Every finding on record at Meridian Care of Alice

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #1) of 5 residents reviewed for infection control practices. The facility failed to ensure Resident #1 had an EBP precaution/isolation sign posted outside of her door or room on 08/05/2026 at 8:50 AM. The facility failed to ensure Resident #1 had an order for EBP on 08/05/2026 at 2:00 PM.The facility failed to ensure Resident #1 had EBP in the baseline care plan on 08/05/2026 at 2:00 PM.These failures could place residents at risk for cross-contamination and infection due to inappropriate policies and precautions being used.The findings included:Record review of Resident #1's face sheet, reviewed 08/05/2026, revealed an [AGE] year-old female with an admission date of 07/31/2026. Pertinent diagnoses included Neuromuscular Dysfunction of Bladder (when nerve damage disrupts the communication between the brain and bladder, leading to impaired bladder and urinary complications) and Gastrostomy Status (a surgically placed gastrostomy tube for nutrition and hydration). Record review of Resident #1's admission Nursing Assessment, dated 07/31/2026, indicated Resident #1 was admitted with an indwelling urinary device (a device used to drain urine) and a PEG tube (a G-tube inserted directly into the stomach to provide nutrition). Record review of Resident #1's BIMS Assessment, dated 07/31/2026, revealed Resident #1 had a BIMS score of 01, which indicated severely impaired cognition. Record review of Resident #1's Physician Order Summary, reviewed 08/05/2026, revealed an order dated 07/31/2026 to change the indwelling urinary device every month, and another order dated 07/31/2026 to check G-tube placement and aspirate residual (to withdraw stomach contents) every shift. Record review of Resident #1's Baseline Care Plan, dated 07/31/2026, indicated Resident #1 had an indwelling urinary catheter device; required a tube feeding (a PEG tube); and had skin integrity issues, which included a stage II pressure ulcer (a partial-thickness loss of skin creating an open wound without exposure of deeper tissue) and a stage III pressure ulcer (a full-thickness loss of skin creating a wound in which fat under the skin is visible).In an observation on 08/05/2026 at 8:50 AM, Resident #1 was observed to have a Foley catheter urinary bag hanging from her bedside. The drainage bag was noted to be approximately half full of dark yellow urine. There was a continuous feeding pump (a medical device used to deliver enteral nutrition, or nutrition delivered into a patient's stomach or intestines) at the bedside. Resident #1's room was not observed to have an EBP sign on the door or wall outside of the room. Attempted to interview Resident #1 on 08/05/2026 at 8:50 AM and again at 4:08 PM, but Resident #1 was non-interviewable as she did not wake up to answer questions and had a low BIMS score. In an interview on 08/05/2026 at 4:25 PM, the DON stated the floor (charge) nurse was responsible for obtaining the EBP order, implementing EBP, and adding EBP to the baseline care plan. She stated the ICP would then make rounds the next morning, or Monday morning if the resident was admitted over the weekend, to make sure all the infection control measures and precautions had been ordered, implemented, and care planned. She stated EBP was utilized on residents with wounds or indwelling medical devices to prevent infections, as well as to prevent cross-contamination. She stated Resident #1 should have had EBP implemented upon admission due to the fact that she had a Foley catheter, a PEG tube, and wounds. The DON stated she would bring copies of the entire Infection Control Policy and the EBP policy. In an interview on 08/05/2026 at 4:50 PM, the ICP stated Resident #1 was admitted with a Foley catheter, PEG tube, and wounds. She stated Resident #1 should have been placed on EBP upon admission. The ICP stated the charge nurse should have ordered and initiated EBP, as well as added it to the baseline care plan and placed the EBP sign on the door. She stated she then followed up on all infection control issues the next business day to make sure everything was in place. The ICP stated she was not sure why EBP was not ordered or implemented for Resident #1, but she guessed it just got overlooked. The ICP initially stated she followed up to make sure EBP had been ordered, implemented, and care planned, then she stated the MDS nurse was the one who followed up behind the floor nurse to make sure EBP on the baseline care plan was completed accurately. The ICP stated she would get copies of the EBP and Infection Control Policy from the DON.In an interview on 08/05/2026 at 5:20 PM, LVN-A stated she typically worked the 100 Hall and was the charge nurse for Resident #1. She stated the charge nurses were the ones who typically placed the order for EBP, as well as implemented EBP, and added EBP to the baseline care plan. She stated sometimes the ICP nurse would do it, but it was typically the charge nurse's responsibility. She was not sure how Resident #1's EBP orders and implementation were overlooked, other than she had been busy and overlooked it. She stated Resident #1 not having EBP implemented could have caused cross-contamination, and placed Resident #1, as well as other residents, at risk for infection. A complete Infection Control Policy was requested during interviews with both the DON and the ICP. The DON asked which portion of the Infection Control Policy was needed since it was a long policy, and it was reiterated the entire Infection Control Policy was needed. On 08/05/2026 at 4:50 PM the DON brought a one-page document and stated this was all she had for the entire Infection Control Policy.Record review of the facility's Nursing Policies and Procedures: Infection Control Policy (a one-page document), undated, revealed Policy: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation: 2. (3) Establish guidelines for implementing isolation precautions. 4. All personnel will be informed of our infection control policies and practices, including where and how to find pertinent procedures. 6. Inquiries concerning our infection control policies and facility practices should be referred to the Infection Control Coordinator or Director of Nursing Services.Record review of the facility's Enhanced Barrier Precautions Policy, revised August 2022, revealed Policy Interpretation and Implementation: 1. Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multidrug-resistant organisms (MDROs) to residents. 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices, regardless of MDRO colonization. 10. Signs are posted on the door or wall outside of the resident room indicating the type of precautions and PPE required.Record review of the CDC: Long-Term Care Facilities (LTCFs): Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 04/02/2024, revealed EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: A. Wounds or indwelling medical devices, regardless of MDRO colonization status; B. Infection or colonization with an MDRO. Contact Precautions: Contact Precautions are intended to prevent transmission of infectious agents, like MDROs, that are spread by direct or indirect contact with the resident or the resident's environment. Enhanced Barrier Precautions: Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices. Implementation: Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE. For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html?CDC_AAref_Val=https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html

Based on observation, interview and record review, the facility failed to ensure the residents' right to dignity and respect for 1 (Resident #1) of 5 residents reviewed for privacy.The facility failed to ensure Resident #1 had a privacy cover or privacy bag over her urinary catheter device on 08/05/2026 at 8:50 AM. This failure could place residents at risk of feeling disrespected and experience a loss of dignity due to a lack of privacy.The findings included:Record review of Resident #1's face sheet, reviewed 08/05/2026, revealed an [AGE] year-old female with an admission date of 07/31/2026. Pertinent diagnoses included Neuromuscular Dysfunction of Bladder (when nerve damage disrupts the communication between the brain and bladder, leading to impaired bladder and urinary complications). Record review of Resident #1's admission Nursing Assessment, dated 07/31/2026, indicated Resident #1 was admitted with an indwelling urinary catheter device (a device used to drain urine) and a PEG tube (a G-tube inserted directly into the stomach to provide nutrition). Record review of Resident #1's BIMS Assessment, dated 07/31/2026, revealed Resident #1 had a BIMS score of 01, which indicated severely impaired cognition. Record review of Resident #1's Physician Order Summary, reviewed 08/05/2026, revealed an order dated 07/31/2026 to change the Foley catheter every month, and another order dated 07/31/2026 to check G-tube placement and aspirate residual (to withdraw stomach contents) every shift. In an observation on 08/05/2026 at 8:50 AM, Resident #1 was observed to have a Foley Catheter urinary bag hanging from her bedside without a privacy cover or privacy bag over the drainage bag. The drainage bag was noted to be approximately half full of dark yellow urine.Attempted to interview Resident #1 on 08/05/2026 at 8:50 AM and again at 4:08 PM, but Resident #1 was non-interviewable as she did not wake up to answer questions and had a low BIMS score. In an interview on 08/05/2026 at 4:25 PM, the DON stated they no longer used privacy bags for foley catheters, but they used the Fig Leaf privacy covers (a urinary drainage bag cover which provides privacy, conceals urine, but allows easy access to view and monitor the urine). The DON stated the floor nurse was responsible for applying and checking if the privacy cover was over the urinary drainage bag. She stated all urinary drainage bags should have a cover to provide for privacy and a sense of dignity for the resident. In an interview on 08/05/2026 at 5:20 PM, LVN-A stated she typically worked the 100 Hall and was the charge nurse for Resident #1. She stated the charge nurses were the ones who typically placed the privacy cover over the urinary drainage bags for residents with Foley catheters. She stated she thought there was a cover over Resident #1's urinary drainage bag, but she could not remember for sure. She stated if there was not one over it, there should have been to provide the resident privacy. In an interview on 08/05/2026 at 5:20 PM, LVN-A stated she typically worked the 100 Hall and was the charge nurse for Resident #1. She stated the charge nurses were the ones who typically placed the privacy cover over the urinary drainage bags for residents with Foley catheters. She stated she thought there was a cover over Resident #1's urinary drainage bag, but she could not remember for sure. She stated if there was not a privacy cover over the urinary drainage bag, there should have been to provide the resident privacy.Record review of the facility's Resident Rights policy, revised August 2009, revealed Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: D. Privacy and confidentiality.

Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (Resident #1) of 6 residents reviewed for supervision. The facility failed to ensure Resident #1 received adequate supervision and Resident #1 left the secured unit and was unaccounted for approximately 10 minutes from 6:30 PM to 6:40 PM on 05/14/26 before a 3rd party notified the facility that Resident #1 was outside the facility. The noncompliance was identified as PNC. The PNC began on 05/14/26 and ended on 05/15/26. The facility had corrected the noncompliance before the investigation began. This failure could place residents requiring supervision at risk for serious injuries, hospitalization, or death.The findings included: Record review of Resident #1's face sheet dated 06/02/26 revealed an [AGE] year-old male with an admission date of 05/07/26 and discharge date of 05/24/26. Resident #1's pertinent diagnosis included unspecified dementia (patient clearly has dementia symptoms-such as memory loss and cognitive decline-but a doctor cannot definitively determine the exact underlying cause). Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMS score of 3 indicating severe cognitive impairment. Record review of Resident #1's comprehensive care plan dated 05/24/26 revealed the focus I WANDER IN THE NURSING HOME AND INTO OTHER RESIDENTS ROOM ***I AM IN A SECURED UNIT*** DX: DEMENTIA initiated on 05/08/26. The goal listed for the focus included I WILL NOT WANDER OUT OF THE FACILITY EVERY SHIFT BY NEXT REVIEW IN 90 DAYS. Interventions for the focus included: ASSIST TO REORIENTATION TO ROOM AND FACILITY ASSURE THAT STAFF IS AWARE THAT RESIDENT WANDERS ENCOURAGE GROUP ACTIVITIES AND KEEP RESIDENT OCCUPIED HELP RESIDENT IDENTIFY THERE [sic] ROOM BY PLACING FAMILIAR ITEMS IN THERE PROVIDE REALITY ORIENTATION THROUGHOUT THE DAY PROVIDE VERBAL CUES AND REMINDING OFTENROUTINE RESIDENT CHECK Q 2HRS AND LOCATE RESIDENT WHEREABOUTS Record review of Resident #1's order summary on 06/02/26 revealed a discontinued order for ADMIT TO THE [Facility] SECURED UNIT UNDER THE CARE OF [Physician] FOR ELOPEMENT RISK initiated on 05/11/26. Record review of the transfer paperwork from the hospice facility Resident #1 came from to arrive at the facility on 06/02/26 revealed a note from written by a hospice nurse on 05/02/26 that stated Frequently ambulates up and down the hallway in [Inpatient Unit]. Is exit seeking. Further review revealed a note written by a different hospice nurse on 05/02/26 that stated [Resident #1] Seen ambulating up and down the hallways - wanders and exit seeking. Record review of Resident #1's wandering assessment dated [DATE] completed by RN E revealed a score of 8 indicating he was low risk. Further review revealed Resident #1's wandering assessment dated [DATE] completed by the ADON revealed a score of 15 indicating he was at a high risk to wander. Record review of the provider investigation report dated 05/18/26 revealed the following narrative: On 05/14/2026 at approximately 6:39pm, a gentleman alerted receptionist desk saw a man walk out onto our back parking lot from secured unit. Receptionist immediately notified [ADON], who immediately went and assisted resident back into facility. [ADON] completed head to toe assessment and placed resident on one-on-one. Employee interviews conducted and no employee saw resident exit facility. IDT held a QA meeting on 05/15/2026, discussed incident resident exiting building, potentially following behind a visitor. Identified a high volume of visitors during 4pm to 7pm, keypad not covered. Administration unable to determine how resident exited facility. During an interview with the FT at 12:58 PM on 06/01/26, the FT stated he was working the day Resident #1 eloped from the facility. The FT stated he did not see anything or hear any alarms that day around the time of the elopement. The FT stated Resident #1 would wander the halls, and he did see him try to enter the employee break room one time but never tried to exit the locked unit. The FT was able to identify the elopement process, location of wandering binder, knowledge on the changes since the elopement incident, what to do if the alarm sounds, identify code pink as the elopement code, and different types of abuse and neglect. During an interview with LVN B at 1:15 PM on 06/01/26, LVN B stated she was not working at the time of Resident #1's elopement. LVN B was able to identify the elopement process, location of wandering binder, knowledge on the changes since the elopement incident, what to do if the alarm sounds, identify code pink as the elopement code, and different types of abuse and neglect. During an interview with LVN C at 1:29 PM on 06/01/26, LVN C stated he was not working at the time of Resident #1's elopement. LVN C was able to identify the elopement process, location of wandering binder, knowledge on the changes since the elopement incident, what to do if the alarm sounds, identify code pink as the elopement code, and different types of abuse and neglect. During an interview with the HK at 1:39 PM on 06/01/26, the HK stated she was not working at the time of the elopement. the HK was able to identify the elopement process, location of wandering binder, knowledge on the changes since the elopement incident, what to do if the alarm sounds, identify code pink as the elopement code, and different types of abuse and neglect. During an interview with CNA D at 1:46 PM on 06/01/26, CNA D stated she was working the day Resident #1 eloped from the facility. CNA D stated she did not see anything or hear any alarms that day around the time of the elopement. CNA D stated she did not know he had eloped until she was informed by her nurse that he had exited the locked unit, but he was back. CNA D stated Resident #1 would wander the halls but she had never seen him try to exit before. CNA D was able to identify the elopement process, location of wandering binder, knowledge on the changes since the elopement incident, what to do if the alarm sounds, identify code pink as the elopement code, and different types of abuse and neglect. During an interview with the ADON at 1:56 PM on 06/01/26, the ADON stated the incident occurred around 6:35 PM. The ADON stated she got a call from the receptionist saying a resident was possibly outside the facility. The ADON stated she went outside and found Resident #1 standing on the sidewalk about 35 feet from the entrance of the facility. The ADON stated she brought Resident #1 back into the facility, performed a skin assessment on him, and found no injuries. The ADON stated Resident #1 was unable to say how he got out of the facility. The ADON stated she never heard any alarm go off during the time frame of Resident #1's elopement. The ADON stated Resident #1 stayed on a one-on-one after he was brought back inside until he was discharged on 05/24/26. The ADON stated she did not know Resident #1 was gone until she was informed by the phone call. The ADON stated it was not safe for Resident #1 to be outside the facility on his own. The ADON was able to identify the elopement process, location of wandering binder, knowledge on the changes since the elopement incident, what to do if the alarm sounds, identify code pink as the elopement code, and different types of abuse and neglect. During an observation at 2:10 PM on 06/01/26 of the location the ADON stated she found Resident #1, the location was on the sidewalk approximately 35 feet from the exit door adjacent to a street with a speed limit of 30 mph. There was no space between the edge of the sidewalk and the beginning of the street. Inspection of all facility exit doors, windows, locks, and alarms indicated all were working properly. During an interview with the MS at 2:30 PM on 06/01/26, the MS stated all locks, alarms, windows, and doors were inspected on 05/14/26 after the elopement and all were working properly. The MS stated the code to exit the locked unit was changed for all doors on 05/14/26 as well. The MS stated the code had not been changed since 01/01/26 prior to changing it on 05/14/26 after the elopement. The MS was able to identify the elopement process, location