [LVN C]. That resident had a fall while being hover transferred to bed by aide Resident Description: Resident Unable to give Description.Review of Resident #1's hospital records dated 07/09/2025 reflected: Discharge Diagnosis: Accidental fall; Laceration of scalp without complication (simple, x 2); Scalp hematoma (a localized collection of clotted blood outside of the circulatory system). HISTORY: Trauma fall backwards out of a lift about 3 feet striking the back of her head on the floor unable to communicate baseline.Review of Resident #1's care plan initiated 7/10/2025 reflected: The resident has an ADL self-care performance deficit r/t immobility, cognitive deficit, communication impairment, bed/chair bound with intervention TRANSFER: The resident requires Mechanical Lift with 2 staff assistance for transfers.During an interview on 07/23/2025 at 10:35 am NA A stated she worked the 6pm-6am shift on 7/9/2025. NA A stated while transferring Resident #1 from chair to bed independently using the mechanical lift, Resident #1 fell out of the mechanical lift sling when she [NA A] went to move the mechanical lift towards Resident #1's bed and the top right strap of the mechanical lift came apart. NA A stated Resident #1 slid out of the mechanical lift and fell and hit her head. NA A stated, After she fell, she was pressed to the side because she was still connected, I unhooked the bottom left part of the sling, so she [Resident #1] was not on her arm. I asked the roommate to push the light. I ran to call the nurses. They hurried down to the room. NA A stated Resident #1 had an injury to the back of her head to the right side.NA A stated RN B, and LVN C went to Resident #1's room and Resident #1 was assessed, EMS notified, and Resident #1 was sent to the ER. NA A stated she was aware mechanical lift transfer required 2 staff, they [CNAs, NAs, MAs,] were not supposed to transfer residents independently but she asked for help from other staff, and everyone was busy. NA A stated the nurses would usually complain when the NAs and CNAs took a long time to put the residents to bed, so they [NAs and CNAs] tried to get it done immediately. NA A stated she mentioned needing help to transfer Resident #1 to RN B and, but RN B was passing medications. NA A stated a mechanical lift required 2 persons to transfer to prevent accidents, to have someone there to help when things like that happen and it was important for resident's safety. NA A stated she was trained on mechanical lift transfers when she first started working at the facility. NA A stated NAs were supposed to provide direct care with a CNA, and they were not supposed to provide direct patient care by themselves. NA A stated she transferred Resident #1 independently because the facility was short staffed, she asked for help, and nobody provided help. NA A stated, whenever they were short-handed with staff and she asked for help and no one helped her, she transferred residents independently. NA A stated she was asked to go home after the incident and had not yet been back to the facility.During an interview on 07/23/2025 at 12:26 pm, RN B stated, she got a call from one of the staff on the night of 07/09/2025 to go to Resident #1's room. RN B stated by the time she got to Resident #1's room, LVN C was already there along with all the aides. RN B stated Resident #1 was on the floor, they had a pack of gauze at her head. RN B said LVN C had already called EMS because Resident #1 was bleeding from the head. RN B stated they gathered Resident #1's papers for transfer to the ER. RN B said they did not move Resident #1 due to her bleeding and did not know the extent of her injury prior to going to the ER. RN B said she did not have to check vital signs because EMS got to the facility fast. RN B stated Resident #1 was at her baseline prior to being transfer to the ER. RN B stated Resident #1 returned to the facility about 4 hours later with staples at her head due to laceration and CT scan (a medical imaging technique that uses X-rays to create detailed, cross-sectional images of the body) was negative for bleeding. RN B stated when she asked NA A what had happened, NA A said the mechanical lift sling broke; RN B said she got the mechanical lift sling out of the trash, and it did not appear to be broken. RN B stated, I think it was hooked improperly. RN B stated NA A did not ask her for help to transfer Resident #1. RN B stated she called the MD, left a message for Resident #1's RP, notified the Administrator and the DON, and completed an incident report. RN B stated NA A was sent home after the incident and she had not seen her back in the facility. RN B stated they were in-serviced on transfers, how mechanical lift required 2 people at all times, using the proper sling and abuse and neglect. RN B said they did mechanical lift check-off as well. During an interview on 07/23/2025 at 12:54 pm CNA D stated she was in-serviced on abuse and neglect after the incident with Resident #1 regarding the mechanical lift. CND D stated it was a big in-service where the Administrator told them to always have 2 staff whenever they had to do mechanical lift transfers, never 1 person, which they already knew. CNA D stated they had to do return demonstration during the mechanical lift check-off, a post test for the mechanical lift and abuse and neglect. CNA D stated the DON asked questions about the mechanical lift every day since the incident with Resident #1.CNA D stated 2 persons were needed for mechanical lift transfer to prevent injury to the residents and staff.During an interview on 07/23/2025 at 1:06 pm, NA E stated they had a big meeting in the dining hall not too long regarding abuse and neglect, and mechanical lift transfers. NA E stated the Administrator, DON, HR staff and the ADON were the ones doing the talking. NA E stated they were told it was always 2 persons when transferring a resident via mechanical lift, never 1 person. NA E said NAs should get a CNA or a nurse to assist with mechanical lift transfers. NA E stated they were taught how to use the right sling, how to put the sling under the residents, to check the sling, and report damaged slings. NA E stated she had to do a test after the in-services on abuse and neglect, mechanical lift transfers and there were also situation base questions. NA E stated it was the corporate nurse doing the demonstration on the mechanical lift transfers. NA E stated they were asked questions every day on mechanical lifts.During an interview on 07/23/2025 at 1:17 pm NA F stated she was in-serviced on abuse and neglect and mechanical lift transfers. NA F stated she was trained that mechanical lift transfer was always 2 persons and never 1 person. NA F stated it was 2 persons because 1 person was there to guard the resident while the other person maneuvered the mechanical lift. She stated it was 2 persons to prevent accident/incidents from happening. During an interview on 07/23/2025 at 1:3 pm the DON stated he expected staff to follow the facility's policy regarding mechanical lift and transfer which was at least 2 staff for transfer and the use of the proper sling. The DON stated staff were trained on mechanical lift transfers upon hire and every year after that. The DON stated, after the incident with Resident #1 on the night of 07/9/2025, the facility held an in-service on abuse and neglect and mechanical lift transfers. The DON stated all the NAs, CNAs, and nurses were trained on the mechanical lift with return demonstration and posttest. The DON stated the facility audited all the charts for residents needing mechanical lift transfer to make sure their care plans were up to date. The DON stated he had been auditing mechanical lift transfers daily, and had daily questionnaire on mechanical lifts to verbally reinforce what the staff already knew.During an interview on 07/23/2025 at 1:45 pm the Administrator stated mechanical lift transfer always required 2 people due to safety issues. The Administrator stated, after the incident regarding Resident #1 on 07/09/2025, Resident #1 was sent to the ER, she [Resident #1] got 4 staples to the back of her head and the skin tear to her right knee. The Administrator stated staff that worked the night of 07/09/2025 were in-service by RN B on abuse and neglect and mechanical transfers. The Administrator stated, the facility conducted competency skills for all staff, with repeat demonstration, the facility ordered 22 more slings for the mechanical lift, and the facility's management staff were asking staff questions every day on mechanical lift transfers. The facility did sensitivity training that was situation based on the mechanical lift. The Administrator stated the facility held an Ad hoc QAPI on 7/10/2025. She stated NA A had been suspended pending the investigation but would be terminated and not allowed back in the facility. She had not worked since the night of the incident (07/09/25). Observation on 07/23/2025 at 2:24 pm revealed Resident #1 in her geri-chair, awake, unable to express herself. Later at 3:53 pm, skin assessment of Resident #1 done with RN H reflected redness to Resident #1's right side head, no hematoma, no staples present, right knee skin tear had healed.Observation on 07/23/2025 at 3:25 pm revealed mechanical lift transfer on Resident #2 by CNA D and CNA G from bed to wheelchair. Staff provided privacy, locked wheelchair and bed, explained to the Resident what they were about to do. CNA D checked sling to ensure it was in good working condition. Staff rolled Resident from side to side while putting the sling under resident. CNA D was controlling the mechanical lift while CNA G was guarding the Resident, protecting feet, holding and positioning chair, protecting his head. Both CNAs were communicating to each other and the resident during the process. The Resident was carefully put in the chair and removed sling from hooks. CNAs asked the Resident if he was comfortable, and Resident said yes.During an interview on 07/23/2025 at 3:36 pm CNA G stated she was aware of the incident with Resident #1 and the mechanical lift. CNA G stated she was in-serviced on abuse and neglect and Mechanical lift transfers after the incident with Resident #1. CNA G stated they were trained on the proper way to transfer a Resident using the mechanical lift, checking the sling, attaching the sling to the resident correctly and always have two staff for transfer. CNA G said they did check off on the mechanical lift, posttest on the mechanical lift and abuse and neglect and every day since the incident, they got a daily questionnaire on mechanical lifts. During an interview on 07/23/2025 at 3:45 pm RN H stated she was in-serviced maybe a week or 2 ago after the incident with Resident #1 regarding mechanical lifts. RN H stated they were trained on proper technique on how to apply the mechanical lift sling, how to transfer a resident via mechanical lift, and a return demonstration was done. RN H stated there should always be at least 2 staff to transfer a resident via mechanical lift, someone to stabilize the resident while the other maneuvered the mechanical lift.During interviews on 07/24/2025 from 12:34 PM - 1:38 PM, NA I, NA J, CNA K, CNA L, MA M, LVN N, RN H, and LVN O all stated they were in-serviced after the incident on 07/10/2025 on abuse and neglect, safe transfers, mechanical lift transfers, and resident safety. All staff stated their abuse and neglect coordinator was the ADM and stated if they saw any type of abuse or neglect towards residents, they would report it to her immediately. The staff stated before any resident was transferred, they needed to look up their transfer status in their Kardex system (CNAs POC for residents). They all stated if a resident was a two-person transfer, they should never transfer them by themselves. They stated all residents requiring a mechanical lift transfer required two people. They aides stated if they could not find another aide available, they would ask their nurse for assistance. The NAs stated they were not to transfer any resident without a CNA or a nurse. All staff were able to describe the proper mechanical lift transfer process - use the appropriate sling and ensure it was connected, make sure the lift was locked, and ensure there was one person there to move the lift and the other person to guide the resident for their safety. The NAs stated they watched staff perform mechanical lift transfers on residents and they performed demonstration checkoffs with the CNAs.During an interview on 07/24/2025 at 1:46 pm the MDS Nurse stated after the incident regarding Resident #1 and the mechanical lift, she reviewed all the residents with mechanical lift transfer care plans and Kardex to ensure it indicated 2 persons required for transfer. The MDS nurse stated the CNAs could access the Kardex and care plan from their kiosk on the halls, but she usually told them to focus on the Kardex because it was resident specific task. The MDS nurse stated there were 21 Residents who needed the mechanical lift for transfer. During an interview on 07/24/2025 at 1:58 pm the ADON stated the facility had an in-service on 07/10/25 about mechanical lifts and abuse and neglect and sensitivity training after the incident with Resident #1. The ADON stated she was also assisting in the process of training the staff on mechanical lifts, telling them to have 2 staff at all times, a CNA and an NA, making sure the sling is applied correctly, positioning the mechanical lift, checking the resident's comfort level. The ADON nurse said the staff had to do return demonstration on what they were taught.Attempts were made on 07/23/2025 by the State Surveyor and the facility's Administrator to interview LVN C but to no avail. It was reported by the Administrator that LVN C was on vacation and unreachable via phone. Resident #1 was assessed and sent to the ER for evaluation on the night of 07/09/2025 to the morning of 07/10/2025. Staff statements dated 07/09/2025.Review of Resident #1's Neurological checks, dated 07/10/25 - 07/12/25, reflected were completed for 72 hours from and her vitals and motor functions were within normal limits.Review of the facility's QAPI meeting agenda, dated 07/10/25, reflected the ADM, the DON, the ADON, and the MD were in attendance.Review of five residents' care plans and Kardex who required mechanical lift transfers, on 07/25/25, reflected they were documented as requiring two persons for the transfers.Review of CNA Competency Checklists, dated 07/10/25, reflected all aides completed the competency checklist with return demonstrations (mechanical lift transfers).Abuse and neglect in-service with posttest initiated 07/10/2025. Review of an In-service, dated 07/10/25 and conducted by the ADON, reflected all staff were in-serviced on their Abuse and Neglect Policy.Review of an In-service, dated 07/10/25 and conducted by the ADON, reflected all nursing staff were in-serviced on their Hoyer Lift Policy.Review of Mechanical Lift Transfer questionnaires, initiated 07/10/25, reflected staff were being questioned daily with no concerns.Review of facility's policy titled Lifting Machine, using a Mechanical dated July 2017 reflected: Purpose The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. General Guidelines1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.2. Mechanical lifts may be used for tasks that require:a. Lifting a resident from the floor;b. Transferring a resident from bed to chair;c. Lateral transfers;d. Lifting limbs;e. Toileting or bathing; [NAME]. Repositioning. An Immediate Jeopardy (IJ) existed from 07/09/25 - 07/10/25. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 3 residents (Resident #1) reviewed for accidents and supervision, in that:The facility failed to ensure Resident #1, who ambulated with the help of a walker, received adequate supervision to prevent him from exiting the facility with a busy highway at the front, undetected on 06/09/25. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 06/09/25 and ended on 06/11/25. The facility corrected the non-compliance before the investigation began on 06/25/25. This failure could place the residents with exit seeking behaviors at risk for injury or death.The findings included:Record review of Resident #1's face sheet dated 06/25/25 reflected a [AGE] year-old male admitted to the facility on [DATE] . His diagnoses included heart failure, lack of coordination, unsteadiness on feet, hypertension, muscle wasting and atrophy, difficulty in walking, pain, incontinence, and dementia. Record review of Resident #1's initial MDS assessment dated [DATE] reflected a BIMS score of 09, indicating Resident #1's cognition was moderately impaired. The MDS stated he had no indication of psychosis or behavioral issues. Record review of Resident #1's care plan dated 04/29/25 reflected Resident #1 had elopement risk and a history of attempts to leave the facility unattended with poor safety awareness. The relevant intervention was, place him in a secured unit for personal safety. Other interventions were, distracting resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books or any other activities that resident prefers. On 6/9/25 an additional intervention of notifying the ADM/DON if resident was out of cigarettes, was added as Resident #1 appeared stressful when he did not have cigarettes. Record review of Resident #1's elopement evaluation dated 06/09/25 reflected Resident #1 had a score of 6 out of 7 indicating he was at high risk for elopement. The initial elopement assessment conducted by DON on 04/29/25 next day after his admission indicated Resident #1 was at high risk of elopement with history of attempts when he was at the previous facility. Record review of a FRI dated 06/10/25 reflected, on 06/09/25 at about 7:41am the facility first learned about the elopement of Resident #1. On 06/09/25 CNA A noted resident in his bedroom asleep at about 5:45 am. CNA B went to check on him at about 7:00am to help him prepare for breakfast and at that time it was realized that he was not in his room. The facility building and grounds were searched for locating him. By 7:41am it was confirmed that resident was not in the premises of the facility. It was believed Resident #1 escaped through a window, as during the search the staff noticed a broken window in the dining area of the memory care unit with the screen pushed out. The resident was located approximately a mile away from the facility and staff brought him back to the facility. During an interview on 06/27/25 at 4:10pm CNA A stated on 06/09/25 she arrived at the facility at about 5:29am as usual for her shift. CNA A stated she had seen Resident #1 in his room at about 5:45 am sound asleep. She said at about 7:00 am another staff member who went into Resident #1's room stated he was not in his room. CNA A stated she began to look in the dining area and noticed Resident #1's walker by the back table and the window was broken with its screen off. She said an immediate search was initiated and resident was not found on the premises. The DON and AD began to search outside the memory care unit and outside of the facility building. She stated she was told later Resident #1 was located by the park about a mile away from the facility and staff brought him back to the facility. CNA A stated she received an in service on elopement on 06/09/25 and elopement drill and Inservice on the missing person policy and procedure on 06/10/25. During a phone interview on 06/25/25 at 4:20pm CNA B stated on 06/09/25 she was working on the 6:00pm to 6:00am shift. She said when Resident #1 went missing in the morning she searched for him in the bathroom, resting areas and out in the courtyard of the memory care unit. CNA B stated generally Resident #1 was quiet and calm however there were moments he would be aggravated. CNA B stated while Resident #1 was on constant observation by a staff , he made another attempt to break the window in the next day after the incident of elopement occurred. She stated later he was relaxed and appeared settled down without any further attempts. CNA B stated she received an in service on elopement on 06/09/25 and elopement drill and Inservice on the missing person policy and procedure on 06/10/25. During a phone interview on 06/25/25 at 4:45pm CNA C stated she worked at the facility's memory care unit in the 6:00pm to 6:00am shift. She stated she knew Resident #1 was at high risk of elopement however never made any attempt since his admission until 06/09/25. She stated she did not know the triggering factor for his elopement. CNA C stated when she came to know Resident #1 was missing, she let the nurse in charge and others know about it and started searching everywhere. CNA C stated she received an in service on elopement on 06/09/25 and elopement drill and Inservice on the missing person policy and procedure on 06/10/25. During an interview on 06/25/25 at 11:30am the AD stated she came into the facility on [DATE] as usual at about 5:30 am to work. She said at about 7:30am the staff let her know that Resident #1 was missing from memory care. She stated she with the help of the floor plan of the facility and checked everywhere inside the facility. The AD stated when she could not find Resident #1 on the facility premises, she took her car and drove through the highway for about two miles looking for him. The AD said when she returned after 30 minutes unsuccessfully, there was police at the facility for searching Resident #1. The AD stated she received an in service on elopement on 06/10/25. During an interview on 06/25/25 at 10:55am the MM stated on 06/09/25 he was asked to change the broken window glass of one of the windows in the memory care dining hall. He stated he replaced it on 06/09/25 with flex glass that was not easily breakable. The MM stated he changed the code for both the exit doors of the memory care unit as well to make sure residents would not wander out of the memory care area unnoticed. During an interview on 06/25/25 at 10:45am CNA D stated she worked at the facility for 6 years and now she works in the memory care unit in the day shift . She stated she was not working on 06/09/25 at the facility when the incident occurred. CNA D stated Resident #1 was okay at the facility after the incident and was not exhibiting any exit seeking. She stated she had attended an Inservice on elopement after the incident, when she came to work. She stated she learned in the in service how to detect the early warning signs of elopement and how to conduct a search and report the incident to nurse in charge and the staff on duty . During an interview on 06/25/25 at 2:10pm CNA E stated he started working at the facility two weeks ago after the incident of Resident #1's elopement occurred. He stated Resident #1 was very quiet normally without any exit seeking behaviors. CNA E stated Resident #1 was a smoker who utilized all the smoking breaks . CNA E stated he had worked closer with Resident #1 as he was assigned 1:1 observation on Resident #1 most of the time to ensure that Resident #1 would not elope. He stated he received an in service on elopement on 06/25/25 in the morning. During an observation and interview on 06/25/25 at 4:45 pm Resident#1 was in the dining hall in the memory care unit. He was sitting at a table quietly and working on a puzzle. He stated he was okay at the facility though 'not over excited'. He said the current facility was better than any other facilities in the area, thus he was not unhappy. When the investigator asked about, how he had managed to escape on 06/09/25, he laughed and stated it was a top secret and could not be disclosed as he might use the same trick again. He said he loosened a pair of screws that held down the window glass and then lifted it easily and escaped through it to the back yard. When asked why he did break the window glass he stated it was easily breakable with a push however did not go through the hole created by it. He stated once he was out in the backyard, he jumped the fence without getting hurt, as there was a way to do it safely. He stated he used a walker while at the facility however 'managed' to walk in the street without it. When asked why he wanted to get out, he stated he was bored at the facility and wanted to go out to socialize with others in the community. He stated if you were out in the public, it would be easy to get cigarettes from members in the community, when you ran out of stock. Resident #1 stated he had no issue with cigarette stock and smokes every day. During an interview on 06/25/25 at 10:45am the DON stated the staff came to know Resident #1 was missing, at about 7:00am . He stated everyone was looking for him everywhere and meanwhile the staff called 911 for police help. He stated staff found Resident #1 about a mile away after about 2 hours. He added, considering Resident #1's condition he was not able to walk that far, and he was made to believe that he might have asked for a lift to a passenger for transportation. The DON stated the moment Resident #1 arrived back at the facility he did a head-to-toe assessment. The DON stated resident had no injuries, deformities, or any pain at that time or afterwards. He said Resident #1 was presented as calm and humorous after his return to the facility. The DON stated as per records Resident #1 made elopement attempts in the past while he was in another facility. He said Resident #1 had long history with TDC and this had taken into consideration while making decisions. He added Resident #1 was placed in the memory care unit as he was at high risk for elopement when he was initially admitted to the facility. The DON said Resident #1 was on 1:1 after the elopement on 06/09/25 and off from it only on 06/24/25 when the MDT team determined that he was safe. The DON stated Resident #1 might have eloped through one of the windows in the dining room in memory care as staff observed it was broken. He said, staff observed a chair in the backyard towards the fence and it was believed Resident #1 might have used the chair to climb up the fence. The DON stated the triggering factor for his elopement was not clear however it was observed that Resident #1 got stressed when his stock of cigarettes got depleted. The DON said recently he ran out of cigarettes due to issues with money from social security. He said the ADM decided to buy cigarettes for him out of pocket until he received money from social security, to keep Resident #1 free from the thoughts of elopement. DON stated he conducted an audit on all residents at the facility to make sure that an elopement risk assessment was conducted on all residents. During an interview on 06/25/25 at 1:35pm the ADM stated the resident was last seen at the memory care unit at 5:45am and the facility came to know about his elopement at about 7:00am. She said the police were informed to get help in the searching process and eventually staff located Resident #1 by a park about one mile away from the facility. The ADM stated Resident #1 said he was walking from the park to the store to cash in a lottery ticket. She stated Resident #1 was particular about having cigarettes consistently and due to some delayed social security payments, he ran out of cigarettes at the time of elopement . She said most likely this triggered him to get out of the facility to procure cigarettes by some other means. The ADM stated it was believed he might have escaped through a window by breaking the glass, stepped out and then by using an unsecured chair in the backyard jumped out of the fence. She stated immediately after Resident #1's return an assessment had been completed to make sure he was unhurt and safe. The ADM stated Resident #1 was under 1:1 observation until 06/17/25, he was referred to psychiatric service and a psych evaluation was completed. A QAPI meeting was conducted, and it was decided to help Resident #1 financially if he ran out of money to ensure an uninterrupted supply of cigarettes. She stated currently the chairs in the backyard were fastened with chains and soon will be anchored to the ground permanently with concrete. The ADM stated she was planning to change the glass panels of all the windows in memory care with non-shatter window glass for further protection from elopement by residents in the future and started collecting quotes for the work from contractors. During an observation on 06/25/25 at 11:30am of the window in memory care revealed that broken glass was replaced. An observation on 06/25/25 at 5:05pm of the backyard revealed the facility was enclosed by a fence. There were two gates on the fence that were locked with padlock. There were two chairs on the patio that were fastened with chains to the wall and not removable. Record review on 06/25/25 of the 1:1 observation check sheet revealed Resident #1 was on 1:1 on arrival back to the facility on [DATE] until 06/24/25. Record review of the Inservice revealed all the staff who worked in the memory care unit were in serviced on Elopement- How to avoid an elopement , What to do during an elopement Record review of the facility's policy Wandering and Elopement revised in 03/2019 reflected: Policy Statement The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation:1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.2. If an employee observes a resident leaving the premises, he/she should:a. attempt to prevent the resident from leaving in a courteous manner;b. get help from other staff members in the immediate vicinity, if necessary; andc. instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises.3. If a resident is missing, initiate the elopement/missing resident emergency procedure:a. Determine if the resident is out on an authorized leave or pass;b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; andc. If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., emergency management, rescue squads, etc.).4. When the resident returns to the facility, the director of nursing services or charge nurse shall:a. Examine the resident for injuries.b. Contact the attending physician and report findings and conditions of the resident;c. Notify the resident's legal representative (sponsor);d. notify search teams that the resident has been located;e. complete and file an incident report; andf. document relevant information in the resident's medical record. Record review and verification on 06/25/25 of the corrective action implemented by the facility beginning on 06/09/2025 reflected: 1. An elopement risk reevaluation was completed on Resident #1 after the incident on 06/09/25 . Record review of Resident #1's Elopement Evaluation dated 06/09/25 reflected Resident #1 was at high risk for elopement. 2. Resident was on 1:1 until 06/17/25 in the memory care unit. Record review of the One to one Monitoring form revealed resident was on 1:1 began at 9:00am on 06/09/25 and discontinued on 06/17/25 by the MD. 3. A Psychiatric evaluation was completed.Record review of the psychiatric periodic evaluation dated 06/18/25 reflected a psychiatric evaluation conducted with Resident was referred to provider by DON for psychiatric evaluation and elopement as the chief complaint. 4. A QAPI meeting to discuss the elopement incident .Record review of QAPI Action Plan dated 06/09/25 revealed an Ad. Hoc QAPI meeting conducted on 06/09/25 with MD attended remotely. 5. The facility made arrangements to ensure Resident #1's stock of cigarettes would be replenished before finished. Record review of the care plan dated 06/09/25 revealed this arrangement was incorporated in the care plan. 6. The chairs in the backyard were secured permanently .An observation on 06/25/25 at 5:00pm revealed the two chairs outside at the smoking area were secured to the wall with chains and was not removable. 7. The codes to doors on the secured unit were changed by the maintenance person to ensure residents would not walk out by using the code.Observation and interview on 06/25/25 at 10:10am revealed MM changing the code. The MM stated he changed it every week to make sure no residents in memory care had access to it. 8. An elopement Inservice with all the staff on the memory care unit was completed on 06/10/25. Record review of the in-service record revealed on 06/09/25 and 06/10/25 an (on going) in service conducted on elopement -How to avoid an elopement what to do during an elopement with 71 staff members participated. 9. The Care plan of Resident #1 was updated on 06/09/25. Record review of careplan revealed the careplan updated on 06/09/25 with added intervention for elopement. 10. Auditing of all the residents' record was completed by 06/14/25 to ensure elopement risk assessment conducted on all residents. Record review on 06/25/25 in E H R of 17 sample residents revealed their elopement evaluations were updated/completed. 11. The MDT determined to review the situation weekly in QOC and Monthly in QAPI for compliance. During an interview on 06/25/25 at 4:15pm the ADM stated the situation was reviewed in the last two weekly QOC meetings and the QAPI is due next month. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 06/25/25 and ended on 06/25/25. The facility corrected the non-compliance before the investigation began on 06/25/25. The Past Non-Compliance form was sent to the Administrator on 06/25/25 at 5:30pm.