of wandering binder, knowledge on the changes since the elopement incident, what to do if the alarm sounds, identify code pink as the elopement code, and different types of abuse and neglect. During an observation at 2:35 PM on 06/01/26, all door alarms, locks, and windows in the locked unit were seen to be working properly. During an interview with the WR at 4:30 PM on 06/01/26, the WR stated she was not working at the time of the elopement. The WR was able to identify the elopement process, location of wandering binder, knowledge on the changes since the elopement incident, what to do if the alarm sounds, identify code pink as the elopement code, and different types of abuse and neglect. During an interview with RN E at 4:38 PM on 06/01/26, RN E stated she was not working the day Resident #1 eloped from the facility. RN E stated Resident #1 would wander the halls, but she had never seen him try to leave the facility before. RN E stated Resident #1 would spend time by the main exit door, but his room was right next to the exit door. RN E was able to identify the elopement process, location of wandering binder, knowledge on the changes since the elopement incident, what to do if the alarm sounds, identify code pink as the elopement code, and different types of abuse and neglect. During an interview with RN F at 4:54 PM on 06/01/26, RN F stated she was working the day Resident #1 elopement from the facility. RN F stated she did not see anything or hear any alarms that day around the time of the elopement. RN F stated she did not know he was gone until the ADON came and told her that he had left the building but was back. RN F stated she had seen a visitor use the code to get out of the locked unit before over a year ago. RN F was able to identify the elopement process, location of wandering binder, knowledge on the changes since the elopement incident, what to do if the alarm sounds, identify code pink as the elopement code, and different types of abuse and neglect. During an interview with CNA A at 5:16 PM on 06/01/26, CNA A stated she was working at the time Resident #1 eloped from the facility. CNA A stated she saw Resident #1 at approximately 6:30 PM in the locked unit. CNA A stated Resident #1 would wander around the locked unit, but she had never seen him try to exit before. CNA A stated she did not know Resident #1 had left the faciity on [DATE] until after he had already been brought back into the locked unit. CNA A stated she did not hear any alarms that day around the time of the elopement. CNA A was able to identify the elopement process, location of wandering binder, knowledge on the changes since the elopement incident, what to do if the alarm sounds, identify code pink as the elopement code, and different types of abuse and neglect. In an interview with the ADM at 5:28 PM on 06/01/26, the ADM stated she was not certain how Resident #1 exited the locked unit. The ADM stated either Resident #1 put the code into the exit door and let himself out, a visitor put the code in to leave and Resident #1 followed them, or a staff member put the code in and Resident #1 followed them. The ADM stated as far as she was aware no alarm sounded during the incident. The ADM was able to identify the elopement process, location of wandering binder, knowledge on the changes since the elopement incident, what to do if the alarm sounds, identify code pink as the elopement code, and different types of abuse and neglect. The ADM stated they made the following changes after the incident:Change the door codes in the locked unit once per monthImplemented a door guard to observe the door from 4:00 PM to 7:00 PM every afternoonPlaced a cover over the keypad so it was difficult to learn the code by watching someone elseNew wandering assessment on all residents in the facilityIn-services for all staff covering elopement procedures, abuse, and neglectSign at exit of locked unit reminding people to not let residents follow them out.Moved resident closer to nurses station and placed on one-to-one. During an interview with CNA G at 5:58 PM on 06/01/26, CNA G stated she was not working when Resident #1 eloped from the facility. CNA G was able to identify the elopement process, location of wandering binder, knowledge on the changes since the elopement incident, what to do if the alarm sounds, identify code pink as the elopement code, and different types of abuse and neglect. During an interview with the DON at 8:31 AM on 06/02/26, the DON stated it was not safe for Resident #1 to be outside the facility on his own. The DON stated residents were assigned to the memory care unit because they were known to be at risk of wandering and possible elopement from the facility. The DON stated she was not certain how Resident #1 made it out of the locked unit. The DON stated the video cameras in position did not reveal how Resident #1 exited the locked unit. The DON was able to identify the elopement process, location of wandering binder, knowledge on the changes since the elopement incident, what to do if the alarm sounds, identify code pink as the elopement code, and different types of abuse and neglect. During an interview with the MDS Nurse at 12:16 PM on 06/02/26, the MDS Nurse stated he reviewed the paperwork for Resident #1 before he was accepted to the facility. The MDS Nurse stated he determined Resident #1 could be accepted, but that he would need to be in the locked unit. The MDS nurse stated he remembered from the documentation Resident #1 had a history of exit seeking behaviors. The MDS Nurse stated the initial wandering assessment on Resident #1 was not completed correctly based on his history. The MDS Nurse was able to identify the elopement process, location of wandering binder, knowledge on the changes since the elopement incident, what to do if the alarm sounds, identify code pink as the elopement code, and different types of abuse and neglect. Record review of the facility policy titled Wandering and Elopements revised March 2019, revealed the following: 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. Verification of the corrective action implemented by the facility beginning on 05/14/26: Resident #1 was moved to a different room closer to the nurse's station on 05/14/26 verified interview with the ADON 1:56 PM on 06/01/26. All staff re-educated and in-serviced beginning on 05/14/26 verified through interviews with various staff members and record review of in-services signed by all staff on 06/02/26.Reporting of Abuse and NeglectIntervening if Abuse or Neglect was witnessedTypes of AbuseCode PinkImmediate Search ProceduresStaff Responsibilities During ElopementLocation of Wandering Binder reviewed at 3:00 PM on 06/02/26 Wandering assessments completed on all residents verified through record review of 10 random resident's wandering assessments and interview with the DON at 8:31 AM on 06/02/26. Weekly maintenance checks on all doors, alarms, windows, and locks in the locked unit verified through record review of weekly maintenance check logs and interview with the MS at 2:30 PM on 06/01/26. Monthly change to the keypad code in the locked unit verified through record review of the monthly change log for keypad codes and observation of the new code used several times from 06/01/26 - 06/02/26. Door guard on duty from 4:00 PM to 7:00 PM in locked unit verified through observation of the WR working as the door guard from 4:15 PM to 6:10 PM on 06/01/26. Keypad cover placed over keypad for enhanced privacy verified through observation on at 1:00 PM on 06/01/26. Signs at exit warning staff and visitors not to allow a resident to follow them out of the locked unit verified through observation at 1:00 PM on 06/01/26 One-to-one for Resident #1 after the incident from 05/14/26 until discharge on [DATE] verified through record review of the one-to-one paperwork signed by various staff on 06/01/26. No other incidents of elopement occurred since Resident #1's elopement incident on 05/14/26 verified through record review of the list of incident and accidents in the facility and interview with the DON at 8:31 AM on 06/02/26.

Based on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported to local law enforcement and HHSC Complaint and Incident Intake immediately, but no later than 2 hours after the allegation was made, if the event that caused the allegation involved abuse for 2 of 6 residents (Resident #15 and Resident #94) reviewed for abuse. The facility failed to report an incident of sexual abuse that occurred on 03/03/26 to local law enforcement and to HHSC when Resident #15 was found in Resident #94's room with his penis in and or around Resident #94's mouth. An Immediate Jeopardy (IJ) was identified on 03/25/26. The IJ template was provided to the facility Administrator on 03/25/26 at 5:42 pm. While the IJ was removed on 03/27/26 at 11:11 am, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to monitor and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of abuse and or continued abuse and could lead to a diminished quality of life and psychosocial harm. The findings included: Record review of Resident #94's admission record reflected an [AGE] year-old female originally admitted to the facility on [DATE] and most recent admission was 01/03/24. Her diagnoses included Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), dementia (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities), major depressive disorder, recurrent (persistently low or depressed mood and a loss of interest in activities that creates significant difficulty in daily life, work, and social functioning), delusional disorder (a type of mental health condition in which a person can't tell what's real from what's imagined), anxiety disorder (mental disorder characterized by excessive and persistent worry, fear, or anxiousness which significantly interferes with daily life), and unspecified psychosis (psychotic symptoms not aligned with a specific psychotic disorder or mental illness). Record review of Resident #94's annual MDS dated [DATE] reflected a BIMS score of 3 which indicated she had severe cognitive impairment. Resident #94's functional abilities reflected she required partial to moderate assistance for sit to stand, sitting to lying, chair/bed to chair-transfer, toileting, bathing, and walking 10 - 50 feet. Resident #94 also had behavioral symptoms directed toward others (such as hitting, scratching, and kicking) and verbal behavioral symptoms directed toward others (such as threatening others, screaming at others, cursing at others) on 1 to 3 days of the observation period. Record review of Resident #94's care plan dated 05/16/20 reflected: Focus: I have a dx: Cognitive Communication [sic] created 11/29/20. Interventions included: Involve in activities that do not rely on communication, monitor for changes in condition, reassurance and patience when resident attempts communication, use hand gestures as needed, use short phrases that require yes or no answers. Focus: I wander in the nursing home and into other residents rooms. DX: Dementia/Alzheimer's. I am in a secured unit. Initiated on 11/29/20. Interventions included: Assist to reorientation to room and facility, assure that staff is aware that resident wanders, routine resident check Q 2Hrs and locate resident whereabouts. Focus: I have cognitive loss; moderately impaired in decisions making; short term memory loss. DX: Alzheimer's/Dementia. Interventions included: Assist in decision making by giving simple choices, assure that resident's wishes are understood by being patient, keep environment free of hazards. Initiated on 11/29/20. Record review of Resident #94's progress notes reflected: A nursing Note dated 03/03/26 at 9:29 am by LVN B stated, Male resident had been going into resident's room exposing himself and this particular incident he made physical contact with her inappropriately and was needing to be redirected. RP called and no answer, left message to call facility. A nursing note effective 03/03/26 at 1:28 pm, created 3/9/2026 at 4:32 pm by the ADON stated, Charge nurse witnessed Female Resident door open calling out for the male resident previously in her room. Hey come here, come here. Female resident inviting male resident to come into her room. Redirected male resident. Record review of Resident #15's admission record reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included moderate intellectual disabilities (developmental delays resulting in an average mental age of 6 to 9 years old), other frontotemporal neurocognitive disorder (also called frontotemporal dementia or FTD- a group of progressive brain diseases that cause neurons to die in the frontal and temporal lobes, causing early-onset dementia with symptoms such as loss of empathy, social inappropriateness, and language difficulties), cognitive communication deficit (difficulty with communication), and dementia with psychotic disturbance (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities with hallucinations or delusions). Record review of Resident #15's quarterly MDS dated [DATE] reflected a BIMS of 00 (severe cognitive impairment). Resident #15's functional abilities reflected independent for, sit to stand, sit to lying, chair/bed to chair-transfer and walking 10 - 50 feet. Resident #15 required setup or clean-up assistance with toileting and supervision or touching assistance for bathing. Record review of Resident #15's care plan dated 10/22/16 and reviewed on 03/25/26 reflected: Focus: I at times exhibit inappropriate behavior of: I refuse to shower or change my clothes. I don't like brushing my teeth. I need great encouragement and assistance in doing my personal hygiene. I will steal money. I will steal sodas. Interventions included: Approach in a calm and reassuring manner, encourage involvement of families and friends, encourage socializations as tolerated, explain care procedures in simple terms, please reinforce positive behavior, report significant changes in behavior status to MD. Focus: I demonstrate socially unacceptable behavior by next review in 90 days. [sic] I will steal drinks from staff and other residents. I will steal food and candy from staff and other residents. I will make farting noises and blame other people. I will call people pigs in spanish. I will use inappropriate gestures towards staff and other residents at times. Interventions included: If behavior does continue, notify MD, family, and SW, provide privacy if needed, psychiatric evaluation if needed, remind resident that behavior is not acceptable, set limits on behavior. Focus: I have a dx: cognitive communication. Interventions included: Always face resident when speaking, monitor for changes in condition, reassurance and patience when resident attempts to communication [sic], use hand gestures as necessary, use short phrases and questions that require yes or no answers. Focus: I wander in the nursing home and into other residents rooms. DX: Dementia. I am in a secured unit. Interventions included: Assist to reorientation to room and facility, assure that staff is aware that resident wanders, encourage group activities and keep resident occupied, help resident identify there [sic] room by placing familiar items in there, provide reality orientation throughout the day, provide verbal cues and reminding often, routine resident check Q2hrs and locate resident whereabouts. Record review of Resident #15's progress notes reflected: A nursing note dated 05/21/25stated, Resident noted standing in from of another resident in room with his pants down and genitalia exposed. Nurse then redirected resident out of room and back to his room. Hall nurse attended to other resident in room. ADON notified. A nursing noted dated 05/22/25 stated, Resident cont. to enter [female resident name] room while trying to expose penis. Writer attempting to redirect resident not successful. Resident not able to remove from rm. Writer utilized w/c and escorted resident back to own rm. Notified charge nurse. A nursing note dated 06/08/25 stated, Inappropriate behavior in front of female resident. Pulled his pants down in front of female. Redirected by CNA. Resident was noted wandering around resident. Frequent monitoring of resident by staff. An interdisciplinary note dated 06/12/25 at 10:09 am stated, IDT weekly psych meeting: Resident started on Paroxetine HCl tablet 20mg. Give 1 tablet by mouth one time a day related to major depressive disorder. S/E and behavior monitoring in place as well as consent. A nursing note dated 06/13/25 at 11:08 am stated, Resident noted in female room {room number] with his hand in his pants and female resident asleep. ADON notified. Interventions: 1) 30 min checks, 2) collect UA/C&S- stat order, 3) suspenders for pants. A nursing note dated 06/25/25 at 2:02 pm stated, Inappropriate behavior at 12:29 pm in from of female resident. Redirected by staff. Constant monitoring, cont. with hourly checks. A nursing note dated 06/28/25 at 6:49 am stated, resident continues with inappropriate behaviors such as exposing his genitals to female residents several times throughout the day. he requires frequent checks and continuous redirection by staff due to this. ADON is aware. A nursing note dated 07/19/25 at 1:21 pm stated, CNA reported she witnessed resident in TV room, with penis out. Male resident hands were placed on his penis. Female resident in TV room and sitting on the chair, when CNA saw she called out for resident and male resident put his penis back in pants. Female resident turned head. Female resident removed from TV room, denies pain or distress. Male resident placed on 15 min checks, notified on call and ADON. UA orders, notified psych services, pending call back. Resident observed lying in bed, eyes closed. No distress or pain noted. A nursing note dated 07/19/25 at 2:05 pm stated, new order from psych services: increase Paxil 40mmg and one time order Ativan 0.5mg x1 dose. Oncoming nurse aware. Care endorsed. An interdisciplinary note dated 07/24/25 at 10:27 am stated, IDT weekly psych meeting: Paxil increased by psych PA. No side effects noted. Continue to monitor. A nursing note dated 07/26/25 at 7:15 am stated, Resident attempting to enter female's room. CNA redirected resident out of the room. Resident cooperative. Will continue to monitor. A nursing note dated 08/03/25 at 1:37 pm stated, Informed by housekeeper she observed resident in female's room [room number] with his pants down and female bent forward. Removed resident from room and instructed not to go into female's rooms anymore. Started on 15 min checks. ADON notified of resident's inappropriate sexual behavior. Will continue to monitor. A nursing