Based on interview and record review, the facility failed to ensure residents were free of significant medications errors for one of one (Resident #1) of three residents reviewed for significant medication errors. The facility failed to ensure Resident #1 was administered her prescribed Bactrim (antibiotic) until seven days after receiving positive UTI results on 04/11/25, causing her to be in increased pain and dysuria (pain with urination). This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements or could result in worsening or exacerbation of chronic medical conditions. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, diabetes, muscle wasting and atrophy (wasting away), and history of UTIs. Review of Resident #1's quarterly MDS assessment, dated 03/13/25, reflected a BIMS score of 10, indicating a moderate cognitive impairment. Section H (Bladder and Bowel) reflected she did not require a catheter and was always incontinent. Review of Resident #1's quarterly care plan, dated 01/26/25, reflected she had a history of urinary tract infections with an intervention of monitoring lab work as ordered and reporting results to her physician. Review of Resident #1's progress notes, dated 04/09/25 at 6:30 PM an documented by LVN A, reflected the following: MD in to evaluate [Resident #1], she reported dysuria to MD. Received new order for UA. Review of Resident #1's lab results, reflected a urine specimen was collected on 04/09/25 and the results were reported to the facility on [DATE]. The C&S reported a high microbial load of Escherichia coli (rod-shaped bacteria), indicating a UTI was present. Review of Resident #1's progress notes, dated 04/14/25 at 2:26 PM and documented by LVN B, reflected the following: Received new order for Bactrim DS 1 tab po BID x7 days for UTI. Review of Resident #1's physician order, dated 04/14/25, reflected Bactrim DS oral tablet - 800-180 MG - Give 1 tablet by mouth two times a day every 7 day(s) related to urinary tract infection. Review of Resident #1's MAR, April of 2025, reflected she was administered one dose of Bactrim on 04/14/25 in the evening by the ADON. No other doses were administered and there was a D/C date of 04/17/25. Review of Resident #1's physician order, dated 04/18/25, reflected Bactrim DS oral tablet - 800-160 MG - Give 1 tablet by mouth two times a day related to urinary tract infection. Review of Resident #1's MAR, April of 2025, reflected she was administered all 14 doses of Bactrim from 04/18/25 - 04/24/25 by either MA C or the ADON. Review of Resident #1's progress notes, from 04/12/25 - 04/17/25, reflected no documentation as to why she was not administered her antibiotics. During an interview on 06/04/25 at 10:02 AM, Resident #1 stated when she had a UTI and did not get her antibiotics on time, she was in increased pain. She stated when she was on antibiotics the pain would go away. She stated she remembered a time in the middle of April (2025) where she had a UTI and went many days without getting antibiotics. She stated it hurt to urinate and she had a radiating pain that went up to her belly button. She stated she was not sure why she did not get her antibiotics on time but she kept asking the nurses. She stated she was scared to not get antibiotics when she had a UTI because it could affect her kidneys and she worried about kidney damage. During an interview on 06/04/25 at 10:47 AM, LVN A stated when UA results came back from the lab, it was the nurse's responsibility to call the doctor and to get orders. She stated it was important to contact the doctor the same day. She stated it would not be normal or right to start an antibiotic seven days later. She stated a negative outcome could be going into septic shock at any time, renal failure, or renal disfunction. She stated receiving one dose of antibiotics and then getting back on it days later could cause antibiotic resistance as well as continued or worsening of symptoms, such as pain. She stated she remembered collecting Resident #1's urine sample in April (2025) but was not the nurse that received the results from the lab. During a telephone interview on 06/04/25 at 10:58 AM, the NP stated she had only been working with the facility for a short time and was not privy to Resident #1's UTI in April (2025). She stated if UA results came back positive, her expectation, as a general rule, would be that she was notified within 24 hours. She stated they have someone in the building every single day, so the sooner the better. She stated a negative outcome of not starting an antibiotic until days after a positive result could cause worsening of the infection because it was not getting treated with the needed antibiotics. She stated worsening of an infection could lead to sepsis. During a telephone interview on 06/04/25 at 11:21 AM, LVN B stated she did not remember why it took four days to get an order of antibiotics for Resident #1. She stated sometimes when they ran the culture and sensitivity it would take a few days to get the results back. She stated she really could not remember the situation as it was so long ago. She stated the normal process was when a nurse received lab results, they were to notify the NP and put in the orders they were given. She stated a negative outcome for not receiving antibiotics when needed could be sepsis or a much worse situation than if they had taken care of it. During an interview on 06/04/25 at 1:33 PM, MA C stated she did not remember why she started administering Resident #1 antibiotics on 04/18/25. She stated she just administered residents the medications that were listed on their MAR. During an interview on 06/04/25 at 1:51 PM with the ADM and ADON, the ADM stated it was the nurse's responsibility to notify the NP immediately after receiving lab results. The ADON stated she was not made aware of Resident #1's positive UTI results on 04/11/25 and she administered a dose of Bactrim on 04/14/25 because she was working as a medication aide it must have popped up on her MAR. The ADON stated she discontinued the antibiotic on 04/17/25 because she noticed Resident #1's MAR had not been getting checked off for it. The ADON stated she got a new order for seven days. The ADON stated Resident #1 could have gone septic. The ADON stated going days without antibiotics after receiving once dose would cause the resident to not get the full effect of the antibiotics. The ADM stated the situation did not meet her expectations and she could not understand how the ball was dropped. Review of the facility's Administering Medications Policy, revised April 2019, reflected the following: Medications are administered in a safe and timely manner, and as prescribed. . 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on interview and record review, the facility failed to promptly notify the ordering physician or nurse practitioner of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 (Resident #1) of three residents reviewed for laboratory services. The facility failed to ensure Resident #1 was administered her prescribed Bactrim (antibiotic) until seven days after receiving positive UTI results on 04/11/25, causing her to be in increased pain and dysuria (pain with urination). This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements or could result in worsening or exacerbation of chronic medical conditions. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, diabetes, muscle wasting and atrophy (wasting away), and history of UTIs. Review of Resident #1's quarterly MDS assessment, dated 03/13/25, reflected a BIMS score of 10, indicating a moderate cognitive impairment. Section H (Bladder and Bowel) reflected she did not require a catheter and was always incontinent. Review of Resident #1's quarterly care plan, dated 01/26/25, reflected she had a history of urinary tract infections with an intervention of monitoring lab work as ordered and reporting results to her physician. Review of Resident #1's progress notes, dated 04/09/25 at 6:30 PM an documented by LVN A, reflected the following: MD in to evaluate [Resident #1], she reported dysuria to MD. Received new order for UA. Review of Resident #1's lab results, reflected a urine specimen was collected on 04/09/25 and the results were reported to the facility on [DATE]. The C&S reported a high microbial load of Escherichia coli (rod-shaped bacteria), indicating a UTI was present. Review of Resident #1's progress notes, dated 04/14/25 at 2:26 PM and documented by LVN B, reflected the following: Received new order for Bactrim DS 1 tab po BID x7 days for UTI. Review of Resident #1's physician order, dated 04/14/25, reflected Bactrim DS oral tablet - 800-180 MG - Give 1 tablet by mouth two times a day every 7 day(s) related to urinary tract infection. Review of Resident #1's MAR, April of 2025, reflected she was administered one dose of Bactrim on 04/14/25 in the evening by the ADON. No other doses were administered and there was a D/C date of 04/17/25. Review of Resident #1's physician order, dated 04/18/25, reflected Bactrim DS oral tablet - 800-160 MG - Give 1 tablet by mouth two times a day related to urinary tract infection. Review of Resident #1's MAR, April of 2025, reflected she was administered all 14 doses of Bactrim from 04/18/25 - 04/24/25 by either MA C or the ADON. Review of Resident #1's progress notes, from 04/12/25 - 04/17/25, reflected no documentation as to why she was not administered her antibiotics. During an interview on 06/04/25 at 10:02 AM, Resident #1 stated when she had a UTI and did not get her antibiotics on time, she was in increased pain. She stated when she was on antibiotics the pain would go away. She stated she remembered a time in the middle of April (2025) where she had a UTI and went many days without getting antibiotics. She stated it hurt to urinate and she had a radiating pain that went up to her belly button. She stated she was not sure why she did not get her antibiotics on time but she kept asking the nurses. She stated she was scared to not get antibiotics when she had a UTI because it could affect her kidneys and she worried about kidney damage. During an interview on 06/04/25 at 10:47 AM, LVN A stated when UA results came back from the lab, it was the nurse's responsibility to call the doctor and to get orders. She stated it was important to contact the doctor the same day. She stated it would not be normal or right to start an antibiotic seven days later. She stated a negative outcome could be going into septic shock at any time, renal failure, or renal disfunction. She stated receiving one dose of antibiotics and then getting back on it days later could cause antibiotic resistance as well as continued or worsening of symptoms, such as pain. She stated she remembered collecting Resident #1's urine sample in April (2025) but was not the nurse that received the results from the lab. During a telephone interview on 06/04/25 at 10:58 AM, the NP stated she had only been working with the facility for a short time and was not privy to Resident #1's UTI in April (2025). She stated if UA results came back positive, her expectation, as a general rule, would be that she was notified within 24 hours. She stated they have someone in the building every single day, so the sooner the better. She stated a negative outcome of not starting an antibiotic until days after a positive result could cause worsening of the infection because it was not getting treated with the needed antibiotics. She stated worsening of an infection could lead to sepsis. During a telephone interview on 06/04/25 at 11:21 AM, LVN B stated she did not remember why it took four days to get an order of antibiotics for Resident #1. She stated sometimes when they ran the culture and sensitivity it would take a few days to get the results back. She stated she really could not remember the situation as it was so long ago. She stated the normal process was when a nurse received lab results, they were to notify the NP and put in the orders they were given. She stated a negative outcome for not receiving antibiotics when needed could be sepsis or a much worse situation than if they had taken care of it. During an interview on 06/04/25 at 1:33 PM, MA C stated she did not remember why she started administering Resident #1 antibiotics on 04/18/25. She stated she just administered residents the medications that were listed on their MAR. During an interview on 06/04/25 at 1:51 PM with the ADM and ADON, the ADM stated it was the nurse's responsibility to notify the NP immediately after receiving lab results. The ADON stated she was not made aware of Resident #1's positive UTI results on 04/11/25 and she administered a dose of Bactrim on 04/14/25 because she was working as a medication aide it must have popped up on her MAR. The ADON stated she discontinued the antibiotic on 04/17/25 because she noticed Resident #1's MAR had not been getting checked off for it. The ADON stated she got a new order for seven days. The ADON stated Resident #1 could have gone septic. The ADON stated going days without antibiotics after receiving once dose would cause the resident to not get the full effect of the antibiotics. The ADM stated the situation did not meet her expectations and she could not understand how the ball was dropped. Review of the facility's Administering Medications Policy, revised April 2019, reflected the following: Medications are administered in a safe and timely manner, and as prescribed. . 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on interview and record review, the facility failed to immediately inform the resident, consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for one (Resident #1) of four residents reviewed for resident rights. The facility failed to notify the facility MD when Resident #1 was experiencing shortness of breath and chest pain on 02/28/25. This failure could place residents at risk of illness, injury, uncontrolled pain, and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including heart failure, hypertension (high blood pressure), chronic kidney disease, age-related physical debility, and muscle wasting and atrophy (wasting away). Review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 10, indicating he was moderately cognitive impaired. Review of Resident #1's quarterly care plan, dated 02/12/25, reflected he desired a DNR code status with an intervention of ensuring staff was aware of his advanced care planning decisions. Review of Resident #1's progress note, dated 02/28/25 at 9:06 PM and documented by the ADON, reflected the following: [Resident #1]'s call light was on and [CNA A] went to assist the resident when he stated to [CNA A] that he was having a hard time breathing and his chest was hurting . This writer raised his head and took his vitals - 106/63 (blood pressure) - 60 (pulse) - 18 (respirations) - 97.2 (temperature) - 97% (oxygen saturations) on RA . [Resident #1] was made comfortable at this time and [Resident #1] stable at this time . [CNA A] called to writer and upon entering room tried to call [Resident #1]'s name with no response . found to have no pulse or respirations at this time . Attempt to interview CNA A was made on 03/05/25 at 12:32 PM. A returned call was not received prior to exit. During an interview on 03/05/25 at 12:47 PM, the ADON stated she worked the night of 02/28/25. She stated Resident #1 was on the light frequently to be changed because he had several bowel movements. She stated his nurse, LVN B, was on break when CNA A came to inform her that Resident #1 was short of breath and his chest was hurting (around 8:30 PM). She stated she went to his room, elevated his bed, and took his vitals which looked normal. She stated to her, he did not complain of pain but just that his chest was uncomfortable because he was short of breath. She stated she did not notify the MD because his vitals were normal, and he appeared comfortable. She stated approximately 15 minutes later he pressed his call light and CNA B went to assist him but could not arouse him. She stated he did not answer and would not respond. During a telephone interview on 03/05/25 at 12:47 PM, LVN B stated she worked with Resident #1 on 02/28/25 but was on break when he passed away. She stated she never heard about him having pain in his chest or being short of breath. She stated if she had known that [NAME] would have assessed his vitals, assessed him, and notified the MD. During a telephone interview on 03/05/25 at 1:20 PM, Resident #1's MD stated if a resident had shortness of breath, pain/tightness in their chest he would expect to be notified. He stated he expected to be notified for any problem whatsoever. He stated being short of breath was something important for him to know as something could be wrong. He stated he was not notified of Resident #1 experiencing pain or shortness of breath before he passed away on 02/28/25. He stated Resident #1 had a long heart history of issues. He stated if he would have been notified, he would have ordered a STAT chest x-ray. He stated in that specific instance, because it was so quick, it would not have made a difference. During an interview on 03/05/25 at 2:12 PM, the DON stated she expected the nurses to notify the MD immediately for any changes in the residents, whether it be complaints of chest pain, or any kind of pain or discomfort. She stated the MD needed to be part of the medical decision-making process. She stated a negative outcome of the MD not being involved could be harm or death. Review of the facility's Change in a Resident's Condition or Status Policy, revised February 2021, reflected the following: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.

Based on interviews and record reviews the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 5 residents (Resident #1) reviewed for dietary services. The facility failed to follow Resident #1's altered diet when CS A gave Resident #1 a peanut butter sandwich on [DATE]. Resident #1 expired on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving their proper diet to meet their individual needs, that can cause serious injury, hospitalization , or death. Findings Include: Record review of Resident #1's face sheet, dated [DATE], reflected a [AGE] year-old-male, with a current admitted [DATE], a latest return admitted [DATE], and a discharge date of [DATE]. Resident #1's status was expired. Resident #1's had diagnoses which included lack of coordination, rheumatoid arthritis (autoimmune disorder that primarily affects joints), muscle wasting, paranoid schizophrenia (delusions of paranoia), dysphagia-oropharyngeal phase (swallowing disorder-disruption or delay in swallowing), cognitive communication deficit (challenges is communication that have underlying cause in cognitive deficit), unspecified dementia (syndrome associated with many neurodegenerative diseases, decline in cognition that affects the ability to perform everyday activities), and anxiety (panic disorder or phobias). Record review of Resident #1's Annual MDS (Minimum Data Set), dated [DATE], reflected a BIMS summary score of 03, indicated a severely impaired cognitive skills for daily decision-making. Resident #1's speech clarity was a 1, which indicated unclear speech-slurred or mumbled words, and ability to understand others was a 2, which indicated sometimes understood-responded adequately to simple, direct communication only. Resident #1's was on a mechanically altered diet. Section GG-Functional Abilities and Goals reflected a score of 03 for Eating, which indicated Partial/Moderate assistance. Section I-Active Diagnoses reflected a code of 7, which indicated Other Neurological Conditions. Section K-Swallowing/Nutritional Status, K0520 reflected Mechanically altered diet-require change in texture of food or liquids, e.g., pureed food, thickened liquids. Record review of Resident #1's, undated, orders reflected an order description, mech (Mechanical) soft/thin liquids-fortified foods with meals, scoop/divided plate, foam cover for built up utensils all meals, and with special instructions, large portions at mealtime, no bread i.e. (that is) cakes, pancakes, sandwiches, rolls, biscuits, close supervision, with a start date: [DATE] and an end date: Open Ended, DC [DATE] reason is discharged . Record review of Resident #1's, undated, care plan, reflected: Problem start date [DATE], category is ADLs Functional Status/Rehabilitation Potential, Resident (Resident #1) is slightly limited in ability to eat and drink AEB self-feeding (self-feeding), required setup/cues at times, goal is Resident (Resident #1) will eat ,d+[DATE]% of meals and maintain hydration independently /with supervision/help, with an approach: - monitor and record intake of food/fluids and provide setup/supervision assistance during eating and drinking, disciplines responsible activities, CNA, Nursing. Problem, start date [DATE], category is Nutritional Status, Potential for weight loss R/T : dysphasia (swallowing disorder) goal is nutritional status will be maintained AEB (As Evidenced By) no weight loss within 3 lbs of current weight over next 90 days, with an approach: - Serve diet per order, disciplines responsible Nursing Problem, start date [DATE], category is Nutritional Status, high risk of aspiration (when something you swallow enters your airway or lungs), nutritional impairment and complications due to dysphasia (swallowing disorder), goal is (Resident #1) will remain free of aspiration, significant weight loss, s/sx, injury or complications related to dysphagia, with approaches: - Assess/record report to MD prn s/sx of aspiration or complications: choking/strangling on liquids, coughing during or after meals, respiratory difficulty or distress, fever, tachypnea (rapid shallow breathing), wheezes/crackles in lung field, and watery eyes, disciplines responsible Nursing. - Ensure resident is eating slowly and notify nurse ASAP if choking. Maintain upright position for 1 hour after eating, when possible, to reduce aspiration risk, disciplines responsible activities, CMA, CNA, dietary, Nursing. - Ensure that snacks and beverages offered at activities comply with diet and fluid consistency restrictions, disciplines responsible activities, CMA, CNA, dietary, Nursing. - serve diet as ordered, disciplines responsible activities, CMA, CNA, dietary, Nursing. Problem, start date [DATE], category is Nutritional status, Resident (Resident #1) requires a mechanically altered diet, goal is Resident (Resident #1) will maintain current body weight of Blank pounds, with approaches: - Encourage oral intake of foods and fluids, disciplines responsible Nursing. - Monitor need to advance diet consistency, disciplines responsible Nursing. Record review of Resident #1's, undated, Meal Ticket reflected Diet: Regular, Texture: mechanical soft, Other: large portions with meals, no bread cakes rolls biscuits, close supervision, Adap Equip Deep Divided Plate; Built up Spoon; Liq Consist thin. Record review of Resident #1's progress note, created and signed by LVN A, dated and timed [DATE] at 08:38 PM, reflected. at approximately 6:20 PM called to secure unit per CNA About resident possibly choking this nurse immediate to dining room and noted resident on floor laying supine (on back) lips blue no respirations or pulse noted sternum rub performed resident gasped another nurse started the Heimlich some spit up food came from residents (Resident #1) mouth did gasp a few more breaths mouth swipe done and nothing noted still without pulse or respirations 911 was called at beginning of finding resident and in facility resident asystole (heart's electrical system fail causing heart to stop pumping, otherwise known as flat-line or flat-lining) noted on monitor RN DON pronounced at 1847 [06:47 p.m.] Family notified and thankful and stated Funeral Home is where he [Resident #1] is going called Cremation Provider due to they own postmortem care was provided and body released at 2015 [08:15 p.m.]. Interview on [DATE] at 11:38 a.m., the ADON stated she worked on [DATE] and was scheduled to be off at 06:00 p.m., although she had to stay because a nurse was coming in late. The ADON was in the middle of giving a report, then she overheard LVN A initially asking to prepare for a crash cart, the ADON obtained the crash cart, went to the locked unit, and observed it was Resident #1. The ADON stated Resident #1 was a DNR, the crash cart not used. The ADON recalled observed LVN A performed a sternal rub (method used when testing an unconscious person's responsiveness). The ADON stated she performed the Heimlich Maneuver as a precaution, due to possible choking. The ADON stated during the Heimlich maneuver (used to treat choking by foreign objects) she could not confirm if food was dislodged as she was behind Resident #1. The ADON stated during the commotion, staff was instructed to call EMS. The ADON stated she could not confirm the exact diet of Resident #1 during interview, but she was aware it was altered. The ADON stated when EMS arrived, they pronounced Resident #1 expired, and recalled there were no concerns brought to her attention by EMS. Interview on [DATE] at 11:59 p.m., CS A stated she worked the night shift from 06:00 a.m. to 06:00 p.m., CS A stated she worked on [DATE] and worked in the unit where Resident #1 resided. CS A stated Resident #1 was in distress, and went to get a nurse, CS A could not recall the nurse she got. CS A arrived back to the unit, and LVN A was present, CS A was instructed to call EMS and did. CS A stated during the commotion other staff arrived, unable to recall other staff, she attempted to assure other residents were watched during the incident. The CS A stated prior to the incident, during that time it was snack time for residents, I gave a snack to Resident #1, I [CS A] gave him a sandwich that day [[DATE]], it was a peanut butter sandwich, Resident #1 liked his sandwiches. CS A knew Resident #1's dietary orders CS A stated, At the time, I didn't know what kind of diet he is on, I do now, I think it was soft or something, I [CS A] worked here for two plus years, most of the time that's what we fed Resident #1, I am part of the evening crew, I don't get in on the meals. CS A stated, yes I think its dangerous for anyone if they don't get the proper diet order. When asked where she obtained the sandwich and the details of when, CS A stated, sandwiches are pre-made by dietary staff, sandwiches are kept at front nurses' station [outside of the unit], they are together on a tray, and we take them to the residents when they want a snack. Interview on [DATE] at 12:19 p.m., the DM stated meal tickets were important for staff to follow. The DM stated for mechanical soft diets, food was placed in a food processor and pulsed to have a chopped and soft texture. The DM stated Resident #1 had a mechanical soft diet, with no breads at all. The DM stated therapy recommended this diet because Resident #1 could not swallow properly, and he could choke. The DM stated at night the facility prepared snacks that included sandwiches, pudding for altered diets, and sometimes fruits. The DM stated Resident #1 should have gotten pudding for his snacks, and it would be dangerous for Resident #1 to eat bread. The DM stated breakfast, lunch, and dinner had meal tickets on food trays that were reviewed before passing it out to residents. The DM stated staff were knowledgeable because they were trained on dietary orders. Interview on [DATE] at 12:31 p.m., the SLP stated she was also the Director of Rehabilitation, the SLP stated Resident #1 was on and off for rehabilitation services because he had difficulty self-feeding, toileting, sitting in an up-right position during meals times, his posture was poor, and he would hunch over. The SLP stated we would have therapy for Resident #1 with goals to correct his posture and sit up-right during meals, Resident #1 needed one on one interaction and constant redirection, he was very much non-compliant and ignored his therapy, but we kept trying to help him. The SLP stated Resident #1's cognition was poor. The SLP stated Resident #1's diet order was a mechanical soft diet with close supervision, with no breads or cakes. The SLP stated if Resident #1 had any bread, it was a dense material. The SLP described Resident #1 during therapy sessions, Resident #1 would tend to overstuff his mouth and continue to eat large portions and Resident #1 could not swallow the portions, she noticed Resident #1 would store the food on his inside cheek, and stated to staff he had swallowed the food, although when the SLP would check his mouth the SLP would see the food inside his mouth, inside his cheeks. The SLP added the training consisted of having Resident #1 learn how to eat smaller portions and learn how to swallow those portions, as the staff were hoping he could return to a full diet. The SLP stated his course was up and down, Resident #1 would have some advancements in therapy then he would decline from them. The SLP stated Resident #1 was not supposed to have dense, dry food, like cornbread. The SLP stated she communicated the needs for residents by communication forms, which informed the dietician, dietary aides, nursing, and she educated staff from different shifts. The SLP stated Resident #1's order was placed to reduce the risk of choking, if Resident #1 was left unsupervised and because his large intakes he had a high risk of choking on a peanut butter sandwich. Interview on [DATE] at 01:31 p.m., the DON stated she worked on [DATE] during the day, although she came back as she was informed Resident #1 expired. The DON stated she was informed Resident #1 was reading his bible in the dining area in the locked unit as this was his routine, and nurses were informed of Resident #1's condition and responded. The DON stated Resident #1 was on a mechanical soft diet. The DON stated the process of informing staff of diet orders was that nurses received a communication on orders, nurses would communicate with the CNAs, the orders were placed in EHR, it would transfer to the POC system, and CNAs could access care plans and orders in the tablets available. The DON stated the POC tablet in the locked unit was not working now, and in the process of getting that corrected. The DON stated she had not personally seen Resident #1 eat sandwiches, staff were educated, and all meals served during breakfast, lunch and dinner had meal tickets that were reviewed by nursing before trays were distributed. The DON stated she would agree Resident #1 would need a pudding or shake as a snack, not a peanut butter sandwich. The DON stated for the night shift, snacks were delivered by dietary staff to the front nurses' station (outside of the locked unit), staff would then be able to pick snacks on resident's needs. The DON's expectation was Resident #1 should have received a snack that met his orders, like a shake or pudding, and close supervision with meals would be always within eyesight. Interview on [DATE] at 02:38 p.m., LVN A stated she worked the 06:00 p.m. to 06:00 a.m. shift, and further stated she worked the locked unit on [DATE] and entered the building at approximately 06:00 p.m. LVN A recalled that evening on [DATE], and stated at the start of her shift she received reports and reviewed them, a minute later CS A informed her Resident #1 did not look good and was possibly choking, he was on the floor blue and was observed with no respirations. LVN A performed a sternum rub, the crash cart was brought by the ADON but was not used as Resident #1 was a DNR. LVN A stated the ADON performed the Heimlich maneuver and a little spit came out. LVN A stated she performed a swipe method to Resident #1's mouth and noticed no food or and dislodged food. LVN A stated she did not believe there was any food in the premises, dinner was usually served at 05:00 p.m., and the dining area in the locked unit had already been cleaned, LVN A stated there were no signs of wrappers, sandwich wrappers, or indications of snacks. LVN A stated when she entered the building, snacks were not served yet, she did not see any at the front nurses' station, and snacks were passed around 08:00 p.m. When asked about the progress note she created and signed, LVN A stated, I did document what I saw, but I did not see actual food, I should have been more descriptive like writing the items I saw as particles or maybe I should have described it as green small pieces, in all happened so quickly. Interview on [DATE] at 04:39 p.m., the ADM stated she was called that evening on [DATE] and was informed Resident #1 expired due to a heart attack, and EMS stated on the report Resident #1 asystole (heart's electrical system fail causing heart to stop pumping, otherwise known as flat-line or flat-lining). The ADM stated she called the local EMS and asked for a report and was informed by local EMS since Resident #1 was not transferred to a hospital or another provider, there was no report. The ADM stated that residents, which included Resident #1, had dinner around 5 p.m. and snacks typically come out at 7 p.m. The ADM stated, when I called CS A to ask if she gave [Resident #1] a sandwich that night, [CS A] said no he [Resident #1] didn't get a sandwich, then she [CS A] later said yes I did give him [Resident #1] a sandwich, then later changed her [CS A] answer to no I didn't give him [Resident #1] a sandwich. On [DATE] at 04:56 p.m., attempt made to contact the local EMS, no findings at this time as local EMS had not made any return calls. Interview on [DATE] at 05:46 p.m., the RD stated there was a nutritional assessment completed around ,d+[DATE], with orders in detail, and further stated, [Resident #1] has no bread, although I do not know if his orders were updated because I know that this particular resident (Resident #1) was not eating and all he wanted was a peanut butter and jelly sandwich, this is okay just as long as there is a one to one person sitting with him (Resident #1) while he eats, although that was just a conversation, to my understanding the last RD that is familiar with him (Resident #1) is on leave, from what I understand SLP allowed him to have sandwiches but with one on one supervision with small bites. The RD stated, if he (Resident #1) is on a mechanical soft diet there would more than likely be a choking. Record review of the facility's Food and Nutrition Services Policy, revised [DATE], reflected a Policy statement that Each resident is provided with nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preference of each resident. 