noted dated 08/18/25 at 10:11 am stated, Notified [PA] of resident increased sexual behavior in female resident room. Pending response. A nursing note effective 03/02/26 at 10:01 am, created 03/03/26 at 9:11 am, and struck out ( incorrect documentation) on 03/25/26 at 7:34 am by LVN B stated, Resident was caught by CNA after breakfast in a female resident's room with his pants down exposing himself to her and having her grab his penis. CNA intervened and redirected him and got him out of female's room. But after a while resident cont. to try and walk back towards that female's room and required constant redirection until he left to center. Cont. to monitor and redirect resident. A nursing note dated 03/03/26 at 9:11 am by LVN B stated, Resident was caught by CNA during breakfast in female resident's room with door closed and was exposing himself to her and had his penis in her mouth. CNA intervened and redirected him out of her room. Will continue to monitor. Notified psych services and RP has been notified of his behaviors. A nursing note dated 03/03/26 at 10:00 am by LVN B stated, Psych services re-evaluated his meds and n/o given. Increase back his abilify. Discontinue abilify 7.5mg QD to start 10mg QD. RP was notified. A nursing note dated 03/03/26 at 10:04 am by the ADON stated, ADON at nurse's station was called by CNA into female resident's room. Male resident had his pants up. Male resident was easily redirected out of female resident's room. Female resident was calm with no verbal refusal, no facial grimacing. Female resident had no signs of distress. Reported to ADM/DON/IDT. Will continue to monitor. A nursing note dated 03/03/26 at 8:20 pm stated, Resident continues with hypersexual behavior. Goes into females room, redirected PRN. Med as ordered. Will continue to monitor. A nursing note dated 03/14/26 at 4:35 pm stated, Resident continues going into female resident room. Redirected this shift and as needed. Will continue to monitor. In an interview on 03/24/26 at 3:30 pm, Resident #94 stated she did not have a boyfriend, and could not recall how old she was and was not able to answer if she felt fearful. In a phone interview on 03/24/26 at 3:41 pm, the RP of Resident #94 stated he would not have given consent for Resident #94 to be involved with any sexual activity. The RP stated Resident #94 had dementia and was incapacitated (made incapable of or unfit for normal functioning) and was not in her right mind. In an interview on 3/24/26 at 3:56 pm, the ADON stated she was at the nurse's station when CNA A started yelling out for her from the doorway of Resident #94's room. The ADON stated she went over and into Resident #94's room and saw Resident #15 with his pants up and standing next to the head of Resident #94's bed. The ADON stated CNA A informed her she saw Resident #15's penis in Resident #94's mouth. The ADON stated Resident #15 was redirected out of the room, and she immediately reported the incident to the ADM and DON. The ADON stated shortly after, Resident #15 left to the day habilitation center that he attends on Mondays, Tuesdays, and Thursdays. The ADON stated Resident #15 did not have a history of any sexual behaviors with any resident. The ADON stated Resident #94 was acting normal, not fearful or crying. The ADON stated Resident #94 had no facial grimacing, and she appeared to be comfortable. The ADON stated she did not recall if a head-to-toe assessment was done for the incident, but if there was not an assessment done, it would not have hurt to have done one. The ADON stated Resident #94's FM was seen talking to LVN B the next day, and the FM did not appear to be upset. The ADON stated Resident #94's FM said something along the lines of well she's been married 3 times, what do you expect. The ADON stated she could not recall if there was an IDT meeting with the family present after the incident. The ADON stated she could not recall what the doctor stated when notified about the incident. The ADON stated she did not witness any consent between Resident #15 and Resident #94, but when she walked into the room during the incident, it appeared consensual. The ADON stated Resident #15's BIMS was a 0 and meant he had severe cognitive impairment. The ADON stated she would have to look but was pretty sure Resident #94 had severe cognitive impairment as well. The ADON could not answer if both residents could consent. The ADON stated that to get consent it would have had to have been discussed through the IDT because the residents had rights. The ADON stated she did not feel comfortable answering if both Resident #15 and Resident #94 could consent since they both had severe cognitive impairment. The ADON stated she did not witness the actual incident, but from what she was told by CNA A, both residents appeared to be consenting due to not showing any fear. In an interview on 03/25/26 at 8:31 am, CNA A stated she was collecting breakfast trays when she went to check on Resident #94 and observed Resident #15 in the room. CNA A stated she observed Resident #94 sitting up in bed and Resident #15 was positioned at the head of the bed, making thrusting movements with his pelvis. CNA A stated she asked Resident #15 what he was doing, at which time he pulled away from the bed. CNA A reported that she then observed Resident #94 with her hands raised, in a grabbing position. CNA A stated she immediately called out for the ADON, who responded to the room and removed Resident #15. CNA A stated Resident #94 indicated she was okay but was unable to explain what had occurred. CNA A reported that, to her knowledge, Resident #94's family had not provided consent for the resident to engage in any sexual activity. In an interview on 03/25/26 at 8:44 am, LVN B stated she did not witness the incident but was informed of it by the ADON. LVN B stated that upon being notified, she contacted the doctor, the PA, and called Resident #94's RP. LVN B reported that she left a message for Resident #15's RP and called Resident #94's second contact. LVN B stated that after notifying the PA, the PA reviewed Resident #15's medications and made adjustments; however, LVN B could not recall the specific changes. LVN B reported that Resident #94's RP did not return her call. LVN B stated that on the day following the incident, 03/04/26, the FM of Resident #94 came to the facility, and she informed the FM of the incident that had occurred on the previous day. LVN B stated that the FM did not appear upset regarding the situation. LVN B stated she was not aware of any consent given by Resident #94's RP to have a sexual relationship. LVN B stated she could not determine whether Resident #15 and Resident #94 were able to consent. LVN B stated that the residents had rights. LVN B stated, as far as she knew, Resident #15 did not have any prior inappropriate sexual behavior. LVN B stated she struck out the nursing note that referred to an incident on 03/02/26 because she, documented the wrong incident. Not that there were two incidents- she just documented wrong. In a phone interview on 03/25/26 at 10:49 am, the FM of Resident #94 stated she was informed about an inappropriate incident that occurred with Resident #94 but was not given details about the incident. The FM stated she assumed a male resident was just wandering in Resident #94's room and the facility was keeping them apart. The FM stated she did not give consent to Resident #94 to have any sexual activity with any resident, and stated Resident #94 did not have the cognition to consent. In a phone interview on 3/25/26 at 10:28 am, the MD stated he was notified about the incident between Resident #15 and Resident #94 on 03/03/26. The MD stated he did not believe Resident #15 or Resident #94 had the capacity to consent to sexual activity and reported that Resident #94 was bed confined. The MD stated Resident #15 may require a transfer to an all-male facility due to his behaviors. The MD further stated Resident #15 had some type of autistic disorder or [NAME]-[NAME] disorder (rare genetic condition that leads to physical, mental and behavioral problems). The MD stated Resident #15 was not able to make independent cognitive decisions. The MD stated that the incident between Resident #15 and Resident #94 should have been reported to the state. The MD further stated he had not participated in an IDT meeting with the RP or FM of Resident #15 and Resident #94 regarding the incident. In a phone interview on 3/25/26 at 10:53 am, the PA stated she was aware of the incident involving Resident #15 and Resident #94 that occurred on 03/03/26. The PA stated she could not recall if she was notified the same day or the following day. The PA stated there had been changes to Resident #15's antipsychotic medication prior to the incident, including a GDR, and reported the incident occurred following the GDR. The PA stated she was upset regarding the situation. The PA stated both Resident #15 and Resident #94 had the cognitive ability of a child between approximately four and five years old and stated neither resident had the capacity to consent to sexual activity or make adult decisions regarding such activity. The PA stated she was not involved in an IDR meeting with Resident #15 and Resident #94's RP or FM, but she knew both families were notified. The PA stated she had not personally spoken to either family. The PA stated the incident should have been reported to the state. In an interview on 03/25/26 at 11:01 am, the DON stated she became aware of the incident on 03/03/26 at approximately 8:30 - 9:00 am, following breakfast. The DON reported that the ADON informed her and the ADM during the morning meeting that staff had reported Resident #15 was in Resident #94's room, and they were being inappropriate with each other. The DON stated after the meeting, CNA A reported she was collecting breakfast trays when she observed Resident #15 in Resident #94's room with his penis exposed and believed it was in Resident #94's mouth. The DON stated the ADON was at the nurse's station and was the first individual CNA A reported the incident to. The DON further stated the ADON reported she did not observe Resident #15's penis upon entering the room, as his pants were up at that time. The DON stated she and the ADM entered the room and spoke with Resident #94, who was in bed and did not appear to be in any distress. The DON reported Resident #94 was unable to recall the incident. The DON stated at that time Resident #15 was getting ready to leave to a day rehabilitation center. The DON stated that she and the ADM initiated staff interviews regarding the incident. The DON reported the MD and psychiatric services were notified, and Resident #15's medication was adjusted. The DON stated the resident's RP's were also notified. The DON stated at times Resident #15 had a history of behaviors, including exposing himself in his room; however, she could not recall any prior incidents involving another female resident. The DON reported the facility had previously sought out psychiatric services for Resident #15, and that medication adjustments and psychiatric interventions appeared to have improved his behaviors. The DON stated there was uncertainty regarding whether Resident #15 and Resident #94 had the capacity to consent to sexual activity and described the situation as a gray area. The DON stated she did not believe the incident constituted sexual abuse and stated that if the facility had determined the incident to be sexual abuse, it would have been reported. The DON stated both residents had similar cognitive impairments. The DON stated she was unsure whether a head-to-toe assessment was completed following the incident but acknowledged that such an assessment, along with safe/safety assessments, should have been conducted. The DON stated she could not recall any specific interventions implemented for Resident #94 following the incident. The DON further stated she was unaware of a history of similar behaviors for Resident #94 but did state she had called out to Resident #15 to go into her room. In an interview on 03/25/26 at 11:47 am, the ADM stated she became aware of the incident on the morning of 03/03/26 through the ADON. The ADM reported the ADON informed her that CNA A entered Resident #94's room and observed Resident #15 with his penis exposed and near Resident #94's mouth. The ADM stated she immediately went to assess Resident #94, who was in bed, did not appear to be in distress, and denied that anything had occurred. The ADM stated Resident #15 also did not appear to be in distress. The ADM reported the ADON was in the process of notifying the MD, psychiatric services, and the family. The ADM stated Resident #15 had a history of exposing himself. The ADM stated she was not aware of prior incidents involving exposure to other female residents. The ADM reported staff would redirect Resident #15 away from female residents as needed. The ADM stated she believed Resident #15 and Resident #94 may have been able to consent to sexual activity but stated she was unsure how to determine whether either resident had the cognitive capacity to consent. The ADM stated the incident was not investigated as potential sexual abuse. The ADM further stated the facility determined the incident did not constitute sexual abuse, as neither resident appeared to be in distress and neither voiced concern. The ADM stated it appeared that both residents were willing participants. Record review of the facility's undated Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property Policy reflected in part: Preface- It is the policy of this facility to encourage and support all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse. Any nursing home employee or volunteer who becomes aware of abuse. shall immediately report to the Nursing Home Administrator. The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements. Centers for Medicaid and Medicare Services (CMS) - Definitions Definitions of Abuse and Neglect The following are the approved CMS definitions of abuse and neglect from the State Operations Manual Appendix PP effective November 28, 2016. a. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. ii. Sexual abuse is non-consensual sexual contact of any type with a resident. h. Immediately: means as soon as possible but ought not to exceed 24 hours after discovery of the incident, in the absence of a shorter State time frame requirement. Abuse Policy It is the policy of [Facility] that each resident will be free from Abuse. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse of any type will be tolerated and residents and staff will be monitored for Protection. Objective of Abuse Policy The objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention. B. Training Components Procedure: Staff and volunteers will receive education about resident mistreatment, neglect and abuse. upon first employment and annually after that, incorporating the following elements: Training on the abuse policies and procedures, The definition of what constitutes resident mistreatment, neglect, or abuse. Review of facility abuse policies and procedures, Annual notification of covered individuals of their obligation to comply with reporting requirements. Additional Investigation Protocols v. Notification of law enforcement and or State Agency. as indicated. F. Reporting and Response Abuse Policy Requirements: It is the policy of this facility that abuse allegations are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse. are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse.to the administrator of the facility and to other officials (including to the State Survey Agency.) in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility. Definitions (in accordance to the Elder Justice Act): Covered individual: A covered individual is defined as anyone who is an owner, operator, employee, manager, agent or contractor of the facility. Procedure: Internal Reporting: a. Employees must always report any abuse or suspicion of abuse immediately to the Administrator. b. The Administrator will involve key leadership personnel as necessary to assist with reporting, investigation and follow-up. c. The Administrator will report to the Medical Director. External Reporting: Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located, any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from the facility and each covered individual shall report immediately, but not more than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Initial reporting of allegations: If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency. A follow-up investigation will be submitted to the State Agency within five (5) working days. Law Enforcement: All reports of suspected crime and or alleged sexual abuse must be immediately reported to local law enforcement to be investigated. Facility staff will fully cooperate with the local law enforcement designee. The Administrator or designee will inform the resident or resident's representative of the report of an incident and that an investigation is being conducted. Covered individuals are obligated to comply with reporting requirements. If uncertain whether to report an incident, call the State Agency for further direction. Informing the Resident and or Responsible Party: The Administrator or designee will inform the resident and or responsible party the results of the investigation. This was determined to be an Immediate Jeopardy (IJ) on 03/25/26 at 5:25 pm. The ADM and DON were notified on 03/25/26 at 5:42 pm. The ADM was provided with the IJ template on 03/25/26 at 5:42 pm. The following Plan of Removal submitted by the facility was accepted on 03/26/26 at 8:04 pm. Plan of Removal for Immediate Jeopardy Problem: F609 Incidents of Abuse, Neglect, and Exploitation Reportable to the Texas Health and Human Services Commission and Law Enforcement Agencies by FacilitiesIn response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to HHSC Complaint and Incident Intake, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse, or result in serious bodily injury. Interventions: On March 25, 2026, the facility reviewed the BIMS of all admitted Residents on the secured memory unit and determined there were 20 female residents with severe cognitive impairment and 16 males with severe cognitive impairment. -Verified on 03/27/26 through record review and interview with the ADM. Training: Conducted on 3/24/26: The facility Administrator and Director of Nursing were in-serviced on PL 2024-14 (Reportable Incidents). -Verified on 03/27/26 through in-service record review and interview with ADM and DON. Training: Conducted on 3/25/26: The facility Administrator and Director of Nursing were in-serviced by the Corporate Nurse on implementing the company Abuse policy, with emphasis that the policy should be followed for any type of abuse. -Verified on 03/27/26 through in-service record review and staff interviews from various shifts. Training: Conducted on 3/25/26: The facility Administrator and Director of Nursing were in-serviced by the Corporate Nurse on the reporting time frame for allegations of abuse utilizing PL 2024-14 (Reportable Incidents). -Verified on 03/27/26 through in-service record review and interviews with the Corporate Nurse, ADM, and DON. Training: Conducted on 3/25/26: The facility Administrator and Director of Nursing were in-serviced by the Corporate Nurse that all allega

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 resident (Resident #15) of 6 residents whose care plans were reviewed. The facility failed to ensure Resident #15's care plan addressed his history of inappropriate sexual behaviors as well as including interventions to manage those behaviors. An Immediate Jeopardy (IJ) was identified on 03/26/26. The IJ template was provided to the facility Administrator on 03/26/26 at 3:26 pm. While the IJ was removed on 03/27/26 at 11:11 am, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to monitor and evaluate the effectiveness of the corrective systems. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services, and the implementation of personalized plan of care developed to address their specific needs. Findings include: Record review of Resident #15's admission record reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included moderate intellectual disabilities (developmental delays resulting in an average mental age of 6 to 9 years old), other frontotemporal neurocognitive disorder (also called frontotemporal dementia- a group of progressive brain diseases that cause neurons to die in the frontal and temporal lobes, causing early-onset dementia with symptoms such as loss of empathy, social inappropriateness, and language difficulties), cognitive communication deficit (difficulty with communication), and dementia with psychotic disturbance (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities with hallucinations or delusions). Record review of Resident #15's quarterly MDS dated [DATE] reflected a BIMS of 00 (severe cognitive impairment). Resident #15's functional abilities reflected independent for, sit to stand, sit to lying, chair/bed to chair-transfer and walking 10 - 50 feet. Resident #15 required setup or clean-up assistance with toileting and supervision or touching assistance for bathing. Resident #15 did have a behavior noted of wandering. Record review of Resident #15's care plan revised on 09/25/25 reflected did not reflect a history of inappropriate sexual behaviors. Record review of Resident #15 progress notes indicated: Resident #15's progress notes indicated he had previous inappropriate sexual behaviors on: 8/3/25- Resident #15 in female's room with his pants down with the female in the room. 7/19/25- Resident #15 was seen in T.V. room with his penis out and a female resident in the room. 6/28/25- Resident #15 exposed genitals to female residents several times 6/13/25- Resident #15 in another female resident's room with his hands in his pants while she slept. 