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appear palatable and attractive, and it is served at a safe and appetizing temperature. a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the food service manager so that a new food tray can be issued. b. Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 05:09 p.m. The Administrator was notified. The Administrator was provided with the IJ template on [DATE] at 6:26 p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] at 4:09 p.m.: Plan of Removal Immediate Jeopardy On [DATE], an abbreviated survey was initiated the Facility. On [DATE], at 6:30 PM, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to provide Food prepared in a form designed to meet individual needs for Resident #1, who was provided a peanut butter and jelly sandwich and choked/passed away. ACTIONS Start Date: [DATE]. Completion Date: [DATE] Responsible: Administrator/Director of Nursing Action: On [DATE], the regional nurse consultant, regional reimbursement consultant, the director of nursing, and the MDS audited all Matrix EHR orders to validate that they matched the RD Dining Meal ticket system and that they were on the Resident Profile so that the CNAs and other facility workers can identify the diet that the resident is on and any precautions that are in place. Any concerns or discrepancies were corrected immediately upon discovery. Snacks ordered for weight loss interventions were audited and all were correct. The director of nursing/designee in-serviced facility staff on where to find the diet information for a resident. Facility staff will receive the information before starting their next assigned shift. Agency staff will receive the information before starting their assigned shift. The CNA who fed the resident bread was individually re-educated by the administrator and the director of nursing on [DATE] regarding following the resident diet and where to find diet information. Start Date: [DATE] Completion Date: [DATE] Responsible: Administrator/Director of Nursing Action: On [DATE], the regional nurse consultant in-serviced the administrator and the director of nursing on new admissions to the facility and the process of entering the diet into the Matrix EHR and completion on the Resident Profile. New admission orders will be reviewed the next morning in the Interdisciplinary Team Meeting (IDT) and corrections made when needed. The RD Dining Meal Ticket system will also be checked at that time to validate that everything matches. The MDS will then develop a care plan for any dietary needs identified by day fourteen (14) or sooner, per the regulation. The RD recommendations will be reviewed upon receiving by the director of nursing/designee for any diet changes and new orders entered per the above processes. The Resident Profile and care plan will be updated at that time. Any concerns will be discussed in the weekly Quality of Care meeting. Speech therapy recommendations will be reviewed upon receiving by the director of nursing/designee for any diet changes and new orders will be entered per the above processes. The Resident Profile and care plan will be updated at that time. Any concerns will be discussed in the weekly Quality of Care meeting. Start Date: [DATE] Completion Date: [DATE] Responsible: Administrator Action: An Ad Hoc QAPI meeting was held with the facility medical director to discuss the deficiency and actions put in place by the facility. The administrator will monitor the new orders for diets from the RD or the Speech Therapist, weekly for one (1) month and randomly thereafter by reviewing the facility activity report, actual food on meal trays, and documenting findings on a log created by the facility. Any concerns or trends will be brought to the monthly QAPI meeting for tracking and trending and new IDT recommendations. Monitoring of the POR included the following: Observation on [DATE] from 03:22 p.m. to 05:19 p.m. revealed staff received in-service training from regional staff, ADM, DON, on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, and to check with charge nurse prior to giving resident(s) an altered diet texture. Interview on [DATE] at 03:31 p.m., the ADM stated she was in-serviced on [DATE], last night, by the Regional Nurse Consultant on new admissions to the facility and the process of entering the diet into the Matrix EHR and completion on the resident profile, also including topics of facility activity report review, new admission orders reviewed every morning to assure diet was completed and entered in EHR, the MDS coordinator would create dietary care plans or before day 14, the RD recommendations would be reviewed upon receiving by the director of nursing/designee for any diet changes and new orders, new orders and concerns would be review in the weekly quality care meeting by the DON, and the new processed would be reviewed in the monthly QAPI meetings for three months. The ADM stated staff were in-serviced on topics of where to find the diet information, and CS A was individually re-educated and the DON on [DATE] regarding following the resident diet and where to find diet information. Interview on [DATE] at 03:39 p.m., the DON stated the Regional Nurse Consultant in-serviced her the evening of [DATE] on new admissions to the facility and the process of entering the diet into the Matrix EHR and completion on the Resident Profile. The DON stated all staff were in-serviced on topics of where to find the diet information, and CS A was individually re-educated by her and the ADM last night ([DATE]) on topics of following the resident diet and where to find diet information in the POC tablets. The DON stated other topics the regional consultant trained her on was the facility activity report review, new admission orders reviewed every morning to assure diet was completed and entered in the EHR, the MDS coordinator would create dietary care plans or before day 14, the RD recommendations would be reviewed upon receiving by the director of nursing/designee for any diet changes and new orders, new orders and concerns would be reviewed in the weekly quality care meeting by the DON, and the new process would be reviewed in the monthly QAPI meetings for three months. Observation and interview on [DATE] at 04:49 p.m., RN A stated she was also the MDS Coordinator and works the day shift, RN A stated she was in-serviced on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, and to check with charge nurse prior to giving resident(s) an altered diet texture. RN A stated she will create dietary care plans or before day 14. Observation of RN A revealed the use of the POC tablet to obtain information on resident diet orders, also including care plans and orders. Observation and interview on [DATE] at 04:53 p.m., the ADON stated in-service training on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, and to check with charge nurse prior to giving resident(s) an altered diet texture. ADON stated all staff were in-serviced on topics of where to find the diet information, and CS A was individually re-educated by the DON and the ADM on ([DATE]) on topics of following the resident diet and where to find diet information in the POC tablets. Observation of ADON revealed the use of POC tablet to obtain information on resident diet orders, also including care plans and orders. The ADON stated new admissions to the facility and the process of entering the diet into the Matrix EHR and completion on the Resident Profile. The ADON stated QAPI was conducted on the evening of [DATE] to discuss the IJ and plan of removal. Interview on [DATE] at 05:01 p.m., LVN B stated she works the day shift. LVN B stated she was in-serviced on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, and to check with charge nurse prior to giving resident(s) an altered diet texture. LVN B further stated CNAs were instructed to come to nursing if they had questions on dietary orders or any orders. Observation on [DATE] at 05:09 p.m., revealed dinner service, trays had meal tickets, nursing reviewed meal tickets before distribution, and staff reviewed meal tickets before serving meals to residents. Interview on [DATE] at 05:11 p.m., CNA A stated she was in-serviced on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, and to check with charge nurse prior to giving resident(s) an altered diet texture. CNA A stated staff were further trained and instructed to monitor snacks they gave to all residents to assure the proper diet order. CNA A stated and explained the process to confirm orders and care plans, ADL needs with the use of POC tablet. Observation and Interview on [DATE] at 05:21 p.m., CMA A stated she was in-serviced on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, and to check with charge nurse prior to giving resident(s) an altered diet texture. CMA A stated staff must always confirm all orders which included dietary orders. CMA A stated she had access to POC on her medication cart as she used this for her duties in medication administration. Observation of CMA A revealed the use of POC to obtain information on resident diet orders, also including care plans and orders. Observation on [DATE] at 05:26 p.m., revealed dinner service in the locked unit, trays had meal tickets, nursing reviewed meal tickets before distribution, and staff reviewed meal tickets before serving meals to residents. Phone interview on [DATE] at 05:40 p.m., CS A stated in-service training on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, and to check with charge nurse prior to giving resident(s) an altered diet texture. CS A stated she was re-trained on the use the facility's POC tablet, accessing diet orders, reviewing residents' profile for diet order and other orders. CS A stated, I took the in-service last night ([DATE]) before I started, if I have any concerns, I am going to check with the nurse to confirm orders, and that I want to avoid and prevent any choking or risks of resident eating fast because that is serious. CS A stated, I have been schooled on the tablet and I am aware of the risks, I come in at the tail end of the shift after everything is said and done, and we want to make sure residents get snacks and I know the risk of giving something they aren't supposed to eat, a resident can choke and that is a very serious matter. Phone interview on [DATE] at 05:51 p.m., LVN A stated she works the night shift. LVN A was in-serviced on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, to check with charge nurse prior to giving resident(s) an altered diet texture. Phone Interview on [DATE] at 05:56 p.m., CNA B stated in-service completed on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, and to check with charge nurse prior to giving resident(s) an altered diet texture. CNA B observed the use of POC to obtain information on resident diet orders, also including care plans and orders. CNA B stated she was aware of the risks of resident noncompliance of dietary orders, further stating, if we don't follow orders, it is dangerous for residents this could be from choking to food allergies, also I'm fully aware that I can always go to a nurse to confirm any orders or care for my residents. Interview on [DATE] at 05:58 p.m., NA A stated she was in-serviced on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, and to check with charge nurse prior to giving resident(s) an altered diet texture. NA A stated. We must follow all orders, this is how we provide care for our residents, all orders, dietary, everything, if we don't, we could cause harm to residents. Interview on [DATE] at 06:11 p.m., the DM stated she completed in-service training on topics of where to find the diet information, how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, the importance of following diet orders, and to check with charge nurse prior to giving resident(s) an altered diet texture, and there was a process of orders to confirm they matched the RD Dining Meal ticket system, and they were on the Resident Profile. Record review of in-services for ADM and DON on [DATE] on topics of new admissions to the facility and the process of entering the diet into the Matrix EHR and completion on the Resident Profile. Record review of in-service from [DATE] to [DATE] on topics of where to find the diet information for a resident completed, Subject: Resident Profile-how to pull up Resident Profile to review-Diets-Diagnosis-Care Plans, all care a resident requires, importance of following diet orders-check with charge nurse prior to giving resident(s) an altered diet texture. Record review of Ad Hoc QAPI meeting occurred [DATE] at 08:30 p.m. with the facility medical director, regional staff, ADM, DON, ADON, RN A to discuss the deficiency and actions put in place by the facility. Record review of in-service for th [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure menus and nutritional adequacy met the nutritional needs of residents in accordance with established national guidelines for 2 of 2 observed meals reviewed for meal accuracy. The facility failed to ensure there was 7 days' worth of food available from 07/31/2024 through 08/06/2024 to prepare and serve their planned and/or alternate menu on 08/06/2024 for lunch and dinner. This deficient practice could place residents at increased risk for inadequate nutrition . Findings include: During an observation on 08/06/2024 at 08:56 AM, in the facility's only kitchen, revealed the following: -Chicken-10-pound bag, 4.86 pounds in the freezer -Ground beef-50 patty, 3.2 oz beef in the freezer, 2-10 pounds beef -1 bag of pasta on the shelf and pasta in the tub. -Chicken on the counter preparing to cook. There were no Emergency food supplies in the kitchen, no potatoes, no beef/meat, no cheese and no fruits, etc . During confidential interviews revealed the facility's menus rarely matched what was served. Confidential interviewee stated they rarely ate from the facility's kitchen because they didn't like what was cooked and food was not prepared according to the menu. During an interview on 08/06/2024 at 10:05 AM, the [NAME] stated sometimes the menu was changed due to food not being available. She stated she got approval from the DS to cook what was available. She stated she was cooking chicken and dressing for lunch on 08/06/2024, that was not on the menu for the day, but the DS said to cook it. She also stated there were alternate meals like chicken tenders, ham and cheese sandwiches and baked potatoes but there were no potatoes, ham and cheese or chicken tenders available in the facility at the time. During an interview on 08/06/2024 at 10:39 AM the Dietary supervisor (DS) stated the facility only had food available for lunch, dinner, and lunch the next day. The DS stated she had to substitute her menus in the last week from 08/01/2024 through 08/06/2024 due to food and ingredients not being available or residents dislikes. She also stated the facility was supposed to have 7 days' worth of food. She stated she usually ordered on Tuesdays and deliveries were done on Wednesdays. The DS stated her orders for last Wednesday, 07/31/2024 was not approved by Corporate because July had 5 Wednesdays, and her budget had exceeded the month for the month of July. She stated she was going to the store daily or more than once a day to purchase food to cook. She stated the Administrator was made aware Corporate did not approve the food order. She stated the Administrator gave her personal credit card to use daily. The DS stated she did not discuss with the RD before substituting the menu for the week. During an interview on 08/06/2024 at 12:18 PM the Administrator (ADM) stated she was made aware by the DS that corporate did not approve the food order on 07/31/2024. The ADM stated she gave the DS her credit card to use and purchase food. The ADM stated as of Wednesday 7/31/2024 the facility had 5 days' worth of food. The ADM stated the facility was supposed to have 7 days' worth of food available in case of emergency. The ADM stated Corporate was not made aware the facility had only 1 day worth of food available until the State Surveyors started to ask. The ADM also stated the DS was supposed to purchase food from the local grocery store on 08/05/2024 but she didn't. The ADM stated the facility did not have emergency food supplies for sheltering in place or evacuations. The administrator provided a list of food for emergency . Interview attempts made to call the RD on 08/06/2024 at about 4:54 PM and 4:57 PM but were unsuccessful During an interview on 08/07/2024 at 09:33 AM, the RD stated her last visit in the facility was about 07/24/2024. She stated she was not contacted by the DS regarding changes made to the menu in the last week. She stated she was contacted last night (08/07/2024) regarding changes for breakfast and lunch on 08/07/2024. The RD stated she told the DS to contact her regarding changes to the menu so she (RD) could sign off on the changes. The RD stated she coached the DS to replace protein for protein, starch for starch and vegetables for vegetable. The RD stated the facility had a liberalized style diet to enable the residents to make decisions to control their meals, more homelike. During an interview on 08/07/2024 at 1:49 PM, [NAME] #2 stated during the last week it had been had to cook due to food not being available. She stated she asked the DS what she was cooking because there was nothing available in the kitchen. She stated it was hard to follow the posted menus because there was no food supply, they had to cook based on what was available in the kitchen. She stated on some days the DS had to go to the local store to get food supplies and juices to be able to feed the residents. She stated the residents complained all the time stating they cook the same food all the time. She stated it made the job harder when the supplies were not available . Record review of the facility's Menu substation form reflected the following changes were made and not signed off by the RD: 08/01/2024 the entire dinner meal was substituted with chop steak with gravy, noodle, broccoli due to residents' dislikes. Record review of facility's invoices for food for the last 60 days reflected food was delivered on the following dates: 06/05/2024, 06/12/2024, 06/19/2024, 06/26/2024, 07/03/2024, 07/10/2024, 07/17/2024, 07/24/2024. No delivery was made 07/31/2024. 08/02/2024 the entire lunch meal was substituted with shrimp, Mac and cheese veggie with no reason for substitution. 08/02/2024 the entire dinner meal was substituted with Enchiladas, rice and salad due to residents dislikes. 08/03/2024 the entire lunch meal of was substituted with chili beans, veggies, and corn bread due to being out of sausages. 08/04/2024 the entire lunch meal of was substituted with fried chicken, mashed potatoes, and veggies due to residents dislikes. 08/05/2024 the entire lunch meal of was substituted with carne guisada , salad, rice due to being out of chicken. 08/06/2024 the entire lunch meal of was substituted with chicken and dressing, veggies, and cake due to being out of beef. 08/06/2024 the entire dinner meal of was substituted with spaghetti, mixed veggies and pudding due to being out of ribs. Record review of the facility's menu for a 4-week period reflected the following: Week #1- Friday 08/01/2024 dinner menu- Homemade Chicken Pot Pie Breaded Okra, Iced Chocolate Brownie Bread Slice/Margarine, Milk, Beverage of Choice, Water Week #1- Saturday 08/02/2024 lunch meal - Sausage Cuts, Blackeye Peas, seasoned Cabbage Cornbread/Margarine Butterscotch Pudding, Beverage of Choice, Water Week #1- Saturday 08/02/2024 Dinner meal - Beef Taco Salad with Shredded Com Nuggets, Tortilla/Margarine, Frosted Cake, Milk, Beverage of Choice, Water Week #2 - Sunday 08/03/3034 lunch meal - Turkey Pot Roast, Gravy, Baked potatoes, sour cream and shredded cheese, glazed carrots, dinner roll/Margarine, beverage of choice, water Week #2 - Monday 08/04/2024 lunch meal - Fried Chicken, broccoli Rice & Cheese, Italian [NAME] Beans, Strawberry Mousse, beverage of choice, water Week #2 - Tuesday 08/05/2024 lunch meal - Meatloaf with Tomato Sauce, Scalloped Potatoes, [NAME] Peas with Sauteed Onions, Bread Slice/Margarine, Peaches & Bananas, Beverage of Choice, Water Week #2 - Wednesday 08/06/2024 lunch meal - Beef & Bean Burrito w/ Cheese & Sour Cream, Mexican Corn, Cilantro-Lime Coleslaw, Frosted Cake, Beverage of Choice, Water Week #2 - Wednesday 08/06/2024 Dinner meal - Ritz Chicken Bake, Seasoned Rice, Broccoli Florets, Dinner Roll/Margarine, Summer Fruit Cup, Milk, Beverage of Choice, Water Record review of the facility's alternate menu for 08/06/2024 reflected the following: House salad, soup of choice, cheese quesadilla, loaded bake potatoes, pancakes and syrup) Record review of the facility's emergency food checklist, dated March 2021, reflected the following: Canned luncheon meats, Tuna, Canned ham and chicken, Cold cereals, Beverage drink, instant, Canned fruit juice, Powdered milk, Peanut butter, Jelly, [NAME] crackers/vanilla wafers Canned Fruit, Soup, Chili, Oatmeal, Biscuit Mix, Mayonnaise/Mustard, Special Snacks/Supplements, Crackers, Bread, Baby food (pureed diets) Canned Ravioli/Spaghetti Canned Vegetables Potatoes (flakes), Gravy Mix, Powdered thickener . Record review of the document provided by facility's ADM regarding food regulations reflected the following: Texas Administrative Code Title 26 Part I Chapter 554 Subchapter L Rule S554.1107; Health and Human Services Health And Human Services Commission Nursing Facility Requirements For [NAME] Censure And Medicaid Certification Food And Nutrition Services Menus, Nutritional Adequacy and Meal Service a) Menus must: (1) meet the nutritional needs of residents in accordance with established national guidelines. (2) be prepared at least one week in advance. (3) be written for each type of diet ordered in the facility, in accordance with the facility's diet manual; (4) be written or completely evaluated for nutritional adequacy by the facility's qualified dietitian; (5) vary from week to week, taking the general age-group of residents into consideration. (6) be followed unless substitutions are documented as required in subsection (d) of this section; (7) reflect, based on a facility's reasonable effort, the religious, cultural, and ethnic needs of the resident population, as well as input received from residents and resident groups; and (c) The facility must ensure that a current diet manual, approved by the qualified dietitian, is readily available to dietary service personnel and the supervisor of nursing service. To be current, the diet manual must be no more than five years old. (d) The facility must retain records of menus served, including substitutions, and food purchased for 30 days. A list of residents receiving special diets and a record of their diets must be kept in the dietary area for at least 30 days. (e) The facility must post the current week's menu: (f) The dietary department must keep a seven-day supply of staple foods and a two-day supply of perishable foods at all times. The facility is allowed the flexibility to use food on hand to make substitutions at any interval as long as comparable nutritional value is maintained. Any substitution of menu items must be recorded on the day of use.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 1 of 1 kitchen reviewed for food safety and sanitation. The facility failed to ensure food that was prepped was labeled and dated. The failure placed residents at risk of foodborne illness. Findings included: Observation of the kitchen on [DATE] at 9:00am revealed milk, orange juice, and cranberry juice were not dated or labeled with the date that they were prepped. There was a pitcher of juice in the refrigerator covered, but not labeled. There was a personal drink in a large Styrofoam cup with name of Sonic on it. There was a package of cheddar cheese in a plastic resealable baggie that was not sealed or dated. There was a large container of Mustard dated [DATE] and large container of Ranch dated [DATE]. In the freezer there was a large container of Blue Bunny Sherbet that was not dated, and lid was on part of the container. In the pantry there was an opened box of taco shells with no dated label or any container or plastic resealable bag to keep food fresh. There was an opened bag of Ruffles in a clear resealable bag but not labeled or dated. An interview with Dietary [NAME] I on [DATE] at 11:20 am revealed that any food that has been opened should be labeled and dated. She told me the reason it is important to the food is to know when it was opened and how long it has been opened. [NAME] A told me the reason food is to be kept cover is to keep bacteria from growing in it and to keep it from becoming contaminated. An interview with Dietary Manager G [DATE] at 11:30 am revealed that all food in refrigerator, freezer and pantry should be dated and labeled. The reason is to know how long it has been there, when it was opened and when it should be thrown out. She revealed the importance of keeping clear resealable bags closed or have food in a sealed bag or container is to keep the food fresh and to keep bacteria and bugs out. An interview with the Administrator on [DATE] at 10:00am revealed that all food items should be labeled and dated. She stated food should be dated to know when it was opened and when it has expired. The importance of keeping food covered, in a container or resealable plastic bag is to keep food from becoming contaminated. Her expectation is the dietary staff know the policy. Record Review of the Food Receiving and Storage Policy reveals All food stored in the refrigerator or freezer will be covered, labeled, and dated.

Based on record review and interview, the facility failed to ensure all Pre-Admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 1 of 5 residents (Resident #32) reviewed for PASRR screening, in that: The facility did not have an accurate PASRR Level 1 assessment for Resident #32 when he had a diagnosis of major depressive disorder and mood disorder unspecified which would have triggered Resident #32 for a positive assessment for mental illness. This failure could place residents with an inaccurate PASRR Level 1 evaluation at risk for not receiving care and services to meet his needs. The findings were: Review of the Face sheet for Resident #32 reflected he was admitted to the facility on [DATE] with diagnoses of: Type 2 Diabetes, Dysphasia with Cerebrovascular disease, Cerebral infarction, Mood disorder due to known physiological condition unspecified, Major Depressive disorder singe episode. Review of the MDS assessment for Resident #32 dated 5/08/24 reflected a BIMS score of 12 indicating mild cognitive impairment. His physical assessment reflected he required one person assist for all ADLs. He mobilized by wheelchair. He was assessed as always continent of bowel and bladder. Review of the Care Plan for Resident #32 dated 6/08/24 reflected interventions were in place for: Safe transfers r/t weakness, ADL deficit r/t weakness (assistance to toilet), Limited in ability to eat and drink, Limited in ability to dress/undress, Psychotropic drug use (antidepressant), Fall Risk high, Speech Impairment, disease complications r/t Cerebral Infarction. Review of Records for Resident #32 reflected one PASRR evaluation was found in his records. A level one evaluation dated 7/23/18 reflected he was negative for mental illness. Review of the physician's orders for Resident #32 dated 7/16/24 reflected he was prescribed Aricept 5 mg at bedtime daily, a medication used to treat memory loss in Alzheimer's disease. No other psychoactive medications were prescribed. Review of Resident #32's Progress notes dated from 3/04/24 to 7/03/24 reflected he was seen by a Psychiatric clinician on 7/01/24 and 6/12/24. No signs of depression or aggressive behavior were reported. In an interview on 7/16/24 at 9:50am the MDS coordinator stated Resident #32 had only a PASRR evaluation dated 7/23/18 on record. She stated the diagnosis of Major Depressive Disorder single episode was added on 11/10/21 and the diagnosis of Mood Disorder Unspecified was added on 9/08/22. The MDS Coordinator stated only certain diagnosis automatically triggered a new PASRR assessment and the ones added for Resident #32 did not. In an interview on 7/16/24 at 10:25 am the DON stated she would defer to the MDS coordinator on the PASRR evaluations question. She stated she was unsure if Resident #32 should have received a new PASRR evaluation. In an interview on 7/16/24 at 11:30 am the ADON stated she was the charge nurse for Resident #32. She stated he was normally calm and collective, she stated she didn't believe he took any psychoactive medications. In an interview on 7/16/24 at 11:46 am the Administrator stated Resident #32 should have had a new PASRR evaluation with each new diagnosis. The Administrator stated the facility utilized the state guidelines for determining the need for PASRR assessments.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 18 of 18 residents (Resident # 1-18) on six of six halls (Halls 100, 200, 300, 400, 500, and 600) reviewed for infection control. 1. Facility failed to cohort 9 residents who had tested positive from their roommates who had tested negative. 2. Facility failed to designate asymptomatic, covid-positive staff only to covid-positive residents and allowed the positive staff to work with residents who had not yet been infected. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 06/16/2020. While the IJ was removed on 06/22/2020, the facility remained out of compliance at a severity level of actual harm at a scope of widespread due to staff needing more time to monitor the plan of removal for effectiveness. This failure could place residents at risk for contracting healthcare-acquired infections. Findings included: 1. Review of COVID-19 test results collected on 6/9/2020 revealed Residents #1-9 tested positive for COVID-19 and Residents #10-18 tested negative. During a telephone interview on 6/14/2020 at 12:58 p.m., the ADM stated the facility had received COVID-19 test results, but she and the DON were still reviewing them. Review of a phone text message dated 6/14/2020 at 9:39 p.m. sent from the ADM to surveyor reflected a breakdown of results to include: 71 residents tested , 36 positive, 34 negative and 1 pending; 78 staff tested , 22 positive, and 56 negative. Review of resident room roster dated 6/15/2020 revealed Residents #1-9 were residing with their roommates (Residents #10-18) who tested negative for COVID-19. Review of this same roster revealed residents who tested positive and residents who tested negative still residing together on halls 100, 200, 300, 500 and 600, halls that had not been exclusively designated as isolation units. Observations on 6/15/2020 at 9:45 a.m. revealed residents who had tested positive (Residents #1-9) remained in their resident rooms with their roommates (Residents #10-18) who tested negative. The room listings were as follows: Resident #1 (positive) and Resident #10 (negative) in room [ROOM NUMBER]; Resident #9 (positive) and Resident #18 (negative) in room [ROOM NUMBER]; Resident #2 (positive) and Resident #11 (negative) in room [ROOM NUMBER]; Resident #3 (positive) and Resident #12 (negative) in room [ROOM NUMBER]; Resident #4 (positive) and Resident #13 (negative) in room [ROOM NUMBER]; Resident #5 (positive) and Resident #14 (negative) in room [ROOM NUMBER]; Resident #6 (positive) and Resident #15 (negative) in room [ROOM NUMBER]; Resident #6 (positive) and Resident #17 (negative) in room [ROOM NUMBER]; and Resident #8 (positive) and Resident #17 (negative) in room [ROOM NUMBER]. During an interview on 6/15/2020 at 9:40 a.m., the DON stated all residents had remained in their original rooms and had not been moved. During an interview on 6/15/2020 at 3:35 p.m., the RVP stated that, after speaking with the epidemiologist again today, the epidemiologist had recommended cohorting the positive residents. He stated they were going to start planning out where to move everyone. During an interview on 6/16/2020 at 10:00 a.m., the DON stated they had already moved everyone the night before, on 6/15/2020. She stated that now halls 200, 400, and 600 had been made positive isolation halls. She stated the 300 hall had been made a quarantine hall for residents who have not tested positive but have symptoms, and halls 100 and 500 were negative halls. She stated she was aware that the asymptomatic positive staff should have been working only with positive residents. During an interview on 6/16/2020 at 11:39 a.m., Resident #14 (tested negative and was the former roommate of Resident #5 who tested positive) stated she was moved to this room on 300 hall just last night. During an interview on 6/16/2020 at 11:41 a.m., Resident #17 (tested negative and was the former roommate of Resident #8 who tested positive) stated she ate dinner last night in her old room and then was moved to this room on 300 hall. Interview on 6/16/2020 at 11:45 a.m., Resident #12 (tested negative and was the former roommate of Resident #3 who tested positive) stated she was just moved to 300 hall last night as well. During an interview on 6/16/2020 at 11:52 a.m., Resident #3 (tested positive) stated she did not have to move (200 hall) but her roommate Resident #12 was moved out of the room they shared yesterday (6/15/20). During an interview on 6/16/2020 at 11:58 a.m. Resident #1 (tested positive) stated she was on 100 hall yesterday but was moved to 400 hall last night (6/15/2020). She is not certain but believe her roommate, Resident #10, remained in the room they shared on 100 hall. Review of the facility COVID-19 policy binder revealed a document entitled Coronavirus Disease 2019 Preparedness Checklist for Nursing Homes and other Long-Term Care Settings. Review of this document revealed a section entitled Identification and Management of Ill Residents: The facility has criteria and a process for cohorting residents with symptoms of respiratory infection, including dedicating HCP to work only on affected units. Review of the facility COVID-19 policy dated June 2020 revealed Residents with Suspected or Confirmed COVID-19 Infection Prevention and Control Guidelines page 9 Isolate symptomatic residents as soon as possible. Set up separate, well ventilated areas, place residents with suspected or confirmed COVID-19 in private rooms with the door closed and private bathroom, as possible, or cohort residents with known or suspected COVID-19. 2. Observation on 6/15/2020 at 10:30 am of halls 100, 200, 300, 500 and 600 revealed staff who tested positive assigned to multiple halls, not exclusively to the 400 isolation hall. Unidentified staff were observed going in and out of resident rooms providing care without regard to whether residents were COVID-19 positive or negative. During an interview on 6/16/2020 at 11:00 a.m., the ICAR RN stated that was a Certified Infeection Control specialist and had conducted an epidemiological site assessment on 6/15/2020 to assist the facility with infection control decision-making. She stated that management told her that positive staff were only taking care of positive residents. She stated that she had interviewed three staff members that stated they were taking care of any resident that needed their assistance, regardless of their COVID-19 status. She stated that the ADON had told her that all staff members were given a list of the positive, but that she had not observed differences in care between the positive and negative residents. During an interview on 6/16/2020 at 11:50 a.m., CNA A stated that the residents were cohorted according to COVID-19 status. She then stated she didn't know which residents were positive. She stated that she would help any resident that needed her, whether she knew that they were actually positive or not. During a telephone interview on 6/16/2020 at 2:20 p.m., CNA B stated she is asymptomatic but has tested positive, so she is able to work with the positive residents. She stated she worked yesterday (100 and 200 hall) before the residents were cohorted. She stated that she did know which residents were positive, because she was given a copy of the census with the positive residents highlighted. She stated that she had provided assistance for some residents who had not tested positive for COVID-19. Review of an email dated 6/15/2020 10:00 a.m. from health department the ADM reflected that printed guidance was provided recommending that, in the event of staffing difficulties, of the use of asymptomatic positive staff members to care for positive residents on isolation units only was recommended. Review of staff sign in sheets/hall assignments dated 6/15/2020 reflected staff who had tested positive who were assigned to halls other than just the 400 (isolation hall). CNA B who tested positive was assigned to care for residents on 100 and 200 halls (regular halls). CNA C who also tested positive was assigned to 300 and 600 halls (regular halls) and 400 (isolation hall). Review of undated facility policy titled Emergency Staffing Infection Prevention and Control Guidelines reflected the following: If infection becomes widespread .Upon approval of the local health and/or HHSC, the facility may allow asymptomatic positive employees to work on the COVID-19 isolation unit with residents that are COVID-19 positive. The employee will limit entrance to the facility to the isolation wing and will not enter any other part of the facility at any time. Review of a facility roster provided on 6/15/2020 reflected 71 residents resided in the building. Review of the facility Infection control policy last revised 6/1/2018 reflected a policy with the goal to help prevent the development and transmission of disease and infection in the community by following the CDC guidelines and the infection control coordinator is responsible for investigation, reporting, control and prevention of infections. The DON was notified on 6/16/2020 at 4:00 p.m. an Immediate Jeopardy situation had been identified due to the above failures. The IJ template was provided to the DON on 6/16/2020 at 5:04 p.m. The following Plan of Removal was submitted by the ADM on 6/16/2020 and accepted on 6/16/2020 at 9:05 p.m. Actions Taken/Plan included: Residents will be moved according to their Covid-19 status into separate, designated areas including: three units for positive COVID-19 residents, one unit for quarantined residents who are new admissions, and the other units for residents who are negative. On 6/16/20 upon advisement of (Health Department Epidemiologist); positive residents were co-horted (sic) on #200, #400, and #600 halls and Quarantined residents were quarantined as appropriate to hall #300. Negative residents were co-horted on halls #100 and #500. Fire barrier doors will be kept closed to protect the rest of the facility on these designated halls. Daily, dedicated staff have been assigned to each hall based on their positive or negative status. Positive Covid-19 asymptomatic employees will not care for quarantined or negative residents. Staff members assigned to the Covid-19 positive units will remain on the hallway and not enter the rest of the building. Daily, a dedicated nurse/certified medication aide will be assigned to work on the positive Covid-19 units; (200, 400, and 600 halls). They will utilize a medication combined nursing cart that will be kept behind closed fire barrier doors. Signage has been placed at the end of each hallway designating the different units and the COVID-19 status of residents residing in this unit. Nursing Assistants assigned to the positive units will enter from a dedicated entrance at the end of the positive hallway. They will complete a self-temperature check and notify the Administrator/Director of Nursing for any reading above 99.5 F. The reading will be kept on a log and turned into the Director of Nursing. On 6/16/20, the morning shift staff will be made aware of the location of positive Covid-19 residents utilizing a temporary roster for their review. Daily, the roster will be kept up by the Director of Nursing/Designee for any changes in condition or moves. The halls are now labeled individually indicating the Covid-19 status of residents residing on that hallway. On 6/15/20, the Director of Nursing educated all staff on appropriate use of PPE in the facility. Staff will don N95 mask, gown, and goggles always while working in the facility. Nurses and/or medication aides leaving the positive Covid-19 unit for any reason will doff their PPE inside the hallway and walk through the fire doors, sanitize their hands, and reapply PPE. Staff not receiving this initial education will be required to receive it before starting their next shift. The Director of Nursing/Designee will monitor for compliance on all halls with donning and doffing, including the appropriate use of approved PPE; daily for one (1) week and randomly thereafter. Any concerns will be corrected immediately. Temperature check logs will be reviewed for nursing assistants working on the Covid-19 positive units. The weekend supervisor or RN will monitor for compliance on the weekend shifts; every shift for one weekend and randomly thereafter. Any concerns will be corrected immediately. The Administrator/Designee will notify new employees verbally upon and will be made aware day one (1) of this plan of removal and which residents are positive for Covid-19. They will also receive training on PPE, including donning and doffing. Current residents that are identified with signs and symptoms; fever, cough, sore throat, shortness of breath, will be immediately assessed by the nurse and moved to a positive hall, if indicated, with a private room if available. Residents testing positive or being admitted from and discharging location testing positive, will be admitted to a Covid-19 positive hall in a private room if available. PPE and receptacles will be placed in appropriate areas of the Covid-19 unit. Staff will be immediately notified by the Director of Nursing/Designee of signs/symptoms a resident is experiencing of Covid-19 or a positive test result. Appropriate signage will be place on newly identified Covid-19 or quarantined resident's door, indicating their status and then removed to the appropriate hall, as necessary. The facility will monitor all residents, every shift (3X a day) for temperature changes and pulse oximetry if temperatures exceed 99.5. Any changes will be brought to the attention of the charge nurse for further assessment and Physician/Responsible Party notification. Any significant changes or signs and symptoms of Covid-19 will warrant further assessment by the nurse and possible move to the Covid-19 unit. Physician and responsible party will be notified as soon as the facility becomes aware. The survey team monitored the plan of removal from 6/17/2020 through 6/21/2020 as follows: Observation on 6/17/2020 revealed that all covid-positive residents had been moved to the 200, 400, and 600 halls with signs on the doors indicating covid-positive status and droplet isolation. Fire doors were kept closed on these halls. Observations on 6/17/2020 and 6/18/2020 revealed sufficient staff on 6 am - 6 pm shift and staff arriving for 6 pm-6 am shift. During interviews on 6/17/2020 and 6/18/2020 staff present stated that they had completed related in-servicing and confirmed understanding. Review of the current room roster for 6/17/2020 and 6/18/2020 cross-referenced to the list of covid-positive residents reflected all positive residents are on designated COVID-19 positive halls (200, 400, 600). Review of staffing sign in sheets for 6/16/2020, 6/17/2020 and 6/18/2020 indicated positive asymptomatic staff were assigned to only the positive COVID-19 halls and negative staff to only negative halls. Review of staff sign in sheet for 6/18/2020 revealed one LVN for negative halls, 2 LVNs for positive halls, 2 CNAs for negative halls, and 3 CNAs for positive halls. Observations on 6/17/2020 from 9:00 a.m. to 3: p.m. revealed that all staff entered from the end of the covid-positive halls if working on them. Review of in-services reflected one on PPE use dated 6/15/2020 and including N95 masks, gloves, eye protection, hand hygiene and change of PPE before and after each resident. Another in-service on positive staff not comingling with negative staff and each carrying a small bottle of alcohol-based hand rub was dated 6/16/2020. Additionally, review reflected in-servicing on 6/12/20 to all staff regarding residents and staff testing positive for COVID-19 with an overview of procedures to follow including PPE use, hand washing and sanitizing surfaces. Observation on 6/17/2020 and 6/18/2020 throughout both days revealed PPE supplies at front of building and at each unit just outside the terminal end of for the positive halls as well as outside rooms with droplet precaution. PPE stock included N95 masks, goggles, gloves, gowns and hand sanitizer. Review of symptom monitoring logs for residents reflected that all residents are monitored three times a day for vital signs and temperature. During an interview on 6/19/2020 at 10:37 a.m., the RNC stated that three new residents had been identified with symptoms and moved to the 300 (quarantine) hall. She stated that they had been tested again for COVID-19 and results were pending. Observation on 6/19/2020 from 9:47 a.m. to 2:00 p.m. revealed that the 200, 400, and 600 isolation halls were clean and tidy. Resident doors were closed with droplet isolation signs and PPE outside the doors. Staff was seen moving in and out of rooms donning and doffing PPE properly. A doffing station was set up just inside the end of each hall and a decontamination table just outside each door at the end of the hall. Observation on 6/19/2020 at 12:05 p.m. revealed HK F sanitizing surfaces, including her dust mop and broom, hand rails, doorknobs, and computer screens in 100, 300, and 500 halls. Observation of her cleaning on the 300 hall revealed that she donned PPE properly before entering the room of a resident on droplet precautions to clean and doffed/decontaminated properly before leaving the room. Observation on 6/20/2020 at 10:15 p.m. revealed two LVNs and six CNAs present in the building. A CNA was assigned to each hall, and LVN I was in charge of the three isolation halls (200, 400, and 600) while LVN H was in charge of the two covid-negative halls (100 and 500), and the one quarantine hall (300). Each of the three isolation halls had a designated CNA who did not exit the isolation hall into the main, non-isolation part of the building. CNA K was seen moving in and out of resident rooms providing care and donning/doffing PPE properly according to CDC guidelines. A CDC-generated sign detailing these procedures had been duplicated and posted near resident doors on the isolation halls. LVN H was seen going out of the designated exits at the end of isolation halls and coming around the front of the building, doffing PPE used on these halls, and decontaminating at the station available in the front courtyard, donning new PPE, and entering another isolation hall through the common area of the building. Observation on 6/21/2020 at 12:30 p.m. revealed that the midday meal cart was pushed into the 600 isolation hall smoke compartment doors. The cart was sent down the hall while meals were passed to rooms in Styrofoam containers. At 12:52 p.m., the cart was observed outside the end of hall 600 being sprayed down with a bleach solution and allowed to dry before being brought into the kitchen through an outside door. During interviews between 6/19/2020 and 6/21/2020, four LVNs, eight CNAs, two MAs, and two HKs reported knowledge and understanding of transmission-based precautions as well as in-service material on PPE, hand hygiene, surface disinfection, and the designation of dedicated staff exclusively to either covid-positive or covid-negative residents. The ADM was notified on 6/21/2020 at 1:23 p.m. that the IJ had been lowered, and that the facility remained out of compliance at a severity of actual harm and a scope identified as a pattern due to a need for ongoing monitoring.

Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures for 2 of 2 allegations of sexual abuse. Resident #2 had made two allegations of being raped by facility staff between November 2011 and May 2012. CNA B reported the first allegation to RN U who failed to document, report or investigate the allegation. CNA B failed to report the second allegation.On 06/25/12 Licensed Vocational Nurse (LVN) K witnessed Resident #2 being raped by Certified Nursing Assistant (CNA) A. This deficient practice resulted in an Immediate Jeopardy (IJ) on 07/10/12. While the IJ was removed on 07/11/12, the facility remained out of compliance at severity level of actual harm with a scope of isolated that is not IJ due to all staff had not been in-serviced on reporting abuse and neglect and the designation of the new Abuse Coordinator. As the result of this deficient practice Resident #2 was raped on 06/25/12 and had the potential to place the additional 11 female residnets identified with cognitive impairement at risk for Abuse and causing mental, physical and/or psychosocial harm and decreased quality of life. Findings include: Review of Resident #2 ' s Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE]. The resident ' s current [DIAGNOSES REDACTED]. Review of Resident #2 ' s most recent quarterly Minimum Data Set ((MDS) dated [DATE] reflected that Resident #2 has severely impaired cognitive status and that she has fluctuating (comes and goes) signs of disorganized thinking and periods of inattention. The MDS reflected that Resident #2 has Clear Speech (distinct intelligible words) and is rarely/never understood and rarely/never understands others. The MDS also reflected that Resident #2 has impaired vision but can see large print. The MDS also reflected that the resident had hallucinations, [MEDICAL CONDITION], and verbal behavior directed towards others. The MDS also reflected that Resident #2 is totally dependent on staff for all functional abilities including bed mobility, transfer, locomotion, dressing, toileting, personal hygiene, and bathing. The MDS reflected that Resident #2 requires limited assistance from staff for eating. The MDS reflected that Resident #2 had not received any antipsychotic, antidepressant, antianxiety, or hypnotic medications during the MDS look back period. Review of the most recent Care Plan last updated on 06/26/12 for Resident #2 reflected a " Problem/Need " onset 08/03/11 of " Activity Care Plan Potential for disrupted activities and/or untherapeutic activity environment related to: Verbally Abusive as evidenced by: Yelling at others. " Another " Problem/Need " onset 01/11/12 reflected " Due to Dementia resident is sometimes understood " with " Approaches " that included " Monitor resident frequently and anticipate needs; Approach resident calmly. Speak in a normal voice. Explain what you are about to do before touching resident; If resident appears agitated, leave alone if safe. Go back when calmer. If no improvement, notify charge nurse; Give resident adequate time to respond to question/conversation etc. " Another " Problem/Need " onset 06/26/12 reflected " Resident has been a victim of sexual assault " with " Approaches " that included " Give one time doses of [MEDICATION NAME] and [MEDICATION NAME] as ordered for possible sexually transmitted infections; Reevaluate for sexually transmitted infections in 3 months if physician orders; Notify Physician if resident has any vaginal bleeding or discharge. Lower abdominal pelvic pain, fever over 100 degrees without an obvious cause, pain or burning on urination. Redness, swelling or pain to injured area; Obtain any needed lab tests and notify physician of results; Keep resident comfortable with familiar staff, monitor resident for any increase in behaviors; No male CNA ' s to perform personal care on resident. " During an interview on 07/10/12 at 9:45 AM, the Director of Nursing (DON) stated that on 06/25/12 around 7:35 PM, LVN K heard a bed hitting the wall in hall 500 which is the locked unit. The DON stated that LVN K opened the door to Resident #2 ' s room and witnessed CNA A raping Resident #2. The DON stated that Resident #2 has advanced Alzheimer ' s, was not able to communicate to staff, recall events and does not show much emotion. The DON stated that Resident #2 is dependent on staff members for all activities of daily living. The DON stated that the curtain was pulled at the time and roommate (Resident #3) was in the room, but also has severe dementia and was not able to recall the events that took place. The DON stated that LVN K immediately told CNA A to leave and the police were called immediately. The DON stated that CNA A admitted to the police that he had raped Resident #2. The DON stated that according to the police, CNA A stated that this is the only resident he had sexually abused and that this was the first time it had happened. The DON stated that the resident was sent to a hospital to have a rape kit done and that the records are sealed and they were unable to get a copy of the results of the SAFE (Sexual Assault Forensic Evidence) kit. Observation on 07/10/12 at 10:00 AM revealed Resident #2 sitting in her wheelchair in the dining room of the secured unit. The resident was not in distress and did not have any signs of injury. The resident could not hold a conversation but would occasionally mumble phrases and sometimes say short clear phrases. Sometimes the resident ' s answers did not fit the question asked. During an interview on 07/10/12 at 10:05 AM, Resident #2 was asked if the surveyor could ask her some questions. The Resident stated " go ahead. " Resident #2 stated " no " when asked if anyone had ever hurt her and " yes " when asked if she felt safe at the facility. The resident also stated " yes " when asked if she likes the staff that worked at the facility. The resident did not show any emotion (negative or positive) during this interview. During an interview on 07/10/12 at 1:06 PM LVN K stated that on 06/25/12 sometime after 7:00 PM, she went to look for the other nurse on duty and was walking down the 500 hall when she heard what she thought sounded like a bed hitting the wall repeatedly. LVN K stated that she opened the door and she could see CNA A with his right arm holding Resident #2 ' s legs up in the air and the left hand trying to pull his pants up. LVN K stated that the resident was lying horizontal at the middle of the bed facing the middle of the room away from the wall. LVN K stated that Resident #2 had a sheet over her head but that the resident was not crying or making any noise. LVN K stated that Resident #2 is too confused and did not seem to know what was going on. LVN K stated that the curtains in room were pulled so that the roommate in the bed by the window could not see what was happening. LVN K stated that the curtain near the doorway was only pulled slightly and she could see straight to the bed when she opened the door. LVN K stated that she immediately asked CNA A what he was doing and he said " I don ' t know. " LVN K stated that she told CNA A to " get out " and " you are fired. " LVN K stated that CNA A was shocked and he was slow as he gathered his stuff before leaving the building. LVN K stated that CNA A left Resident #2 ' s room with bags of trash and placed them in the trash and linen bins as we walked out. LVN K stated that she immediately went to call the police when she exited the room and the police arrived shortly after CNA A had left. LVN K stated that the police took the trash and linen bins with them. LVN K stated that she would have never imagined that CNA A would do something like that. LVN K stated there is no one working at this facility that she would imagine would sexually abuse a resident. During an interview on 07/10/12 at 2:10 PM, the Detective stated that CNA A was in jail. The Detective stated that he is waiting the DNA results for CNA A. The Detective stated the case is still open and he is still working on it. The Detective stated that CNA A openly confessed to him that he raped Resident #2. During an interview on 07/10/12 at 2:35 PM the DON stated that CNA B reported to her on 07/05/12 that she (CNA B) had previously reported to Registered Nurse (RN) U sometime between November 2011 and January 2012 that Resident #2 had made an allegation that a CNA had raped her. The DON stated that CNA B told her that she witnessed Resident #2 make this allegation twice but she only reported it to RN U the first time and did not report the second allegation because nothing had ever come from the first allegation. The DON stated that RN U did not report it to administration. The DON stated that as of the State's entrance dated on 07/10/12, she had not investigated the two allegations of sexual abuse that CNA B reported to her (the DON) on 07/04/12 because she felt that CNA B was just feeling guilty about what had happened to Resident #2. During an interview on 07/10/12 at 3:15 PM, CNA B stated that the first allegation was about 6-7 months ago when CNA B was in the room with CNA C. CNA B stated that Resident #2 looked up at CNA C and said " he raped me " , but then Resident #2 looked up again and stated " no, not him. " CNA B stated that she reported this allegation to RN U and thought it was investigated. CNA B stated on 07/05/12 that, sometime around Mother ' s Day weekend in May 2012, she and CNA D were in the room with Resident #2 when CNA A came to the doorway. CNA B stated that Resident #2 looked up at CNA A and stated " he raped me. " CNA B stated that she did not report this allegation because she had reported the previous allegation to RN U and she thought it had already been investigated and didn ' t think anything of it. CNA B stated that now she wishes she had reported it. During an interview on 07/10/12 at 3:35 PM, RN U stated that CNA B did report to her about 6-7 months ago that Resident #2 had made an allegation that she had been raped. RN U stated that she assessed the resident, but that the resident says " off the wall things " and she didn ' t find " any injuries or unusual issues with the resident. " RN U stated that when she asked the resident about what happened the resident did not repeat the allegation and she was not able to get any information from the resident. RN U stated that CNA B had told her that Resident #2 had claimed a man had raped her and thought it was CNA C but then claimed it wasn ' t him. RN U stated that the resident wasn ' t making sense so she " put it on the backburner " and continued to " monitor " her. RN U stated that "If I reported every little thing, the DON would have a huge stack of complaints on her desk to investigate. " During an interview on 07/10/12 at 3:00 PM, CNA C stated that he did not recall this incident where Resident #2 claimed someone raped her. CNA C stated that Resident #2 can ' t really talk or make conversation. CNA C stated that he would have never thought that CNA A would sexually abuse anyone. During an interview on 07/10/12 at 4:00 PM, CNA D stated that she did not recall the incident when Resident #2 stated that CNA A raped her. CNA D stated that she had not witnessed any allegations reported by Resident #2 of rape. CNA D stated that Resident #2 cannot hold a complete conversation and that she will only say short phrases like " no " or " I want to go home. " CNA D also stated that she didn ' t think that CNA A would ever sexually abuse any residents and that she was surprised to hear he was caught sexually abusing Resident #2. During an interview on 07/10/12 at 4:20 PM the DON stated that RN U did not report the allegation of sexual abuse made by Resident #2 to the DON who was the Abuse Prevention Coordinator. The DON stated that RN U did not report the allegation because Resident #2 was not a reliable source of information due to her dementia. The DON stated that RN U should have mentioned the allegation to administration, but she did not. The DON stated that she interviewed RN U on 07/04/12, the same day that CNA B reported the allegations to the DON, RN U reported that she " did not think anything was unusual. " The DON stated that she told CNA B on 07/05/12 that she should have followed up with RN U and the DON on the first allegation. The DON stated that she did not document any of the information provided to her on 07/05/12 or any of the conversations held on the two allegations made by Resident #2. The DON stated that RN U should have reported the allegation that Resident #2 made that was reported to her by CNA B. The DON stated that she expects that the staff members " can ' t just assume (residents) are confused " when they make an allegation of abuse or neglect. The DON stated that the other CNA ' s did not recall the event when she asked them about it on the date of this interview (07/10/12). During an interview on 07/10/12 at 4:45 PM, the Administrator stated that he would start an investigation immediately regarding the two allegations that were brought to their attention by CNA B. The Administrator stated that he " can ' t see why anyone withholds information " and " it ' s the first (time). " During an interview on 07/10/12 at 5:30 PM, RN U stated that next time an allegation of abuse or neglect is reported to her she would report to the DON. RN U stated that she did not report the previous allegation because she did a full body assessment of Resident #2 and " she was fine, had no injuries, and the resident didn ' t directly report to her. " RN U stated that she did not document this assessment or that CNA B had reported anything to her. RN U stated that she had been trained on reported abuse and neglect prior to this incident. Review of the signed and dated statement provided to the surveyor by CNA B on 07/10/12 at 6:00 PM reflected " Statement for Dept of Aging and Disability Services: During the winter months perhaps Nov, Dec, Jan (I do not recall exact date) I was working in the (secured) unit at (the facility) serving as a CNA. I was putting (Resident #2) into bed one evening. I had asked for help from a co-worker male who also is a CNA and works in the building. I believe it was CNA C but I might be wrong. (Resident #2) made a comment while the male employee was standing at the foot of her bed. She said ' He raped me. ' I didn ' t hear her say it but CNA C stopped me mid-sentence and said what (Resident #2) had said. He stated that (Resident #2) accused him of raping her. (Resident #2) then lifted her head off of the pillow, took a closer look at CNA C and said ' no, no it wasn ' t him. ' I was relieved and told CNA C ' I didn ' t think he was capable of such a thing. ' The charge nurse on duty was RN U. RN U approached the room and CNA C explained what had just happened. RN U immediately turned around and said she was going to report that. I stuck my head out the door and RN U repeated that she was going to report that incident. CNA C left the room upset. I finished caring for (Resident #2) with peri-care, but nothing else was said by Resident #2. Fast forward to just before Mother ' s day weekend. I was in the room of (Resident #2) again. CNA D was present caring for Resident #2 and CNA A was standing in the doorway to (Resident #2) ' s room. Resident #2 said aloud ' he raped me. ' CNA D told Resident #2 ' no one is raping you now. ' I do not remember if CNA D ordered CNA A to leave the unit first, or if I told CNA D I had heard Resident #2 make a comment like that before only there was a different man in the room when it happened. CNA A was told to leave the unit. CNA D and I talked for a few minutes about what had just happened. I told her about the incident that occurred before. CNA D asked me if I was sure it was reported and I said yes. I didn ' t say aloud who the charge nurse was that I reported it to, but I had faith it had been reported and investigated. We discussed what to do and we both were concerned for (Resident #2). CNA D asked me again if I was sure it had been reported and I said yes. I asked her, or she asked me what we should do now and we both said I don ' t know. Fast forward to July 2nd (2012) I was confiding in a different charge nurse (LVN L) about all my experiences with Resident #2 prior to the incident that happened on June 25th (2012). LVN L said that (the DON) had been asking the employees to tell her of any instance of abuse, regarding (CNA A) too, or if we noticed anything unusual. I wasn ' t aware (the DON) had asked that of the employees until (LVN L) mentioned it. (LVN L) urged me to talk to (the DON) about this. Fast forward to July 4th (2012) I came in to have a talk with (the DON). It came to my attention that the first incident had not been reported and neither had the second. " Signed (CNA B). Review of a signed and dated statement provided by RN U dated 07/10/12 reflected " My name is (RN U). I am the weekend RN at (the facility) and have been employed here for eight years. I would like to relate about an incident reported to me by (CNA B) sometime in the past- date unknown. CNA B told me that (Resident #2) said she was raped by someone- the name (CNA C) was mentioned-. I told her I would look into it. I checked (Resident #2) over, could see no bruises, no bleeding, no discharges from vaginal/anus- no bruises, no fearful behavior, no signs or symptoms that would lead me to believe (Resident #2) was truly raped. I ' filed it in my memory ' watched for any other persons to come forward with a complaint- there were none. (Resident #2) says all kinds of off the wall things due to dementia, as do numerous other residents here. Residents confused or with dementia can say things that seem bizarre. I watched (Resident #2) -indeed- ALL residents- it ' s my job. I never saw any behavior that could be construed as coming from a sexually abused resident. I was waiting to see if anything would corroborate the statement but I found none. The resident did not tell me directly. She allegedly told (CNA B) about this event which may or may not have happened. (Another resident) is always ' having babies ' yes we do know it can ' t be possible. I do take any allegation seriously but (Resident #2) told (CNA B) I received the info second hand so to speak and on assessment of the resident found no (signs/symptoms) of abuse. If I would have believe (SIC) for one minute that (Resident #2) were raped, I would have said something- there was no evidence at the time. I can ' t emphasize that enough. I saw nothing during my assessment of (Resident #2) at the time that would indicate abuse. There was nothing out of the ordinary about her (Resident #2)- baseline- physically or emotionally/ mentally. I would never cover up abuse and know to report to my DON. " Signed (RN U). Review of a signed and dated statement provided by LVN L dated 07/10/12 reflected " On July 2, 2012 (CNA B) told me that a while back not sure when that ' her and (CNA C) was changing (Resident #2) and (Resident #2) said ' he ' s raping me ' and (CNA B) reported it to RN U. ' She (CNA B) also said that sometime after that " her, CNA D, and CNA A were in (Resident #2) ' s room and (CNA A) was standing in the doorway and (Resident #2) turned and looked at (CNA A) and started saying ' he ' s raping me. ' (CNA B) said she then told (Resident #2) that ' he ' s not raping you (Resident #2). ' -Didn ' t report it. (CNA B) also told me that one time (CNA A) was working 100 hall and she went to help him and he was in (another resident) ' s room and had his bag with him and showed her (CNA B) that he had his dad ' s Playboy books in his bag and (CNA B) said she told him ' I guess that ' s ok as long as you don ' t take them out at work. ' (CNA B) said she felt bad now because she never reported that and she feels like maybe it would have prevented the incident with (Resident #2 and CNA A) somehow. I told (CNA B) that she needed to report all of it to (the DON) and that anytime anything like that happens to report it immediately. I then asked (the DON) if (CNA B) had talked to her about it and she said yes. " Signed (LVN L). Review of the incident report dated 06/25/12 at 7:40 PM reflected " Witness: LVN K, Narrative: Per (LVN K) report, she went into secure unit looking for the other nurse(LVN M), when she go to room [ROOM NUMBER] she heard a loud sounding noise on the wall that sounded like the bed hitting the wall. When she opened the door she saw (CNA A) with his pants down and he had his right arm and hand holding the residents legs in the air. She reports that (Resident #2) was on her back cross ways on the bed. With his left hand he was pulling on his own pants, pulling them up. Resident was without clothes. " " Immediate Actions Take: (CNA A) was told by (LVN K), Charge Nurse, that he was fired and to leave the (facility). The police and DON were called. Police came to investigate and retrieve evidence from the room ...brief was left intact per request of the investigating officer for transfer to (a local hospital). Review of Nurse ' s Notes dated 06/25/12 reflected " 9:15 PM (late entry) for 7:40 PM. I went from hall 1 to hall 5 (the unit) looking for the other nurse when I got to room [ROOM NUMBER] I heard a loud sounding noise on the wall that sounded like the bed hitting the wall. Coming from 504A. When I opened the door of that room I saw (CNA A) with his pants down. He had his right arm and hand holding her legs in the air (Resident #2). (Resident #2) was on her back crossways on the bed. He had one hand (left) pulling on his own pants, pulling them up. (Resident #2) was without clothes. I yelled at him ' What are you doing? ' He said ' I don ' t know. ' I yelled ' Get out ' at him. After that I called (the DON) and dialed 911. (7:52 PM) the police arrived at facility. " Signed by LVN K. " 8:00 PM Medical Director called re: incident. Resident to be transported to (a local hospital) for exam. Daughter called and notified of incident. Police here to investigate. In room with resident collecting evidence. Resident asleep at moment. " " 9:20 PM Ok ' ed by police to move resident. Resident in geri chair transported by van to (hospital in Austin). " Signed by DON. Review of in-services for the last 12 months reflected that RN U had received her last Abuse and Neglect training on 07/11/11 and 08/10/11 and CNA B, C and D had all received training on Abuse and Neglect preventing and reporting on 07/11/11, 08/10/11, 04/10/12, 05/10/12, 06/11/12 and 06/26/12. CNA A had received training on Abuse and Neglect prevention and reporting on 07/11/11, 08/10/11, 04/10/12, 05/10/12, and 06/11/12. These in-services included training on the facility's abuse and neglect policy and until the 06/26/12 in-service on abuse and neglect, the training lacked an emphasis on identifying abuse in individuals with cognitive impairment. Review of CNA A ' s employee file on 07/10/12 at 10:45 AM on reflected a hire date of 01/22/08 and that all appropriate background checks had been completed prior to date of hire. Two reference checks were done and both previous employers indicated that CNA A was ' not eligible for rehire. ' The first employer indicated CNA A was terminated on 09/01/05 and the second indicated that CNA A was terminated on 01/18/08. During an interview on 07/10/12 at 12:30 PM the Assistant DON (ADON) stated that the reason CNA A was not eligible for rehire at the other facilities was not due to abuse or neglect so the reference did not prevent him from being eligible for hire at this facility. The ADON stated that the previous Administrator hired CNA A and had been the Administrator at the other facility when CNA A was terminated. The ADON stated that the Administrator at the time had indicated that CNA A was terminated at the other facility in 2008 due to not following the facility's policy on tranfers. Review of the facility ' s policy on " Reporting Abuse to Facility Management " dated 06/2004 reflected " It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors etc., to promptly report any incident or suspected incident of neglect or resident abuse, including of an unknown source, and theft or misappropriation of resident property to facility management. " " Employees, facility consultants and/or attending physicians must report any suspected abuse or incidents of abuse to the director of nursing services promptly. In the absence of the director of nursing service such reports may be made to the nurse supervisor on duty. " " The administrator and director of nursing services must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the administrator and director of nursing services must be called at home or must be paged and informed of such incident. " " Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident ' s medical record. (Note: If sexual abuse is suspected, DO NOT bathe the resident or wash the resident ' s clothing or linen. Do not take items from the area in which the incident occurred. Call the police immediately.) " The person performing the examination must complete a " Resident Abuse Report Form " and obtain a written, signed, dated statement from the person reporting the incident. " " Any staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall report, or cause a report to be made of, the mistreatment, or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information. " "All suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities of individuals as may be requried by law. The facility Administrator and DON were notified on 07/10/12 at 6:30 PM that an Immediate Jeopardy situation had been identified due to the above failures. The Administrator submitted the facility's Plan of Removal on 07/11/12 at 10:36 AM. The facility's Plan of Removal was accepted on 07/1112 at 11:42 AM. The facility presented a plan of removal which included the following: 1. All residents confused and oriented were interviewed regarding any complaints or concerns regarding abuse. Confused residents received a head to toe assessment looking for any signs of trauma or changes in behavior that may indicate abuse. No complaints were received and no assessment revealed any signs or symptoms of abuse. 2. All staff were called for an emergency inservice on abuse. The attached form was reviewed with staff. All but two staff members have been contacted. The remaining two can not work until they have been inserviced. Staff are to report all concerns of oriented as well as confused residents. 3. All staff but two have been interviewed regarding any knowledge they may have of abuse occurring at (the facility). They were instructed that failure to report abuse is grounds for termination. During interview, one other allegation of abuse regarding resident (#4) was mentioned. This allegation is currently under investigation. 4. (RN U) was terminated on 07/10/11 for failure to report comments of (Resident #2) to abuse coordinator. (CNA B) has been suspended (on 07/10/11) pending investigation. (CNA E) has been suspended (on 07/10/11) pending investigation of incident regarding (Resident #4). 5. (The DON)/Abuse Coordinator was retrained by the Administrator on 07/11/12 on the abuse neglect protocol. (The DON) was suspended (on 07/11/12) pending investigation for failure to report and investigate abuse. The Administrator is now the Abuse Coordinator. Systemic Changes to Prevent Future Problems 1. The Abuse Coordinator is (The Administrator) and (provided phone number) was posted in the employee lounge for easy access by staff at all times. All staff were in-serviced on name and contact information of the Abuse Coordinator. 2. In-service regarding abuse, how to contact abuse coordinator and failure to report abuse being grounds for termination will be included in new hire packet and reviewed with employees on hire. 3. Complaint/Concern form was created and placed in employee lounge to further encourage staff to report any concern they have. The new form states (the Administrator) is to be contacted if abuse or neglect is suspected and Administrator ' s cell phone number is posted on the form. The surveyor confirmed that the facility did the following: During an interview on 07/11/12 at 9:15 AM, the DON stated after interviewing all staff again regarding any unreported incidents of abuse or neglect only one new incident came to their attention. The DON stated that CNA B reported that an LVN student witnessed back in September of 2011 another CNA student (CNA E) slapped a Resident #4 ' s hands when changing his brief when he was trying to play with feces. The DON stated that the LVN student did not work here at the time and the LVN student reported this to her instructor. The DON stated that they had started an investigation as of the time of the report. The DON stated that they interviewed the resident and CNA E who was also suspended pending outcome of investigation, and she denied that she ever slapped the resident on the hand. The DON stated that they interviewed Resident #4 who denied ever been slapped. The DON stated they were not able to contact the LVN instructor who the incident was reported to. Observation on 07/11/12 at 9:45 AM revealed Resident #4 with no bruising or injuries. During an interview on 07/11/12 at 9:50 AM, Resident #4 stated that no one has ever hurt him at the facility. Resident #4 stated that all the staff members treat him well. Resident #4 stated that he had never been mistreated in any way at the facility. Resident #4 stated that he is happy. Interviews on 07/11/12 between 9:37 AM and 10:36 AM with CNA C, F, and G revealed that they had been in-serviced on reporting abuse and neglect and they had no unreported incidents to report. Interview on 07/11/12 at 11:16 AM the Administrator stated that he would suspend the DON until the conclusion of all investigations. On 07/11/12 at 2:15 PM, the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope of isolated. The facility was continuing to in-service staff. The facility Administrator reported on 07/11/2012 that from the current Residnet census of 69, there are 12 female residents with cognitive impairment.

Based on observation, interview and record review, the facility failed to ensure residents were free from sexual abuse for one 1 of 6 residents reviewed for abuse. Resident #2 had made two allegations of being raped by facility staff between November 2011 and May 2012. CNA B reported the first allegation to RN U who failed to document, report or investigate the allegation. CNA B failed to report the second allegation. On 06/25/12 Licensed Vocational Nurse (LVN) K witnessed Resident #2 being raped by Certified Nursing Assistant (CNA) A. This deficient practice resulted in an Immediate Jeopardy (IJ) on 07/10/12. While the IJ was removed on 07/11/12, the facility remained out of compliance at severity level of actual harm with a scope of isolated that is not IJ due to all staff had not been in-serviced on reporting abuse and neglect and the designation of the new Abuse Coordinator. As the result of this deficient practice Resident #2 was raped on 06/25/12 and had the potential to place the additional 11 female residnets identified with cognitive impairement at risk for Abuse and causing mental, physical and/or psychosocial harm and decreased quality of life. Findings include: Review of Resident #2 ' s Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE]. The resident ' s current [DIAGNOSES REDACTED]. Review of Resident #2 ' s most recent quarterly Minimum Data Set ((MDS) dated [DATE] reflected that Resident #2 has severely impaired cognitive status and that she has fluctuating (comes and goes) signs of disorganized thinking and periods of inattention. The MDS reflected that Resident #2 has Clear Speech (distinct intelligible words) and is rarely/never understood and rarely/never understands others. The MDS also reflected that Resident #2 has impaired vision but can see large print. The MDS also reflected that the resident had hallucinations, [MEDICAL CONDITION], and verbal behavior directed towards others. The MDS also reflected that Resident #2 is totally dependent on staff for all functional abilities including bed mobility, transfer, locomotion, dressing, toileting, personal hygiene, and bathing. The MDS reflected that Resident #2 requires limited assistance from staff for eating. The MDS reflected that Resident #2 had not received any antipsychotic, antidepressant, antianxiety, or hypnotic medications during the MDS look back period. Review of the most recent Care Plan last updated on 06/26/12 for Resident #2 reflected a " Problem/Need " onset 08/03/11 of " Activity Care Plan Potential for disrupted activities and/or untherapeutic activity environment related to: Verbally Abusive as evidenced by: Yelling at others. " Another " Problem/Need " onset 01/11/12 reflected " Due to Dementia resident is sometimes understood " with " Approaches " that included " Monitor resident frequently and anticipate needs; Approach resident calmly. Speak in a normal voice. Explain what you are about to do before touching resident; If resident appears agitated, leave alone if safe. Go back when calmer. If no improvement, notify charge nurse; Give resident adequate time to respond to question/conversation etc. " Another " Problem/Need " onset 06/26/12 reflected " Resident has been a victim of sexual assault " with " Approaches " that included " Give one time doses of [MEDICATION NAME] and [MEDICATION NAME] as ordered for possible sexually transmitted infections; Reevaluate for sexually transmitted infections in 3 months if physician orders; Notify Physician if resident has any vaginal bleeding or discharge. Lower abdominal pelvic pain, fever over 100 degrees without an obvious cause, pain or burning on urination. Redness, swelling or pain to injured area; Obtain any needed lab tests and notify physician of results; Keep resident comfortable with familiar staff, monitor resident for any increase in behaviors; No male CNA ' s to perform personal care on resident. " During an interview on 07/10/12 at 9:45 AM, the Director of Nursing (DON) stated that on 06/25/12 around 7:35 PM, LVN K heard a bed hitting the wall in hall 500 which is the locked unit. The DON stated that LVN K opened the door to Resident #2 ' s room and witnessed CNA A raping Resident #2. The DON stated that Resident #2 has advanced Alzheimer ' s, was not able to communicate to staff, recall events and does not show much emotion. The DON stated that Resident #2 is dependent on staff members for all activities of daily living. The DON stated that the curtain was pulled at the time and roommate (Resident #3) was in the room, but also has severe dementia and was not able to recall the events that took place. The DON stated that LVN K immediately told CNA A to leave and the police were called immediately. The DON stated that CNA A admitted to the police that he had raped Resident #2. The DON stated that according to the police, CNA A stated that this is the only resident he had sexually abused and that this was the first time it had happened. The DON stated that the resident was sent to a hospital to have a rape kit done and that the records are sealed and they were unable to get a copy of the results of the SAFE (Sexual Assault Forensic Evidence) kit. Observation on 07/10/12 at 10:00 AM revealed Resident #2 sitting in her wheelchair in the dining room of the secured unit. The resident was not in distress and did not have any signs of injury. The resident could not hold a conversation but would occasionally mumble phrases and sometimes say short clear phrases. Sometimes the resident ' s answers did not fit the question asked. During an interview on 07/10/12 at 10:05 AM, Resident #2 was asked if the surveyor could ask her some questions. The Resident stated " go ahead. " Resident #2 stated " no " when asked if anyone had ever hurt her and " yes " when asked if she felt safe at the facility. The resident also stated " yes " when asked if she likes the staff that worked at the facility. The resident did not show any emotion (negative or positive) during this interview. During an interview on 07/10/12 at 1:06 PM LVN K stated that on 06/25/12 sometime after 7:00 PM, she went to look for the other nurse on duty and was walking down the 500 hall when she heard what she thought sounded like a bed hitting the wall repeatedly. LVN K stated that she opened the door and she could see CNA A with his right arm holding Resident #2 ' s legs up in the air and the left hand trying to pull his pants up. LVN K stated that the resident was lying horizontal at the middle of the bed facing the middle of the room away from the wall. LVN K stated that Resident #2 had a sheet over her head but that the resident was not crying or making any noise. LVN K stated that Resident #2 is too confused and did not seem to know what was going on. LVN K stated that the curtains in room were pulled so that the roommate in the bed by the window could not see what was happening. LVN K stated that the curtain near the doorway was only pulled slightly and she could see straight to the bed when she opened the door. LVN K stated that she immediately asked CNA A what he was doing and he said " I don ' t know. " LVN K stated that she told CNA A to " get out " and " you are fired. " LVN K stated that CNA A was shocked and he was slow as he gathered his stuff before leaving the building. LVN K stated that CNA A left Resident #2 ' s room with bags of trash and placed them in the trash and linen bins as we walked out. LVN K stated that she immediately went to call the police when she exited the room and the police arrived shortly after CNA A had left. LVN K stated that the police took the trash and linen bins with them. LVN K stated that she would have never imagined that CNA A would do something like that. LVN K stated there is no one working at this facility that she would imagine would sexually abuse a resident. During an interview on 07/10/12 at 2:10 PM, the Detective stated that CNA A was in jail. The Detective stated that he is waiting the DNA results for CNA A. The Detective stated the case is still open and he is still working on it. The Detective stated that CNA A openly confessed to him that he raped Resident #2. During an interview on 07/10/12 at 2:35 PM the DON stated that CNA B reported to her on 07/05/12 that she (CNA B) had previously reported to Registered Nurse (RN) U sometime between November 2011 and January 2012 that Resident #2 had made an allegation that a CNA had raped her. The DON stated that CNA B told her that she witnessed Resident #2 make this allegation twice but she only reported it to RN U the first time and did not report the second allegation because nothing had ever come from the first allegation. The DON stated that RN U did not report it to administration. The DON stated that as of the State's entrance dated on 07/10/12, she had not investigated the two allegations of sexual abuse that CNA B reported to her (the DON) on 07/04/12 because she felt that CNA B was just feeling guilty about what had happened to Resident #2. During an interview on 07/10/12 at 3:15 PM, CNA B stated that the first allegation was about 6-7 months ago when CNA B was in the room with CNA C. CNA B stated that Resident #2 looked up at CNA C and said " he raped me " , but then Resident #2 looked up again and stated " no, not him. " CNA B stated that she reported this allegation to RN U and thought it was investigated. CNA B stated on 07/05/12 that, sometime around Mother ' s Day weekend in May 2012, she and CNA D were in the room with Resident #2 when CNA A came to the doorway. CNA B stated that Resident #2 looked up at CNA A and stated " he raped me. " CNA B stated that she did not report this allegation because she had reported the previous allegation to RN U and she thought it had already been investigated and didn ' t think anything of it. CNA B stated that now she wishes she had reported it. During an interview on 07/10/12 at 3:35 PM, RN U stated that CNA B did report to her about 6-7 months ago that Resident #2 had made an allegation that she had been raped. RN U stated that she assessed the resident, but that the resident says " off the wall things " and she didn ' t find " any injuries or unusual issues with the resident. " RN U stated that when she asked the resident about what happened the resident did not repeat the allegation and she was not able to get any information from the resident. RN U stated that CNA B had told her that Resident #2 had claimed a man had raped her and thought it was CNA C but then claimed it wasn ' t him. RN U stated that the resident wasn ' t making sense so she " put it on the backburner " and continued to " monitor " her. RN U stated that "If I reported every little thing, the DON would have a huge stack of complaints on her desk to investigate. " During an interview on 07/10/12 at 3:00 PM, CNA C stated that he did not recall this incident where Resident #2 claimed someone raped her. CNA C stated that Resident #2 can ' t really talk or make conversation. CNA C stated that he would have never thought that CNA A would sexually abuse anyone. During an interview on 07/10/12 at 4:00 PM, CNA D stated that she did not recall the incident when Resident #2 stated that CNA A raped her. CNA D stated that she had not witnessed any allegations reported by Resident #2 of rape. CNA D stated that Resident #2 cannot hold a complete conversation and that she will only say short phrases like " no " or " I want to go home. " CNA D also stated that she didn ' t think that CNA A would ever sexually abuse any residents and that she was surprised to hear he was caught sexually abusing Resident #2. During an interview on 07/10/12 at 4:20 PM the DON stated that RN U did not report the allegation of sexual abuse made by Resident #2 to the DON who was the Abuse Prevention Coordinator. The DON stated that RN U did not report the allegation because Resident #2 was not a reliable source of information due to her dementia. The DON stated that RN U should have mentioned the allegation to administration, but she did not. The DON stated that she interviewed RN U on 07/04/12, the same day that CNA B reported the allegations to the DON, RN U reported that she " did not think anything was unusual. " The DON stated that she told CNA B on 07/05/12 that she should have followed up with RN U and the DON on the first allegation. The DON stated that she did not document any of the information provided to her on 07/05/12 or any of the conversations held on the two allegations made by Resident #2. The DON stated that RN U should have reported the allegation that Resident #2 made that was reported to her by CNA B. The DON stated that she expects that the staff members " can ' t just assume (residents) are confused " when they make an allegation of abuse or neglect. The DON stated that the other CNA ' s did not recall the event when she asked them about it on the date of this interview (07/10/12). During an interview on 07/10/12 at 4:45 PM, the Administrator stated that he would start an investigation immediately regarding the two allegations that were brought to their attention by CNA B. The Administrator stated that he " can ' t see why anyone withholds information " and " it ' s the first (time). " During an interview on 07/10/12 at 5:30 PM, RN U stated that next time an allegation of abuse or neglect is reported to her she would report to the DON. RN U stated that she did not report the previous allegation because she did a full body assessment of Resident #2 and " she was fine, had no injuries, and the resident didn ' t directly report to her. " RN U stated that she did not document this assessment or that CNA B had reported anything to her. RN U stated that she had been trained on reported abuse and neglect prior to this incident. Review of the signed and dated statement provided to the surveyor by CNA B on 07/10/12 at 6:00 PM reflected " Statement for Dept of Aging and Disability Services: During the winter months perhaps Nov, Dec, Jan (I do not recall exact date) I was working in the (secured) unit at (the facility) serving as a CNA. I was putting (Resident #2) into bed one evening. I had asked for help from a co-worker male who also is a CNA and works in the building. I believe it was CNA C but I might be wrong. (Resident #2) made a comment while the male employee was standing at the foot of her bed. She said ' He raped me. ' I didn ' t hear her say it but CNA C stopped me mid-sentence and said what (Resident #2) had said. He stated that (Resident #2) accused him of raping her. (Resident #2) then lifted her head off of the pillow, took a closer look at CNA C and said ' no, no it wasn ' t him. ' I was relieved and told CNA C ' I didn ' t think he was capable of such a thing. ' The charge nurse on duty was RN U. RN U approached the room and CNA C explained what had just happened. RN U immediately turned around and said she was going to report that. I stuck my head out the door and RN U repeated that she was going to report that incident. CNA C left the room upset. I finished caring for (Resident #2) with peri-care, but nothing else was said by Resident #2. Fast forward to just before Mother ' s day weekend. I was in the room of (Resident #2) again. CNA D was present caring for Resident #2 and CNA A was standing in the doorway to (Resident #2) ' s room. Resident #2 said aloud ' he raped me. ' CNA D told Resident #2 ' no one is raping you now. ' I do not remember if CNA D ordered CNA A to leave the unit first, or if I told CNA D I had heard Resident #2 make a comment like that before only there was a different man in the room when it happened. CNA A was told to leave the unit. CNA D and I talked for a few minutes about what had just happened. I told her about the incident that occurred before. CNA D asked me if I was sure it was reported and I said yes. I didn ' t say aloud who the charge nurse was that I reported it to, but I had faith it had been reported and investigated. We discussed what to do and we both were concerned for (Resident #2). CNA D asked me again if I was sure it had been reported and I said yes. I asked her, or she asked me what we should do now and we both said I don ' t know. Fast forward to July 2nd (2012) I was confiding in a different charge nurse (LVN L) about all my experiences with Resident #2 prior to the incident that happened on June 25th (2012). LVN L said that (the DON) had been asking the employees to tell her of any instance of abuse, regarding (CNA A) too, or if we noticed anything unusual. I wasn ' t aware (the DON) had asked that of the employees until (LVN L) mentioned it. (LVN L) urged me to talk to (the DON) about this. Fast forward to July 4th (2012) I came in to have a talk with (the DON). It came to my attention that the first incident had not been reported and neither had the second. " Signed (CNA B). Review of a signed and dated statement provided by RN U dated 07/10/12 reflected " My name is (RN U). I am the weekend RN at (the facility) and have been employed here for eight years. I would like to relate about an incident reported to me by (CNA B) sometime in the past- date unknown. CNA B told me that (Resident #2) said she was raped by someone- the name (CNA C) was mentioned-. I told her I would look into it. I checked (Resident #2) over, could see no bruises, no bleeding, no discharges from vaginal/anus- no bruises, no fearful behavior, no signs or symptoms that would lead me to believe (Resident #2) was truly raped. I ' filed it in my memory ' watched for any other persons to come forward with a complaint- there were none. (Resident #2) says all kinds of off the wall things due to dementia, as do numerous other residents here. Residents confused or with dementia can say things that seem bizarre. I watched (Resident #2) -indeed- ALL residents- it ' s my job. I never saw any behavior that could be construed as coming from a sexually abused resident. I was waiting to see if anything would corroborate the statement but I found none. The resident did not tell me directly. She allegedly told (CNA B) about this event which may or may not have happened. (Another resident) is always ' having babies ' yes we do know it can ' t be possible. I do take any allegation seriously but (Resident #2) told (CNA B) I received the info second hand so to speak and on assessment of the resident found no (signs/symptoms) of abuse. If I would have believe (SIC) for one minute that (Resident #2) were raped, I would have said something- there was no evidence at the time. I can ' t emphasize that enough. I saw nothing during my assessment of (Resident #2) at the time that would indicate abuse. There was nothing out of the ordinary about her (Resident #2)- baseline- physically or emotionally/ mentally. I would never cover up abuse and know to report to my DON. " Signed (RN U). Review of a signed and dated statement provided by LVN L dated 07/10/12 reflected " On July 2, 2012 (CNA B) told me that a while back not sure when that ' her and (CNA C) was changing (Resident #2) and (Resident #2) said ' he ' s raping me ' and (CNA B) reported it to RN U. ' She (CNA B) also said that sometime after that " her, CNA D, and CNA A were in (Resident #2) ' s room and (CNA A) was standing in the doorway and (Resident #2) turned and looked at (CNA A) and started saying ' he ' s raping me. ' (CNA B) said she then told (Resident #2) that ' he ' s not raping you (Resident #2). ' -Didn ' t report it. (CNA B) also told me that one time (CNA A) was working 100 hall and she went to help him and he was in (another resident) ' s room and had his bag with him and showed her (CNA B) that he had his dad ' s Playboy books in his bag and (CNA B) said she told him ' I guess that ' s ok as long as you don ' t take them out at work. ' (CNA B) said she felt bad now because she never reported that and she feels like maybe it would have prevented the incident with (Resident #2 and CNA A) somehow. I told (CNA B) that she needed to report all of it to (the DON) and that anytime anything like that happens to report it immediately. I then asked (the DON) if (CNA B) had talked to her about it and she said yes. " Signed (LVN L). Review of the incident report dated 06/25/12 at 7:40 PM reflected " Witness: LVN K, Narrative: Per (LVN K) report, she went into secure unit looking for the other nurse(LVN M), when she go to room [ROOM NUMBER] she heard a loud sounding noise on the wall that sounded like the bed hitting the wall. When she opened the door she saw (CNA A) with his pants down and he had his right arm and hand holding the residents legs in the air. She reports that (Resident #2) was on her back cross ways on the bed. With his left hand he was pulling on his own pants, pulling them up. Resident was without clothes. " " Immediate Actions Take: (CNA A) was told by (LVN K), Charge Nurse, that he was fired and to leave the (facility). The police and DON were called. Police came to investigate and retrieve evidence from the room ...brief was left intact per request of the investigating officer for transfer to (a local hospital). Review of Nurse ' s Notes dated 06/25/12 reflected " 9:15 PM (late entry) for 7:40 PM. I went from hall 1 to hall 5 (the unit) looking for the other nurse when I got to room [ROOM NUMBER] I heard a loud sounding noise on the wall that sounded like the bed hitting the wall. Coming from 504A. When I opened the door of that room I saw (CNA A) with his pants down. He had his right arm and hand holding her legs in the air (Resident #2). (Resident #2) was on her back crossways on the bed. He had one hand (left) pulling on his own pants, pulling them up. (Resident #2) was without clothes. I yelled at him ' What are you doing? ' He said ' I don ' t know. ' I yelled ' Get out ' at him. After that I called (the DON) and dialed 911. (7:52 PM) the police arrived at facility. " Signed by LVN K. " 8:00 PM Medical Director called re: incident. Resident to be transported to (a local hospital) for exam. Daughter called and notified of incident. Police here to investigate. In room with resident collecting evidence. Resident asleep at moment. " " 9:20 PM Ok ' ed by police to move resident. Resident in geri chair transported by van to (hospital in Austin). " Signed by DON. Review of in-services for the last 12 months reflected that RN U had received her last Abuse and Neglect training on 07/11/11 and 08/10/11 and CNA B, C and D had all received training on Abuse and Neglect preventing and reporting on 07/11/11, 08/10/11, 04/10/12, 05/10/12, 06/11/12 and 06/26/12. CNA A had received training on Abuse and Neglect prevention and reporting on 07/11/11, 08/10/11, 04/10/12, 05/10/12, and 06/11/12. These in-services included training on the facility's abuse and neglect policy and until the 06/26/12 in-service on abuse and neglect, the training lacked an emphasis on identifying abuse in individuals with cognitive impairment. Review of CNA A ' s employee file on 07/10/12 at 10:45 AM on reflected a hire date of 01/22/08 and that all appropriate background checks had been completed prior to date of hire. Two reference checks were done and both previous employers indicated that CNA A was ' not eligible for rehire. ' The first employer indicated CNA A was terminated on 09/01/05 and the second indicated that CNA A was terminated on 01/18/08. During an interview on 07/10/12 at 12:30 PM the Assistant DON (ADON) stated that the reason CNA A was not eligible for rehire at the other facilities was not due to abuse or neglect so the reference did not prevent him from being eligible for hire at this facility. The ADON stated that the previous Administrator hired CNA A and had been the Administrator at the other facility when CNA A was terminated. The ADON stated that the Administrator at the time had indicated that CNA A was terminated at the other facility in 2008 due to not following the facility's policy on tranfers. Review of the facility ' s policy on " Reporting Abuse to Facility Management " dated 06/2004 reflected " It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors etc., to promptly report any incident or suspected incident of neglect or resident abuse, including of an unknown source, and theft or misappropriation of resident property to facility management. " " Employees, facility consultants and/or attending physicians must report any suspected abuse or incidents of abuse to the director of nursing services promptly. In the absence of the director of nursing service such reports may be made to the nurse supervisor on duty. " " The administrator and director of nursing services must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the administrator and director of nursing services must be called at home or must be paged and informed of such incident. " " Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident ' s medical record. (Note: If sexual abuse is suspected, DO NOT bathe the resident or wash the resident ' s clothing or linen. Do not take items from the area in which the incident occurred. Call the police immediately.) " The person performing the examination must complete a " Resident Abuse Report Form " and obtain a written, signed, dated statement from the person reporting the incident. " " Any staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall report, or cause a report to be made of, the mistreatment, or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information. " "All suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities of individuals as may be requried by law. The facility Administrator and DON were notified on 07/10/12 at 6:30 PM that an Immediate Jeopardy situation had been identified due to the above failures. The Administrator submitted the facility's Plan of Removal on 07/11/12 at 10:36 AM. The facility's Plan of Removal was accepted on 07/1112 at 11:42 AM. The facility presented a plan of removal which included the following: 1. All residents confused and oriented were interviewed regarding any complaints or concerns regarding abuse. Confused residents received a head to toe assessment looking for any signs of trauma or changes in behavior that may indicate abuse. No complaints were received and no assessment revealed any signs or symptoms of abuse. 2. All staff were called for an emergency inservice on abuse. The attached form was reviewed with staff. All but two staff members have been contacted. The remaining two can not work until they have been inserviced. Staff are to report all concerns of oriented as well as confused residents. 3. All staff but two have been interviewed regarding any knowledge they may have of abuse occurring at (the facility). They were instructed that failure to report abuse is grounds for termination. During interview, one other allegation of abuse regarding resident (#4) was mentioned. This allegation is currently under investigation. 4. (RN U) was terminated on 07/10/11 for failure to report comments of (Resident #2) to abuse coordinator. (CNA B) has been suspended (on 07/10/11) pending investigation. (CNA E) has been suspended (on 07/10/11) pending investigation of incident regarding (Resident #4). 5. (The DON)/Abuse Coordinator was retrained by the Administrator on 07/11/12 on the abuse neglect protocol. (The DON) was suspended (on 07/11/12) pending investigation for failure to report and investigate abuse. The Administrator is now the Abuse Coordinator. Systemic Changes to Prevent Future Problems 1. The Abuse Coordinator is (The Administrator) and (provided phone number) was posted in the employee lounge for easy access by staff at all times. All staff were in-serviced on name and contact information of the Abuse Coordinator. 2. In-service regarding abuse, how to contact abuse coordinator and failure to report abuse being grounds for termination will be included in new hire packet and reviewed with employees on hire. 3. Complaint/Concern form was created and placed in employee lounge to further encourage staff to report any concern they have. The new form states (the Administrator) is to be contacted if abuse or neglect is suspected and Administrator ' s cell phone number is posted on the form. The surveyor confirmed that the facility did the following: During an interview on 07/11/12 at 9:15 AM, the DON stated after interviewing all staff again regarding any unreported incidents of abuse or neglect only one new incident came to their attention. The DON stated that CNA B reported that an LVN student witnessed back in September of 2011 another CNA student (CNA E) slapped a Resident #4 ' s hands when changing his brief when he was trying to play with feces. The DON stated that the LVN student did not work here at the time and the LVN student reported this to her instructor. The DON stated that they had started an investigation as of the time of the report. The DON stated that they interviewed the resident and CNA E who was also suspended pending outcome of investigation, and she denied that she ever slapped the resident on the hand. The DON stated that they interviewed Resident #4 who denied ever been slapped. The DON stated they were not able to contact the LVN instructor who the incident was reported to. Observation on 07/11/12 at 9:45 AM revealed Resident #4 with no bruising or injuries. During an interview on 07/11/12 at 9:50 AM, Resident #4 stated that no one has ever hurt him at the facility. Resident #4 stated that all the staff members treat him well. Resident #4 stated that he had never been mistreated in any way at the facility. Resident #4 stated that he is happy. Interviews on 07/11/12 between 9:37 AM and 10:36 AM with CNA C, F, and G revealed that they had been in-serviced on reporting abuse and neglect and they had no unreported incidents to report. Interview on 07/11/12 at 11:16 AM the Administrator stated that he would suspend the DON until the conclusion of all investigations. On 07/11/12 at 2:15 PM, the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope identified as isolated. The facility was continuing to in-service staff. The facility Administrator reported on 07/11/2012 that from the current Residnet census of 69, there are 12 female residents with cognitive impairment.

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit abuse of residents for 1 of 6 residents reviewed for sexual abuse. Resident #2 had made two allegations of being raped by facility staff between November 2011 and May 2012. CNA B reported the first allegation to RN U who failed to document, report or investigate the allegation. CNA B failed to report the second allegation.On 06/25/12 Licensed Vocational Nurse (LVN) K witnessed Resident #2 being raped by Certified Nursing Assistant (CNA) A. This deficient practice resulted in an Immediate Jeopardy (IJ) on 07/10/12. While the IJ was removed on 07/11/12, the facility remained out of compliance at severity level of actual harm with a scope of isolated that is not IJ due to all staff had not been in-serviced on reporting abuse and neglect and the designation of the new Abuse Coordinator. As the result of this deficient practice Resident #2 was raped on 06/25/12 and had the potential to place the additional 11 female residnets identified with cognitive impairement at risk for Abuse and causing mental, physical and/or psychosocial harm and decreased quality of life. Findings include: Review of the facility ' s policy on " Reporting Abuse to Facility Management " dated 06/2004 reflected " It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors etc., to promptly report any incident or suspected incident of neglect or resident abuse, including of an unknown source, and theft or misappropriation of resident property to facility management. " " Employees, facility consultants and/or attending physicians must report any suspected abuse or incidents of abuse to the director of nursing services promptly. In the absence of the director of nursing service such reports may be made to the nurse supervisor on duty. " " The administrator and director of nursing services must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the administrator and director of nursing services must be called at home or must be paged and informed of such incident. " " Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident ' s medical record. (Note: If sexual abuse is suspected, DO NOT bathe the resident or wash the resident ' s clothing or linen. Do not take items from the area in which the incident occurred. Call the police immediately.) " The person performing the examination must complete a " Resident Abuse Report Form " and obtain a written, signed, dated statement from the person reporting the incident. " " Any staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall report, or cause a report to be made of, the mistreatment, or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information. " "All suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities of individuals as may be requried by law. Review of Resident #2 ' s Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE]. The resident ' s current [DIAGNOSES REDACTED]. Review of Resident #2 ' s most recent quarterly Minimum Data Set ((MDS) dated [DATE] reflected that Resident #2 has severely impaired cognitive status and that she has fluctuating (comes and goes) signs of disorganized thinking and periods of inattention. The MDS reflected that Resident #2 has Clear Speech (distinct intelligible words) and is rarely/never understood and rarely/never understands others. The MDS also reflected that Resident #2 has impaired vision but can see large print. The MDS also reflected that the resident had hallucinations, [MEDICAL CONDITION], and verbal behavior directed towards others. The MDS also reflected that Resident #2 is totally dependent on staff for all functional abilities including bed mobility, transfer, locomotion, dressing, toileting, personal hygiene, and bathing. The MDS reflected that Resident #2 requires limited assistance from staff for eating. The MDS reflected that Resident #2 had not received any antipsychotic, antidepressant, antianxiety, or hypnotic medications during the MDS look back period. Review of the most recent Care Plan last updated on 06/26/12 for Resident #2 reflected a " Problem/Need " onset 08/03/11 of " Activity Care Plan Potential for disrupted activities and/or untherapeutic activity environment related to: Verbally Abusive as evidenced by: Yelling at others. " Another " Problem/Need " onset 01/11/12 reflected " Due to Dementia resident is sometimes understood " with " Approaches " that included " Monitor resident frequently and anticipate needs; Approach resident calmly. Speak in a normal voice. Explain what you are about to do before touching resident; If resident appears agitated, leave alone if safe. Go back when calmer. If no improvement, notify charge nurse; Give resident adequate time to respond to question/conversation etc. " Another " Problem/Need " onset 06/26/12 reflected " Resident has been a victim of sexual assault " with " Approaches " that included " Give one time doses of [MEDICATION NAME] and [MEDICATION NAME] as ordered for possible sexually transmitted infections; Reevaluate for sexually transmitted infections in 3 months if physician orders; Notify Physician if resident has any vaginal bleeding or discharge. Lower abdominal pelvic pain, fever over 100 degrees without an obvious cause, pain or burning on urination. Redness, swelling or pain to injured area; Obtain any needed lab tests and notify physician of results; Keep resident comfortable with familiar staff, monitor resident for any increase in behaviors; No male CNA ' s to perform personal care on resident. " During an interview on 07/10/12 at 9:45 AM, the Director of Nursing (DON) stated that on 06/25/12 around 7:35 PM, LVN K heard a bed hitting the wall in hall 500 which is the locked unit. The DON stated that LVN K opened the door to Resident #2 ' s room and witnessed CNA A raping Resident #2. The DON stated that Resident #2 has advanced Alzheimer ' s, was not able to communicate to staff, recall events and does not show much emotion. The DON stated that Resident #2 is dependent on staff members for all activities of daily living. The DON stated that the curtain was pulled at the time and roommate (Resident #3) was in the room, but also has severe dementia and was not able to recall the events that took place. The DON stated that LVN K immediately told CNA A to leave and the police were called immediately. The DON stated that CNA A admitted to the police that he had raped Resident #2. The DON stated that according to the police, CNA A stated that this is the only resident he had sexually abused and that this was the first time it had happened. The DON stated that the resident was sent to a hospital to have a rape kit done and that the records are sealed and they were unable to get a copy of the results of the SAFE (Sexual Assault Forensic Evidence) kit. Observation on 07/10/12 at 10:00 AM revealed Resident #2 sitting in her wheelchair in the dining room of the secured unit. The resident was not in distress and did not have any signs of injury. The resident could not hold a conversation but would occasionally mumble phrases and sometimes say short clear phrases. Sometimes the resident ' s answers did not fit the question asked. During an interview on 07/10/12 at 10:05 AM, Resident #2 was asked if the surveyor could ask her some questions. The Resident stated " go ahead. " Resident #2 stated " no " when asked if anyone had ever hurt her and " yes " when asked if she felt safe at the facility. The resident also stated " yes " when asked if she likes the staff that worked at the facility. The resident did not show any emotion (negative or positive) during this interview. During an interview on 07/10/12 at 1:06 PM LVN K stated that on 06/25/12 sometime after 7:00 PM, she went to look for the other nurse on duty and was walking down the 500 hall when she heard what she thought sounded like a bed hitting the wall repeatedly. LVN K stated that she opened the door and she could see CNA A with his right arm holding Resident #2 ' s legs up in the air and the left hand trying to pull his pants up. LVN K stated that the resident was lying horizontal at the middle of the bed facing the middle of the room away from the wall. LVN K stated that Resident #2 had a sheet over her head but that the resident was not crying or making any noise. LVN K stated that Resident #2 is too confused and did not seem to know what was going on. LVN K stated that the curtains in room were pulled so that the roommate in the bed by the window could not see what was happening. LVN K stated that the curtain near the doorway was only pulled slightly and she could see straight to the bed when she opened the door. LVN K stated that she immediately asked CNA A what he was doing and he said " I don ' t know. " LVN K stated that she told CNA A to " get out " and " you are fired. " LVN K stated that CNA A was shocked and he was slow as he gathered his stuff before leaving the building. LVN K stated that CNA A left Resident #2 ' s room with bags of trash and placed them in the trash and linen bins as we walked out. LVN K stated that she immediately went to call the police when she exited the room and the police arrived shortly after CNA A had left. LVN K stated that the police took the trash and linen bins with them. LVN K stated that she would have never imagined that CNA A would do something like that. LVN K stated there is no one working at this facility that she would imagine would sexually abuse a resident. During an interview on 07/10/12 at 2:10 PM, the Detective stated that CNA A was in jail. The Detective stated that he is waiting the DNA results for CNA A. The Detective stated the case is still open and he is still working on it. The Detective stated that CNA A openly confessed to him that he raped Resident #2. During an interview on 07/10/12 at 2:35 PM the DON stated that CNA B reported to her on 07/05/12 that she (CNA B) had previously reported to Registered Nurse (RN) U sometime between November 2011 and January 2012 that Resident #2 had made an allegation that a CNA had raped her. The DON stated that CNA B told her that she witnessed Resident #2 make this allegation twice but she only reported it to RN U the first time and did not report the second allegation because nothing had ever come from the first allegation. The DON stated that RN U did not report it to administration. The DON stated that as of the State's entrance dated on 07/10/12, she had not investigated the two allegations of sexual abuse that CNA B reported to her (the DON) on 07/04/12 because she felt that CNA B was just feeling guilty about what had happened to Resident #2. During an interview on 07/10/12 at 3:15 PM, CNA B stated that the first allegation was about 6-7 months ago when CNA B was in the room with CNA C. CNA B stated that Resident #2 looked up at CNA C and said " he raped me " , but then Resident #2 looked up again and stated " no, not him. " CNA B stated that she reported this allegation to RN U and thought it was investigated. CNA B stated on 07/05/12 that, sometime around Mother ' s Day weekend in May 2012, she and CNA D were in the room with Resident #2 when CNA A came to the doorway. CNA B stated that Resident #2 looked up at CNA A and stated " he raped me. " CNA B stated that she did not report this allegation because she had reported the previous allegation to RN U and she thought it had already been investigated and didn ' t think anything of it. CNA B stated that now she wishes she had reported it. During an interview on 07/10/12 at 3:35 PM, RN U stated that CNA B did report to her about 6-7 months ago that Resident #2 had made an allegation that she had been raped. RN U stated that she assessed the resident, but that the resident says " off the wall things " and she didn ' t find " any injuries or unusual issues with the resident. " RN U stated that when she asked the resident about what happened the resident did not repeat the allegation and she was not able to get any information from the resident. RN U stated that CNA B had told her that Resident #2 had claimed a man had raped her and thought it was CNA C but then claimed it wasn ' t him. RN U stated that the resident wasn ' t making sense so she " put it on the backburner " and continued to " monitor " her. RN U stated that "If I reported every little thing, the DON would have a huge stack of complaints on her desk to investigate. " During an interview on 07/10/12 at 3:00 PM, CNA C stated that he did not recall this incident where Resident #2 claimed someone raped her. CNA C stated that Resident #2 can ' t really talk or make conversation. CNA C stated that he would have never thought that CNA A would sexually abuse anyone. During an interview on 07/10/12 at 4:00 PM, CNA D stated that she did not recall the incident when Resident #2 stated that CNA A raped her. CNA D stated that she had not witnessed any allegations reported by Resident #2 of rape. CNA D stated that Resident #2 cannot hold a complete conversation and that she will only say short phrases like " no " or " I want to go home. " CNA D also stated that she didn ' t think that CNA A would ever sexually abuse any residents and that she was surprised to hear he was caught sexually abusing Resident #2. During an interview on 07/10/12 at 4:20 PM the DON stated that RN U did not report the allegation of sexual abuse made by Resident #2 to the DON who was the Abuse Prevention Coordinator. The DON stated that RN U did not report the allegation because Resident #2 was not a reliable source of information due to her dementia. The DON stated that RN U should have mentioned the allegation to administration, but she did not. The DON stated that she interviewed RN U on 07/04/12, the same day that CNA B reported the allegations to the DON, RN U reported that she " did not think anything was unusual. " The DON stated that she told CNA B on 07/05/12 that she should have followed up with RN U and the DON on the first allegation. The DON stated that she did not document any of the information provided to her on 07/05/12 or any of the conversations held on the two allegations made by Resident #2. The DON stated that RN U should have reported the allegation that Resident #2 made that was reported to her by CNA B. The DON stated that she expects that the staff members " can ' t just assume (residents) are confused " when they make an allegation of abuse or neglect. The DON stated that the other CNA ' s did not recall the event when she asked them about it on the date of this interview (07/10/12). During an interview on 07/10/12 at 4:45 PM, the Administrator stated that he would start an investigation immediately regarding the two allegations that were brought to their attention by CNA B. The Administrator stated that he " can ' t see why anyone withholds information " and " it ' s the first (time). " During an interview on 07/10/12 at 5:30 PM, RN U stated that next time an allegation of abuse or neglect is reported to her she would report to the DON. RN U stated that she did not report the previous allegation because she did a full body assessment of Resident #2 and " she was fine, had no injuries, and the resident didn ' t directly report to her. " RN U stated that she did not document this assessment or that CNA B had reported anything to her. RN U stated that she had been trained on reported abuse and neglect prior to this incident. Review of the signed and dated statement provided to the surveyor by CNA B on 07/10/12 at 6:00 PM reflected " Statement for Dept of Aging and Disability Services: During the winter months perhaps Nov, Dec, Jan (I do not recall exact date) I was working in the (secured) unit at (the facility) serving as a CNA. I was putting (Resident #2) into bed one evening. I had asked for help from a co-worker male who also is a CNA and works in the building. I believe it was CNA C but I might be wrong. (Resident #2) made a comment while the male employee was standing at the foot of her bed. She said ' He raped me. ' I didn ' t hear her say it but CNA C stopped me mid-sentence and said what (Resident #2) had said. He stated that (Resident #2) accused him of raping her. (Resident #2) then lifted her head off of the pillow, took a closer look at CNA C and said ' no, no it wasn ' t him. ' I was relieved and told CNA C ' I didn ' t think he was capable of such a thing. ' The charge nurse on duty was RN U. RN U approached the room and CNA C explained what had just happened. RN U immediately turned around and said she was going to report that. I stuck my head out the door and RN U repeated that she was going to report that incident. CNA C left the room upset. I finished caring for (Resident #2) with peri-care, but nothing else was said by Resident #2. Fast forward to just before Mother ' s day weekend. I was in the room of (Resident #2) again. CNA D was present caring for Resident #2 and CNA A was standing in the doorway to (Resident #2) ' s room. Resident #2 said aloud ' he raped me. ' CNA D told Resident #2 ' no one is raping you now. ' I do not remember if CNA D ordered CNA A to leave the unit first, or if I told CNA D I had heard Resident #2 make a comment like that before only there was a different man in the room when it happened. CNA A was told to leave the unit. CNA D and I talked for a few minutes about what had just happened. I told her about the incident that occurred before. CNA D asked me if I was sure it was reported and I said yes. I didn ' t say aloud who the charge nurse was that I reported it to, but I had faith it had been reported and investigated. We discussed what to do and we both were concerned for (Resident #2). CNA D asked me again if I was sure it had been reported and I said yes. I asked her, or she asked me what we should do now and we both said I don ' t know. Fast forward to July 2nd (2012) I was confiding in a different charge nurse (LVN L) about all my experiences with Resident #2 prior to the incident that happened on June 25th (2012). LVN L said that (the DON) had been asking the employees to tell her of any instance of abuse, regarding (CNA A) too, or if we noticed anything unusual. I wasn ' t aware (the DON) had asked that of the employees until (LVN L) mentioned it. (LVN L) urged me to talk to (the DON) about this. Fast forward to July 4th (2012) I came in to have a talk with (the DON). It came to my attention that the first incident had not been reported and neither had the second. " Signed (CNA B). Review of a signed and dated statement provided by RN U dated 07/10/12 reflected " My name is (RN U). I am the weekend RN at (the facility) and have been employed here for eight years. I would like to relate about an incident reported to me by (CNA B) sometime in the past- date unknown. CNA B told me that (Resident #2) said she was raped by someone- the name (CNA C) was mentioned-. I told her I would look into it. I checked (Resident #2) over, could see no bruises, no bleeding, no discharges from vaginal/anus- no bruises, no fearful behavior, no signs or symptoms that would lead me to believe (Resident #2) was truly raped. I ' filed it in my memory ' watched for any other persons to come forward with a complaint- there were none. (Resident #2) says all kinds of off the wall things due to dementia, as do numerous other residents here. Residents confused or with dementia can say things that seem bizarre. I watched (Resident #2) -indeed- ALL residents- it ' s my job. I never saw any behavior that could be construed as coming from a sexually abused resident. I was waiting to see if anything would corroborate the statement but I found none. The resident did not tell me directly. She allegedly told (CNA B) about this event which may or may not have happened. (Another resident) is always ' having babies ' yes we do know it can ' t be possible. I do take any allegation seriously but (Resident #2) told (CNA B) I received the info second hand so to speak and on assessment of the resident found no (signs/symptoms) of abuse. If I would have believe (SIC) for one minute that (Resident #2) were raped, I would have said something- there was no evidence at the time. I can ' t emphasize that enough. I saw nothing during my assessment of (Resident #2) at the time that would indicate abuse. There was nothing out of the ordinary about her (Resident #2)- baseline- physically or emotionally/ mentally. I would never cover up abuse and know to report to my DON. " Signed (RN U). Review of a signed and dated statement provided by LVN L dated 07/10/12 reflected " On July 2, 2012 (CNA B) told me that a while back not sure when that ' her and (CNA C) was changing (Resident #2) and (Resident #2) said ' he ' s raping me ' and (CNA B) reported it to RN U. ' She (CNA B) also said that sometime after that " her, CNA D, and CNA A were in (Resident #2) ' s room and (CNA A) was standing in the doorway and (Resident #2) turned and looked at (CNA A) and started saying ' he ' s raping me. ' (CNA B) said she then told (Resident #2) that ' he ' s not raping you (Resident #2). ' -Didn ' t report it. (CNA B) also told me that one time (CNA A) was working 100 hall and she went to help him and he was in (another resident) ' s room and had his bag with him and showed her (CNA B) that he had his dad ' s Playboy books in his bag and (CNA B) said she told him ' I guess that ' s ok as long as you don ' t take them out at work. ' (CNA B) said she felt bad now because she never reported that and she feels like maybe it would have prevented the incident with (Resident #2 and CNA A) somehow. I told (CNA B) that she needed to report all of it to (the DON) and that anytime anything like that happens to report it immediately. I then asked (the DON) if (CNA B) had talked to her about it and she said yes. " Signed (LVN L). Review of the incident report dated 06/25/12 at 7:40 PM reflected " Witness: LVN K, Narrative: Per (LVN K) report, she went into secure unit looking for the other nurse(LVN M), when she go to room [ROOM NUMBER] she heard a loud sounding noise on the wall that sounded like the bed hitting the wall. When she opened the door she saw (CNA A) with his pants down and he had his right arm and hand holding the residents legs in the air. She reports that (Resident #2) was on her back cross ways on the bed. With his left hand he was pulling on his own pants, pulling them up. Resident was without clothes. " " Immediate Actions Take: (CNA A) was told by (LVN K), Charge Nurse, that he was fired and to leave the (facility). The police and DON were called. Police came to investigate and retrieve evidence from the room ...brief was left intact per request of the investigating officer for transfer to (a local hospital). Review of Nurse ' s Notes dated 06/25/12 reflected " 9:15 PM (late entry) for 7:40 PM. I went from hall 1 to hall 5 (the unit) looking for the other nurse when I got to room [ROOM NUMBER] I heard a loud sounding noise on the wall that sounded like the bed hitting the wall. Coming from 504A. When I opened the door of that room I saw (CNA A) with his pants down. He had his right arm and hand holding her legs in the air (Resident #2). (Resident #2) was on her back crossways on the bed. He had one hand (left) pulling on his own pants, pulling them up. (Resident #2) was without clothes. I yelled at him ' What are you doing? ' He said ' I don ' t know. ' I yelled ' Get out ' at him. After that I called (the DON) and dialed 911. (7:52 PM) the police arrived at facility. " Signed by LVN K. " 8:00 PM Medical Director called re: incident. Resident to be transported to (a local hospital) for exam. Daughter called and notified of incident. Police here to investigate. In room with resident collecting evidence. Resident asleep at moment. " " 9:20 PM Ok ' ed by police to move resident. Resident in geri chair transported by van to (hospital in Austin). " Signed by DON. Review of in-services for the last 12 months reflected that RN U had received her last Abuse and Neglect training on 07/11/11 and 08/10/11 and CNA B, C and D had all received training on Abuse and Neglect preventing and reporting on 07/11/11, 08/10/11, 04/10/12, 05/10/12, 06/11/12 and 06/26/12. CNA A had received training on Abuse and Neglect prevention and reporting on 07/11/11, 08/10/11, 04/10/12, 05/10/12, and 06/11/12. These in-services included training on the facility's abuse and neglect policy and until the 06/26/12 in-service on abuse and neglect, the training lacked an emphasis on identifying abuse in individuals with cognitive impairment. Review of CNA A ' s employee file on 07/10/12 at 10:45 AM on reflected a hire date of 01/22/08 and that all appropriate background checks had been completed prior to date of hire. Two reference checks were done and both previous employers indicated that CNA A was ' not eligible for rehire. ' The first employer indicated CNA A was terminated on 09/01/05 and the second indicated that CNA A was terminated on 01/18/08. During an interview on 07/10/12 at 12:30 PM the Assistant DON (ADON) stated that the reason CNA A was not eligible for rehire at the other facilities was not due to abuse or neglect so the reference did not prevent him from being eligible for hire at this facility. The ADON stated that the previous Administrator hired CNA A and had been the Administrator at the other facility when CNA A was terminated. The ADON stated that the Administrator at the time had indicated that CNA A was terminated at the other facility in 2008 due to not following the facility's policy on tranfers. The facility Administrator and DON were notified on 07/10/12 at 6:30 PM that an Immediate Jeopardy had been identified due to the above failures. The Administrator submitted the facility's Plan of Removal on 07/11/12 at 10:36 AM. The facility's Plan of Removal was accepted on 07/1112 at 11:42 AM. The facility presented a plan of removal which included the following: 1. All residents confused and oriented were interviewed regarding any complaints or concerns regarding abuse. Confused residents received a head to toe assessment looking for any signs of trauma or changes in behavior that may indicate abuse. No complaints were received and no assessment revealed any signs or symptoms of abuse. 2. All staff were called for an emergency inservice on abuse. The attached form was reviewed with staff. All but two staff members have been contacted. The remaining two can not work until they have been inserviced. Staff are to report all concerns of oriented as well as confused residents. 3. All staff but two have been interviewed regarding any knowledge they may have of abuse occurring at (the facility). They were instructed that failure to report abuse is grounds for termination. During interview, one other allegation of abuse regarding resident (#4) was mentioned. This allegation is currently under investigation. 4. (RN U) was terminated on 07/10/11 for failure to report comments of (Resident #2) to abuse coordinator. (CNA B) has been suspended (on 07/10/11) pending investigation. (CNA E) has been suspended (on 07/10/11) pending investigation of incident regarding (Resident #4). 5. (The DON)/Abuse Coordinator was retrained by the Administrator on 07/11/12 on the abuse neglect protocol. (The DON) was suspended (on 07/11/12) pending investigation for failure to report and investigate abuse. The Administrator is now the Abuse Coordinator. Systemic Changes to Prevent Future Problems 1. The Abuse Coordinator is (The Administrator) and (provided phone number) was posted in the employee lounge for easy access by staff at all times. All staff were in-serviced on name and contact information of the Abuse Coordinator. 2. In-service regarding abuse, how to contact abuse coordinator and failure to report abuse being grounds for termination will be included in new hire packet and reviewed with employees on hire. 3. Complaint/Concern form was created and placed in employee lounge to further encourage staff to report any concern they have. The new form states (the Administrator) is to be contacted if abuse or neglect is suspected and Administrator ' s cell phone number is posted on the form. The surveyor confirmed that the facility did the following: During an interview on 07/11/12 at 9:15 AM, the DON stated after interviewing all staff again regarding any unreported incidents of abuse or neglect only one new incident came to their attention. The DON stated that CNA B reported that an LVN student witnessed back in September of 2011 another CNA student (CNA E) slapped a Resident #4 ' s hands when changing his brief when he was trying to play with feces. The DON stated that the LVN student did not work here at the time and the LVN student reported this to her instructor. The DON stated that they had started an investigation as of the time of the report. The DON stated that they interviewed the resident and CNA E who was also suspended pending outcome of investigation, and she denied that she ever slapped the resident on the hand. The DON stated that they interviewed Resident #4 who denied ever been slapped. The DON stated they were not able to contact the LVN instructor who the incident was reported to. Observation on 07/11/12 at 9:45 AM revealed Resident #4 with no bruising or injuries. During an interview on 07/11/12 at 9:50 AM, Resident #4 stated that no one has ever hurt him at the facility. Resident #4 stated that all the staff members treat him well. Resident #4 stated that he had never been mistreated in any way at the facility. Resident #4 stated that he is happy. Interviews on 07/11/12 between 9:37 AM and 10:36 AM with CNA C, F, and G revealed that they had been in-serviced on reporting abuse and neglect and they had no unreported incidents to report. Interview on 07/11/12 at 11:16 AM the Administrator stated that he would suspend the DON until the conclusion of all investigations. On 07/11/12 at 2:15 PM, the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope of isolated. The facility was continuing to in-service staff. The facility Administrator reported on 07/11/2012 that from the current Residnet census of 69, there are 12 female residents with cognitive impairment.

Based on observation, interview, and record review the facility failed to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 6 residents reviewed for abuse. 1. The facility Administrator failed to monitor the effectiveness of the staff inservice training on Abuse that the facility director of Nursing (DON) had provided. 2. The Director of Nursing (DON failed to effectively train, supervise and monitor staff to ensure staff folllowed the facility Abuse policy for identifying, reporting, protecting Residents following an allegation of Abuse. 3. Registered Nurse (RN U) failed to follow the facility Abuse policy when she failed to document, report, investigate and protect Resident #2 following reports from CNA B that Resident #2 told her she had been raped. Resident #2 had made two allegations of being raped by facility staff between November 2011 and May 2012. CNA B reported the first allegation to RN U who failed to document, report or investigate the allegation. CNA B failed to report the second allegation.On 06/25/12 Licensed Vocational Nurse (LVN) K witnessed Resident #2 being raped by Certified Nursing Assistant (CNA) A. These deficient practices resulted in an Immediate Jeopardy (IJ) on 07/10/12. While the IJ was removed on 07/11/12, the facility remained out of compliance at severity level of actual harm with a scope of isolated that is not IJ due to all staff had not been in-serviced on reporting abuse and neglect and the designation of the new Abuse Coordinator. As the result of these deficient practices Resident #2 was raped on 06/25/12 and had the potential to place the additional 11 female residnets identified with cognitive impairement at risk for Abuse and causing mental, physical and/or psychosocial harm and decreased quality of life. Findings include: Review of Resident #2 ' s Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE]. The resident ' s current [DIAGNOSES REDACTED]. Review of Resident #2 ' s most recent quarterly Minimum Data Set ((MDS) dated [DATE] reflected that Resident #2 has severely impaired cognitive status and that she has fluctuating (comes and goes) signs of disorganized thinking and periods of inattention. The MDS reflected that Resident #2 has Clear Speech (distinct intelligible words) and is rarely/never understood and rarely/never understands others. The MDS also reflected that Resident #2 has impaired vision but can see large print. The MDS also reflected that the resident had hallucinations, [MEDICAL CONDITION], and verbal behavior directed towards others. The MDS also reflected that Resident #2 is totally dependent on staff for all functional abilities including bed mobility, transfer, locomotion, dressing, toileting, personal hygiene, and bathing. The MDS reflected that Resident #2 requires limited assistance from staff for eating. The MDS reflected that Resident #2 had not received any antipsychotic, antidepressant, antianxiety, or hypnotic medications during the MDS look back period. Review of the most recent Care Plan last updated on 06/26/12 for Resident #2 reflected a " Problem/Need " onset 08/03/11 of " Activity Care Plan Potential for disrupted activities and/or untherapeutic activity environment related to: Verbally Abusive as evidenced by: Yelling at others. " Another " Problem/Need " onset 01/11/12 reflected " Due to Dementia resident is sometimes understood " with " Approaches " that included " Monitor resident frequently and anticipate needs; Approach resident calmly. Speak in a normal voice. Explain what you are about to do before touching resident; If resident appears agitated, leave alone if safe. Go back when calmer. If no improvement, notify charge nurse; Give resident adequate time to respond to question/conversation etc. " Another " Problem/Need " onset 06/26/12 reflected " Resident has been a victim of sexual assault " with " Approaches " that included " Give one time doses of [MEDICATION NAME] and [MEDICATION NAME] as ordered for possible sexually transmitted infections; Reevaluate for sexually transmitted infections in 3 months if physician orders; Notify Physician if resident has any vaginal bleeding or discharge. Lower abdominal pelvic pain, fever over 100 degrees without an obvious cause, pain or burning on urination. Redness, swelling or pain to injured area; Obtain any needed lab tests and notify physician of results; Keep resident comfortable with familiar staff, monitor resident for any increase in behaviors; No male CNA ' s to perform personal care on resident. " During an interview on 07/10/12 at 9:45 AM, the Director of Nursing (DON) stated that on 06/25/12 around 7:35 PM, LVN K heard a bed hitting the wall in hall 500 which is the locked unit. The DON stated that LVN K opened the door to Resident #2 ' s room and witnessed CNA A raping Resident #2. The DON stated that Resident #2 has advanced Alzheimer ' s, was not able to communicate to staff, recall events and does not show much emotion. The DON stated that Resident #2 is dependent on staff members for all activities of daily living. The DON stated that the curtain was pulled at the time and roommate (Resident #3) was in the room, but also has severe dementia and was not able to recall the events that took place. The DON stated that LVN K immediately told CNA A to leave and the police were called immediately. The DON stated that CNA A admitted to the police that he had raped Resident #2. The DON stated that according to the police, CNA A stated that this is the only resident he had sexually abused and that this was the first time it had happened. The DON stated that the resident was sent to a hospital to have a rape kit done and that the records are sealed and they were unable to get a copy of the results of the SAFE (Sexual Assault Forensic Evidence) kit. Observation on 07/10/12 at 10:00 AM revealed Resident #2 sitting in her wheelchair in the dining room of the secured unit. The resident was not in distress and did not have any signs of injury. The resident could not hold a conversation but would occasionally mumble phrases and sometimes say short clear phrases. Sometimes the resident ' s answers did not fit the question asked. During an interview on 07/10/12 at 10:05 AM, Resident #2 was asked if the surveyor could ask her some questions. The Resident stated " go ahead. " Resident #2 stated " no " when asked if anyone had ever hurt her and " yes " when asked if she felt safe at the facility. The resident also stated " yes " when asked if she likes the staff that worked at the facility. The resident did not show any emotion (negative or positive) during this interview. During an interview on 07/10/12 at 1:06 PM LVN K stated that on 06/25/12 sometime after 7:00 PM, she went to look for the other nurse on duty and was walking down the 500 hall when she heard what she thought sounded like a bed hitting the wall repeatedly. LVN K stated that she opened the door and she could see CNA A with his right arm holding Resident #2 ' s legs up in the air and the left hand trying to pull his pants up. LVN K stated that the resident was lying horizontal at the middle of the bed facing the middle of the room away from the wall. LVN K stated that Resident #2 had a sheet over her head but that the resident was not crying or making any noise. LVN K stated that Resident #2 is too confused and did not seem to know what was going on. LVN K stated that the curtains in room were pulled so that the roommate in the bed by the window could not see what was happening. LVN K stated that the curtain near the doorway was only pulled slightly and she could see straight to the bed when she opened the door. LVN K stated that she immediately asked CNA A what he was doing and he said " I don ' t know. " LVN K stated that she told CNA A to " get out " and " you are fired. " LVN K stated that CNA A was shocked and he was slow as he gathered his stuff before leaving the building. LVN K stated that CNA A left Resident #2 ' s room with bags of trash and placed them in the trash and linen bins as we walked out. LVN K stated that she immediately went to call the police when she exited the room and the police arrived shortly after CNA A had left. LVN K stated that the police took the trash and linen bins with them. LVN K stated that she would have never imagined that CNA A would do something like that. LVN K stated there is no one working at this facility that she would imagine would sexually abuse a resident. During an interview on 07/10/12 at 2:10 PM, the Detective stated that CNA A was in jail. The Detective stated that he is waiting the DNA results for CNA A. The Detective stated the case is still open and he is still working on it. The Detective stated that CNA A openly confessed to him that he raped Resident #2. During an interview on 07/10/12 at 2:35 PM the DON stated that CNA B reported to her on 07/05/12 that she (CNA B) had previously reported to Registered Nurse (RN) U sometime between November 2011 and January 2012 that Resident #2 had made an allegation that a CNA had raped her. The DON stated that CNA B told her that she witnessed Resident #2 make this allegation twice but she only reported it to RN U the first time and did not report the second allegation because nothing had ever come from the first allegation. The DON stated that RN U did not report it to administration. The DON stated that as of the State's entrance dated on 07/10/12, she had not investigated the two allegations of sexual abuse that CNA B reported to her (the DON) on 07/04/12 because she felt that CNA B was just feeling guilty about what had happened to Resident #2. During an interview on 07/10/12 at 3:15 PM, CNA B stated that the first allegation was about 6-7 months ago when CNA B was in the room with CNA C. CNA B stated that Resident #2 looked up at CNA C and said " he raped me " , but then Resident #2 looked up again and stated " no, not him. " CNA B stated that she reported this allegation to RN U and thought it was investigated. CNA B stated on 07/05/12 that, sometime around Mother ' s Day weekend in May 2012, she and CNA D were in the room with Resident #2 when CNA A came to the doorway. CNA B stated that Resident #2 looked up at CNA A and stated " he raped me. " CNA B stated that she did not report this allegation because she had reported the previous allegation to RN U and she thought it had already been investigated and didn ' t think anything of it. CNA B stated that now she wishes she had reported it. During an interview on 07/10/12 at 3:35 PM, RN U stated that CNA B did report to her about 6-7 months ago that Resident #2 had made an allegation that she had been raped. RN U stated that she assessed the resident, but that the resident says " off the wall things " and she didn ' t find " any injuries or unusual issues with the resident. " RN U stated that when she asked the resident about what happened the resident did not repeat the allegation and she was not able to get any information from the resident. RN U stated that CNA B had told her that Resident #2 had claimed a man had raped her and thought it was CNA C but then claimed it wasn ' t him. RN U stated that the resident wasn ' t making sense so she " put it on the backburner " and continued to " monitor " her. RN U stated that "If I reported every little thing, the DON would have a huge stack of complaints on her desk to investigate. " During an interview on 07/10/12 at 3:00 PM, CNA C stated that he did not recall this incident where Resident #2 claimed someone raped her. CNA C stated that Resident #2 can ' t really talk or make conversation. CNA C stated that he would have never thought that CNA A would sexually abuse anyone. During an interview on 07/10/12 at 4:00 PM, CNA D stated that she did not recall the incident when Resident #2 stated that CNA A raped her. CNA D stated that she had not witnessed any allegations reported by Resident #2 of rape. CNA D stated that Resident #2 cannot hold a complete conversation and that she will only say short phrases like " no " or " I want to go home. " CNA D also stated that she didn ' t think that CNA A would ever sexually abuse any residents and that she was surprised to hear he was caught sexually abusing Resident #2. During an interview on 07/10/12 at 4:20 PM the DON stated that RN U did not report the allegation of sexual abuse made by Resident #2 to the DON who was the Abuse Prevention Coordinator. The DON stated that RN U did not report the allegation because Resident #2 was not a reliable source of information due to her dementia. The DON stated that RN U should have mentioned the allegation to administration, but she did not. The DON stated that she interviewed RN U on 07/04/12, the same day that CNA B reported the allegations to the DON, RN U reported that she " did not think anything was unusual. " The DON stated that she told CNA B on 07/05/12 that she should have followed up with RN U and the DON on the first allegation. The DON stated that she did not document any of the information provided to her on 07/05/12 or any of the conversations held on the two allegations made by Resident #2. The DON stated that RN U should have reported the allegation that Resident #2 made that was reported to her by CNA B. The DON stated that she expects that the staff members " can ' t just assume (residents) are confused " when they make an allegation of abuse or neglect. The DON stated that the other CNA ' s did not recall the event when she asked them about it on the date of this interview (07/10/12). During an interview on 07/10/12 at 4:45 PM, the Administrator stated that he would start an investigation immediately regarding the two allegations that were brought to their attention by CNA B. The Administrator stated that he " can ' t see why anyone withholds information " and " it ' s the first (time). " During an interview on 07/10/12 at 5:30 PM, RN U stated that next time an allegation of abuse or neglect is reported to her she would report to the DON. RN U stated that she did not report the previous allegation because she did a full body assessment of Resident #2 and " she was fine, had no injuries, and the resident didn ' t directly report to her. " RN U stated that she did not document this assessment or that CNA B had reported anything to her. RN U stated that she had been trained on reported abuse and neglect prior to this incident. Review of the signed and dated statement provided to the surveyor by CNA B on 07/10/12 at 6:00 PM reflected " Statement for Dept of Aging and Disability Services: During the winter months perhaps Nov, Dec, Jan (I do not recall exact date) I was working in the (secured) unit at (the facility) serving as a CNA. I was putting (Resident #2) into bed one evening. I had asked for help from a co-worker male who also is a CNA and works in the building. I believe it was CNA C but I might be wrong. (Resident #2) made a comment while the male employee was standing at the foot of her bed. She said ' He raped me. ' I didn ' t hear her say it but CNA C stopped me mid-sentence and said what (Resident #2) had said. He stated that (Resident #2) accused him of raping her. (Resident #2) then lifted her head off of the pillow, took a closer look at CNA C and said ' no, no it wasn ' t him. ' I was relieved and told CNA C ' I didn ' t think he was capable of such a thing. ' The charge nurse on duty was RN U. RN U approached the room and CNA C explained what had just happened. RN U immediately turned around and said she was going to report that. I stuck my head out the door and RN U repeated that she was going to report that incident. CNA C left the room upset. I finished caring for (Resident #2) with peri-care, but nothing else was said by Resident #2. Fast forward to just before Mother ' s day weekend. I was in the room of (Resident #2) again. CNA D was present caring for Resident #2 and CNA A was standing in the doorway to (Resident #2) ' s room. Resident #2 said aloud ' he raped me. ' CNA D told Resident #2 ' no one is raping you now. ' I do not remember if CNA D ordered CNA A to leave the unit first, or if I told CNA D I had heard Resident #2 make a comment like that before only there was a different man in the room when it happened. CNA A was told to leave the unit. CNA D and I talked for a few minutes about what had just happened. I told her about the incident that occurred before. CNA D asked me if I was sure it was reported and I said yes. I didn ' t say aloud who the charge nurse was that I reported it to, but I had faith it had been reported and investigated. We discussed what to do and we both were concerned for (Resident #2). CNA D asked me again if I was sure it had been reported and I said yes. I asked her, or she asked me what we should do now and we both said I don ' t know. Fast forward to July 2nd (2012) I was confiding in a different charge nurse (LVN L) about all my experiences with Resident #2 prior to the incident that happened on June 25th (2012). LVN L said that (the DON) had been asking the employees to tell her of any instance of abuse, regarding (CNA A) too, or if we noticed anything unusual. I wasn ' t aware (the DON) had asked that of the employees until (LVN L) mentioned it. (LVN L) urged me to talk to (the DON) about this. Fast forward to July 4th (2012) I came in to have a talk with (the DON). It came to my attention that the first incident had not been reported and neither had the second. " Signed (CNA B). Review of a signed and dated statement provided by RN U dated 07/10/12 reflected " My name is (RN U). I am the weekend RN at (the facility) and have been employed here for eight years. I would like to relate about an incident reported to me by (CNA B) sometime in the past- date unknown. CNA B told me that (Resident #2) said she was raped by someone- the name (CNA C) was mentioned-. I told her I would look into it. I checked (Resident #2) over, could see no bruises, no bleeding, no discharges from vaginal/anus- no bruises, no fearful behavior, no signs or symptoms that would lead me to believe (Resident #2) was truly raped. I ' filed it in my memory ' watched for any other persons to come forward with a complaint- there were none. (Resident #2) says all kinds of off the wall things due to dementia, as do numerous other residents here. Residents confused or with dementia can say things that seem bizarre. I watched (Resident #2) -indeed- ALL residents- it ' s my job. I never saw any behavior that could be construed as coming from a sexually abused resident. I was waiting to see if anything would corroborate the statement but I found none. The resident did not tell me directly. She allegedly told (CNA B) about this event which may or may not have happened. (Another resident) is always ' having babies ' yes we do know it can ' t be possible. I do take any allegation seriously but (Resident #2) told (CNA B) I received the info second hand so to speak and on assessment of the resident found no (signs/symptoms) of abuse. If I would have believe (SIC) for one minute that (Resident #2) were raped, I would have said something- there was no evidence at the time. I can ' t emphasize that enough. I saw nothing during my assessment of (Resident #2) at the time that would indicate abuse. There was nothing out of the ordinary about her (Resident #2)- baseline- physically or emotionally/ mentally. I would never cover up abuse and know to report to my DON. " Signed (RN U). Review of a signed and dated statement provided by LVN L dated 07/10/12 reflected " On July 2, 2012 (CNA B) told me that a while back not sure when that ' her and (CNA C) was changing (Resident #2) and (Resident #2) said ' he ' s raping me ' and (CNA B) reported it to RN U. ' She (CNA B) also said that sometime after that " her, CNA D, and CNA A were in (Resident #2) ' s room and (CNA A) was standing in the doorway and (Resident #2) turned and looked at (CNA A) and started saying ' he ' s raping me. ' (CNA B) said she then told (Resident #2) that ' he ' s not raping you (Resident #2). ' -Didn ' t report it. (CNA B) also told me that one time (CNA A) was working 100 hall and she went to help him and he was in (another resident) ' s room and had his bag with him and showed her (CNA B) that he had his dad ' s Playboy books in his bag and (CNA B) said she told him ' I guess that ' s ok as long as you don ' t take them out at work. ' (CNA B) said she felt bad now because she never reported that and she feels like maybe it would have prevented the incident with (Resident #2 and CNA A) somehow. I told (CNA B) that she needed to report all of it to (the DON) and that anytime anything like that happens to report it immediately. I then asked (the DON) if (CNA B) had talked to her about it and she said yes. " Signed (LVN L). Review of the incident report dated 06/25/12 at 7:40 PM reflected " Witness: LVN K, Narrative: Per (LVN K) report, she went into secure unit looking for the other nurse(LVN M), when she go to room [ROOM NUMBER] she heard a loud sounding noise on the wall that sounded like the bed hitting the wall. When she opened the door she saw (CNA A) with his pants down and he had his right arm and hand holding the residents legs in the air. She reports that (Resident #2) was on her back cross ways on the bed. With his left hand he was pulling on his own pants, pulling them up. Resident was without clothes. " " Immediate Actions Take: (CNA A) was told by (LVN K), Charge Nurse, that he was fired and to leave the (facility). The police and DON were called. Police came to investigate and retrieve evidence from the room ...brief was left intact per request of the investigating officer for transfer to (a local hospital). Review of Nurse ' s Notes dated 06/25/12 reflected " 9:15 PM (late entry) for 7:40 PM. I went from hall 1 to hall 5 (the unit) looking for the other nurse when I got to room [ROOM NUMBER] I heard a loud sounding noise on the wall that sounded like the bed hitting the wall. Coming from 504A. When I opened the door of that room I saw (CNA A) with his pants down. He had his right arm and hand holding her legs in the air (Resident #2). (Resident #2) was on her back crossways on the bed. He had one hand (left) pulling on his own pants, pulling them up. (Resident #2) was without clothes. I yelled at him ' What are you doing? ' He said ' I don ' t know. ' I yelled ' Get out ' at him. After that I called (the DON) and dialed 911. (7:52 PM) the police arrived at facility. " Signed by LVN K. " 8:00 PM Medical Director called re: incident. Resident to be transported to (a local hospital) for exam. Daughter called and notified of incident. Police here to investigate. In room with resident collecting evidence. Resident asleep at moment. " " 9:20 PM Ok ' ed by police to move resident. Resident in geri chair transported by van to (hospital in Austin). " Signed by DON. Review of in-services for the last 12 months reflected that RN U had received her last Abuse and Neglect training on 07/11/11 and 08/10/11 and CNA B, C and D had all received training on Abuse and Neglect preventing and reporting on 07/11/11, 08/10/11, 04/10/12, 05/10/12, 06/11/12 and 06/26/12. CNA A had received training on Abuse and Neglect prevention and reporting on 07/11/11, 08/10/11, 04/10/12, 05/10/12, and 06/11/12. These in-services included training on the facility's abuse and neglect policy and until the 06/26/12 in-service on abuse and neglect, the training lacked an emphasis on identifying abuse in individuals with cognitive impairment. Review of CNA A ' s employee file on 07/10/12 at 10:45 AM on reflected a hire date of 01/22/08 and that all appropriate background checks had been completed prior to date of hire. Two reference checks were done and both previous employers indicated that CNA A was ' not eligible for rehire. ' The first employer indicated CNA A was terminated on 09/01/05 and the second indicated that CNA A was terminated on 01/18/08. During an interview on 07/10/12 at 12:30 PM the Assistant DON (ADON) stated that the reason CNA A was not eligible for rehire at the other facilities was not due to abuse or neglect so the reference did not prevent him from being eligible for hire at this facility. The ADON stated that the previous Administrator hired CNA A and had been the Administrator at the other facility when CNA A was terminated. The ADON stated that the Administrator at the time had indicated that CNA A was terminated at the other facility in 2008 due to not following the facility's policy on tranfers. Review of the facility ' s policy on " Reporting Abuse to Facility Management " dated 06/2004 reflected " It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors etc., to promptly report any incident or suspected incident of neglect or resident abuse, including of an unknown source, and theft or misappropriation of resident property to facility management. " " Employees, facility consultants and/or attending physicians must report any suspected abuse or incidents of abuse to the director of nursing services promptly. In the absence of the director of nursing service such reports may be made to the nurse supervisor on duty. " " The administrator and director of nursing services must be promptly notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the administrator and director of nursing services must be called at home or must be paged and informed of such incident. " " Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident ' s medical record. (Note: If sexual abuse is suspected, DO NOT bathe the resident or wash the resident ' s clothing or linen. Do not take items from the area in which the incident occurred. Call the police immediately.) " The person performing the examination must complete a " Resident Abuse Report Form " and obtain a written, signed, dated statement from the person reporting the incident. " " Any staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall report, or cause a report to be made of, the mistreatment, or offense. Failure to report such an incident may result in legal/criminal action being filed against the individual(s) withholding such information. " "All suspected violations and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities of individuals as may be requried by law. The facility Administrator and DON were notified on 07/10/12 at 6:30 PM that an Immediate Jeopardy had been identified due to the above failures. The Administrator submitted the facility's Plan of Removal on 07/11/12 at 10:36 AM. The facility's Plan of Removal was accepted on 07/1112 at 11:42 AM. The facility presented a plan of removal which included the following: 1. All residents confused and oriented were interviewed regarding any complaints or concerns regarding abuse. Confused residents received a head to toe assessment looking for any signs of trauma or changes in behavior that may indicate abuse. No complaints were received and no assessment revealed any signs or symptoms of abuse. 2. All staff were called for an emergency inservice on abuse. The attached form was reviewed with staff. All but two staff members have been contacted. The remaining two can not work until they have been inserviced. Staff are to report all concerns of oriented as well as confused residents. 3. All staff but two have been interviewed regarding any knowledge they may have of abuse occurring at (the facility). They were instructed that failure to report abuse is grounds for termination. During interview, one other allegation of abuse regarding resident (#4) was mentioned. This allegation is currently under investigation. 4. (RN U) was terminated on 07/10/11 for failure to report comments of (Resident #2) to abuse coordinator. (CNA B) has been suspended (on 07/10/11) pending investigation. (CNA E) has been suspended (on 07/10/11) pending investigation of incident regarding (Resident #4). 5. (The DON)/Abuse Coordinator was retrained by the Administrator on 07/11/12 on the abuse neglect protocol. (The DON) was suspended (on 07/11/12) pending investigation for failure to report and investigate abuse. The Administrator is now the Abuse Coordinator. Systemic Changes to Prevent Future Problems 1. The Abuse Coordinator is (The Administrator) and (provided phone number) was posted in the employee lounge for easy access by staff at all times. All staff were in-serviced on name and contact information of the Abuse Coordinator. 2. In-service regarding abuse, how to contact abuse coordinator and failure to report abuse being grounds for termination will be included in new hire packet and reviewed with employees on hire. 3. Complaint/Concern form was created and placed in employee lounge to further encourage staff to report any concern they have. The new form states (the Administrator) is to be contacted if abuse or neglect is suspected and Administrator ' s cell phone number is posted on the form. The surveyor confirmed that the facility did the following: During an interview on 07/11/12 at 9:15 AM, the DON stated after interviewing all staff again regarding any unreported incidents of abuse or neglect only one new incident came to their attention. The DON stated that CNA B reported that an LVN student witnessed back in September of 2011 another CNA student (CNA E) slapped a Resident #4 ' s hands when changing his brief when he was trying to play with feces. The DON stated that the LVN student did not work here at the time and the LVN student reported this to her instructor. The DON stated that they had started an investigation as of the time of the report. The DON stated that they interviewed the resident and CNA E who was also suspended pending outcome of investigation, and she denied that she ever slapped the resident on the hand. The DON stated that they interviewed Resident #4 who denied ever been slapped. The DON stated they were not able to contact the LVN instructor who the incident was reported to. Observation on 07/11/12 at 9:45 AM revealed Resident #4 with no bruising or injuries. During an interview on 07/11/12 at 9:50 AM, Resident #4 stated that no one has ever hurt him at the facility. Resident #4 stated that all the staff members treat him well. Resident #4 stated that he had never been mistreated in any way at the facility. Resident #4 stated that he is happy. Interviews on 07/11/12 between 9:37 AM and 10:36 AM with CNA C, F, and G revealed that they had been in-serviced on reporting abuse and neglect and they had no unreported incidents to report. Interview on 07/11/12 at 11:16 AM the Administrator stated that he would suspend the DON until the conclusion of all investigations. On 07/11/12 at 2:15 PM, the Administrator was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope of isolated. The facility was continuing to in-service staff. The facility Administrator reported on 07/11/2012 that from the current Residnet census of 69, there are 12 female residents with cognitive impairment.