6/8/25- Resident #15 pulled his pants down in front of a female resident. 5/22/25- Resident #15 continuously tried to enter a female resident's room with his penis exposed. 5/21/25- Resident #15 was seen standing in front of another resident's room with his pants down and his penis exposed. In an interview on 03/24/26 at 3:56 pm, the ADON stated Resident #15 did not have a prior history of inappropriate sexual behaviors with other residents. The ADON stated the MDS was responsible for care plans, and it was important to care plan resident behaviors, as care plans are individualized to address each resident's needs, including medications, behaviors, and activities of daily living. The ADON stated that if Resident #15's inappropriate sexual behaviors were not care planned, there could be an increased risk of harm to other residents related to sexual, physical, or behavioral interactions. In an interview on 03/25/26 at 10:53 am, the PA stated she was aware of Resident #15's sexual inappropriate behaviors and reported he had a history of such behaviors, which escalated following a GDR of Aripiprazole (an antipsychotic medication) from 10mg to 7.5mg on 01/22/26. In an interview on 03/26/26 at 11:05 am, the MDS stated he was responsible for care plans for all residents. The MDS stated he was not aware of any sexual behaviors for Resident #15 prior to the incident. The MDS stated if such behaviors were not care planned, staff would have clear guidance on what to monitor or how to respond. The MDS reported the nursing staff discussed the incident that occurred on 03/03/26 the following day and acknowledged the behavior should have been incorporated into the care plan but was not completed. The MDS stated he knew he should have documented the incident in the care plan, but it slipped through the cracks. The MDS stated he did not have to be directly told to put updates or changes in the care plan as he was the only one to update care plans.In an interview on 03/26/26 at 12:06 pm, the DON stated Resident #15 had a history of inappropriate sexual behaviors, including exposing himself and engaging in self-stimulatory behaviors in his room. The DON stated that if such behaviors were not care planned, they could continue without appropriate monitoring and staff may not know how to appropriately supervise or intervene. The DON further stated that failure to care plan Resident #15's inappropriate sexual behaviors could lead to incidents involving other residents and result in improper care. Record review of the facilities Care Plans, Comprehensive Person-centered policy dated March 2022 reflected: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship and between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition: b. when the desired outcome is not met This was determined to be an Immediate Jeopardy (IJ) on 03/25/26 at 5:25 pm. The ADM and DON were notified on 03/25/26 at 5:42 pm. The ADM was provided with the IJ template on 03/26/26 at 3:26 pm. The following Plan of Removal submitted by the facility was accepted on 03/26/26 at 8:04 pm. Plan of Removal for Immediate Jeopardy Problem: F656 The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights.A resident has a known history of inappropriate sexual behaviors and aggression, but the comprehensive care plan did not address the resident's inappropriate sexual behaviors or aggression which placed the resident and other residents in the facility at risk for serious physical and/or psychosocial injury, harm, impairment, or death.Interventions: On March 25, 2026, the facility reviewed the BIMS of all admitted Residents on the secured memory unit and determined there were 20 female residents with severe cognitive impairment and 16 males with severe cognitive impairment. -Verified on 03/27/26 through record review and interview with the ADM. Training: Conducted on 3/24/26: The facility Administrator and Director of Nursing were in-serviced on reportable incidents. -Verified on 03/27/26 through in-service record review and interview with ADM and DON. Training: Conducted on 3/25/26: The facility Administrator and Director of Nursing were in-serviced by the Corporate Nurse on implementing the company Abuse policy, with emphasis that the policy should be followed for any type of abuse. -Verified on 03/27/26 through in-service record review and staff interviews from various shifts. Training: Conducted on 3/25/26: The facility Administrator and Director of Nursing were in-serviced by the Corporate Nurse on the reporting timeframe for allegations of abuse utilizing PL 2024-14. -Verified on 03/27/26 through in-service record review and interviews with the Corporate Nurse, ADM, and DON. Training: Conducted on 3/25/26: The facility Administrator and Director of Nursing were in-serviced by the Corporate Nurse that all allegations of abuse must be investigated, and notification of the allegation details must be made to the Resident's Responsible Party. -Verified on 03/27/26 through in-service record review and interviews with the Corporate Nurse, ADM, and DON. Staff interviews from various shifts beginning on 03/27/26 at 8:00 am, revealed the ADM, DON, ADON, MDS, CNA A, LVN B, RNVC, LVN D, RN E, CNA F, LVN G, CNA H, CNA I, CNA J, LA, CMA K, CMA L, LVN M, LVN N, CNA O, HK, RN R, the AD, and RN T were able to identify the different types of abuse, neglect and who the Abuse Coordinator was. Staff stated regardless of the resident's cognition, all suspected abuse/sexual abuse would be stopped and reported to the ADM immediately. All staff were able to identify the yellow dot program and where it would be located. All CNA's were able to state in addition to the yellow dot being located on the resident's name plate outside of their room, those residents would also be listed on their shower sheets. Training: Will be completed by 3/26/26 as follows: All staff in-servicing on: what is abuse utilizing a combined definition on reportable incidents for the THHS and CMS definitions. what is sexual abuse; and reporting of all sexual abuse and/or sexual behaviors to the Administrator. (This includes all incidents regardless of a Resident's diagnosis and/or cognitive status as the Administrator will then follow the new procedure outlined below)a Resident's cognitive status influences their ability to consent.all instances of staff encounters with Resident sexual behaviors, especially those Residents with dementia, will be stopped, Resident's separated, Resident safety ensured, and immediate report made to the Administrator. Residents will be kept separated and monitored while Administrator makes a determination on ability to consent of Resident(s).Administrator and/or Designee will ensure continuity of transfer of information to staff between shifts. going forward, any Residents with a diagnosis of dementia and an occurrence of inappropriate sexual behaviors with another Resident and place a yellow dot on the Resident's nameplate to identify to staff 1) the Resident has the diagnosis and inappropriate sexual behavior with another Resident, and 2) to be more vigilant in monitoring the Resident's location. All newly admitted Residents will be reviewed for a diagnosis of dementia and a history of inappropriate sexual behaviors; any Residents who meet these criteria will have a yellow dot added to their nameplate. In-service sign in sheets will be cross referenced with employee roster. New Procedures: Effective 3/25/26: The Administrator and DON were verbally educated that all instances of sexual activity, sexual contact, sexual behaviors, and/or sexual abuse will be called to the Corporate Nurse for review. The review will include use of Attachment 2: How to Report Abuse, Neglect, Exploitation (ANE), Other Incidents and Sexual Activity included with PL 2024-14. The review process will involve the Resident's physician, and Resident and/or the Resident's Responsible Party. The Administrator will keep a log of all reported instances along with the outcome of the call. Special emphasis will be placed on any Resident(s) with BIMS of 12 or below. Going forward, the Facility will identify Residents with a diagnosis of dementia and an occurrence of inappropriate sexual behaviors with another Resident and place a yellow dot on the Resident's nameplate to signify to staff 1) the Resident has the diagnosis and inappropriate sexual behavior with another Resident, and 2) to be more vigilant in monitoring the Resident's location. All newly admitted Residents will be reviewed for a diagnosis of dementia and a history of inappropriate sexual behaviors; any Residents who meet these criteria will have a yellow dot added to their nameplate. The DON and/or Designee will be responsible for ensuring the yellow dot is placed on the Resident's nameplate in a timely manner. Quality Assurance Performance Improvement: On March 25, 2026, the Quality Assessment and Assurance Committee members to include the Medical Director (via telephone), Administrator, Director of Nursing, Assistant Director of Nursing, Social Worker, and Corporate Nurse met to review and approve this plan. -Verified on 03/27/26 through in-service record review and interviews with ADM, DON, and ADON. The Administrator and/or Designee will provide a copy of the log of instances of reported sexual activity, sexual contact, sexual behaviors, and/or sexual abuse to the Corporate Nurse for a second review weekly for 2 months. -Verified on 03/27/26 through an interview with the Corporate Nurse. The results of the Administrator and/or Designee reviews will be presented to the Quality Assessment and Assurance Committee for review of trends and/or negative findings and further recommendations during the scheduled meetings for 2 months. The committee will make recommendations for further education as warranted and develop further performance improvement plans as necessary. -Verified on 03/27/26 through interview with the ADM and DON. The ADM was informed that the Immediate Jeopardy was removed on 03/27/26 at 11:11 am. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interviews and record reviews, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for 2 of 6 residents (Resident #15 and Resident #94) reviewed for developing and implementing abuse and neglect policies and procedures. The facility failed to follow their policy to investigate suspected sexual abuse of Resident #94 by Resident #15 on 03/03/26 when Resident #15 was witnessed in Resident #94's room with his penis in and or on Resident #94's mouth. An Immediate Jeopardy (IJ) was identified on 03/25/26. The IJ template was provided to the facility Administrator on 03/25/26 at 5:42 pm. While the IJ was removed on 03/27/26 at 11:11 am, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to monitor and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of abuse and or continued abuse and could lead to a diminished quality of life and psychosocial harm. The findings included: Record review of Resident #94's admission record reflected an [AGE] year-old female originally admitted to the facility on [DATE] and most recent admission was 01/03/24. Her diagnoses included Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), dementia (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities), major depressive disorder, recurrent (persistently low or depressed mood and a loss of interest in activities that creates significant difficulty in daily life, work, and social functioning), delusional disorder (a type of mental health condition in which a person can't tell what's real from what's imagined), anxiety disorder (mental disorder characterized by excessive and persistent worry, fear, or anxiousness which significantly interferes with daily life), and unspecified psychosis (psychotic symptoms not aligned with a specific psychotic disorder or mental illness). Record review of Resident #94's annual MDS dated [DATE] reflected a BIMS score of 3 which indicated she had severe cognitive impairment. Resident #94's functional abilities reflected she required partial to moderate assistance for sit to stand, sitting to lying, chair/bed to chair-transfer, toileting, bathing, and walking 10 - 50 feet. Resident #94 also had behavioral symptoms directed toward others (such as hitting, scratching, and kicking) and verbal behavioral symptoms directed toward others (such as threatening others, screaming at others, cursing at others) on 1 to 3 days of the observation period. Record review of Resident #94's care plan dated 05/16/20 reflected: Focus: I have a dx: Cognitive Communication [sic] created 11/29/20. Interventions included: Involve in activities that do not rely on communication, monitor for changes in condition, reassurance and patience when resident attempts communication, use hand gestures as needed, use short phrases that require yes or no answers. Focus: I wander in the nursing home and into other resident's rooms. DX: Dementia/Alzheimer's. I am in a secured unit. Initiated on 11/29/20. Interventions included: Assist to reorientation to room and facility, assure that staff is aware that resident wanders, routine resident check Q 2Hrs and locate resident whereabouts. Focus: I have cognitive loss; moderately impaired in decisions making; short term memory loss. DX: Alzheimer's/Dementia. Interventions included: Assist in decision making by giving simple choices, assure that resident's wishes are understood by being patient, keep environment free of hazards. Initiated on 11/29/20. Record review of Resident #94's progress notes reflected: A nursing Note dated 03/03/26 at 9:29 am by LVN B stated, Male resident had been going into resident's room exposing himself and this particular incident he made physical contact with her inappropriately and was needing to be redirected. RP called and no answer, left message to call facility. A nursing note effective 03/03/26 at 1:28 pm, created 3/9/2026 at 4:32 pm by the ADON stated, Charge nurse witnessed Female Resident door open calling out for the male resident previously in her room. Hey come here, come here. Female resident inviting male resident to come into her room. Redirected male resident. Record review of Resident #94's assessments reflected Resident #94 had a weekly skin assessment completed on 03/02/26 and a weekly skin assessment completed on 03/09/26. There were no assessments documented on 03/03/26. Record review of Resident #15's admission record reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included moderate intellectual disabilities (developmental delays resulting in an average mental age of 6 to 9 years old), other frontotemporal neurocognitive disorder (also called frontotemporal dementia or FTD- a group of progressive brain diseases that cause neurons to die in the frontal and temporal lobes, causing early-onset dementia with symptoms such as loss of empathy, social inappropriateness, and language difficulties), cognitive communication deficit (difficulty with communication), and dementia with psychotic disturbance (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities with hallucinations or delusions). Record review of Resident #15's quarterly MDS dated [DATE] reflected a BIMS of 00 (severe cognitive impairment). Resident #15's functional abilities reflected independent for, sit to stand, sit to lying, chair/bed to chair-transfer and walking 10 - 50 feet. Resident #15 required setup or clean-up assistance with toileting and supervision or touching assistance for bathing. Record review of Resident #15's care plan dated 10/22/16 and reviewed on 03/25/26 reflected: Focus: I at times exhibit inappropriate behavior of: I refuse to shower or change my clothes. I don't like brushing my teeth. I need great encouragement and assistance in doing my personal hygiene. I will steal money. I will steal sodas. Interventions included: Approach in a calm and reassuring manner, encourage involvement of families and friends, encourage socializations as tolerated, explain care procedures in simple terms, please reinforce positive behavior, report significant changes in behavior status to MD. Focus: I demonstrate socially unacceptable behavior by next review in 90 days. [sic] I will steal drinks from staff and other residents. I will steal food and candy from staff and other residents. I will make farting noises and blame other people. I will call people pigs in spanish. I will use inappropriate gestures towards staff and other residents at times. Interventions included: If behavior does continue, notify MD, family, and SW, provide privacy if needed, psychiatric evaluation if needed, remind resident that behavior is not acceptable, set limits on behavior. Focus: I have a dx: cognitive communication. Interventions included: Always face resident when speaking, monitor for changes in condition, reassurance and patience when resident attempts to communication [sic], use hand gestures as necessary, use short phrases and questions that require yes or no answers. Focus: I wander in the nursing home and into other residents rooms. DX: Dementia. I am in a secured unit. Interventions included: Assist to reorientation to room and facility, assure that staff is aware that resident wanders, encourage group activities and keep resident occupied, help resident identify there [sic] room by placing familiar items in there, provide reality orientation throughout the day, provide verbal cues and reminding often, routine resident check Q2hrs and locate resident whereabouts. Record review of Resident #15's progress notes reflected: A nursing note dated 05/21/25 stated, Resident noted standing in from of another resident in room with his pans down and genitalia exposed. Nurse then redirected resident out of room and back to his room. Hall nurse attended to other resident in room. ADON notified. A nursing noted dated 05/22/25 stated, Resident cont. to enter [female resident name] room while trying to expose penis. Writer attempting to redirect resident not successful. Resident not able to remove from rm. Writer utilized w/c and escorted resident back to own rm. Notified charge nurse. A nursing note dated 06/08/25 stated, Inappropriate behavior in front of female resident. Pulled his pants down in front of female. Redirected by CNA. Resident was noted wandering around resident. Frequent monitoring of resident by staff. An interdisciplinary note dated 06/12/25 at 10:09 am stated, IDT weekly psych meeting: Resident started on Paroxetine HCl tablet 20mg. Give 1 tablet by mouth one time a day related to major depressive disorder. S/E and behavior monitoring in place as well as consent. A nursing note dated 06/13/25 at 11:08 am stated, Resident noted in female room {room number] with his hand in his pants and female resident asleep. ADON notified. Interventions: 1) 30 min checks, 2) collect UA/C&S- stat order, 3) suspenders for pants. A nursing note dated 06/25/25 at 2:02 pm stated, Inappropriate behavior at 12:29 pm in from of female resident. Redirected by staff. Constant monitoring, cont. with hourly checks. A nursing note dated 06/28/25 at 6:49 am which stated, resident continues with inappropriate behaviors such as exposing his genitals to female residents several times throughout the day. he requires frequent checks and continuous redirection by staff due to this. ADON is aware. Nursing note dated 07/19/25 at 1:21 pm stated, CNA reported she witnessed resident in TV room, with penis out. Male resident hands were placed on his penis. Female resident in TV room and sitting on the chair, when CNA saw she called out for resident and male resident put his penis back in pants. Female resident turned head. Female resident removed from TV room, denies pain or distress. Male resident placed on 15 min checks, notified on call and ADON. UA orders, notified psych services, pending call back. Resident observed lying in bed, eyes closed. No distress or pain noted. A nursing note dated 07/19/25 at 2:05 pm stated, new order from psych services: increase Paxil 40mg and one time order Ativan 0.5mg x1 dose. Oncoming nurse aware. Care endorsed. An interdisciplinary note dated 07/24/25 at 10:27 am stated, IDT weekly psych meeting: Paxil increased by psych PA. No side effects noted. Continue to monitor. A nursing note dated 07/26/25 at 7:15 am stated, Resident attempting to enter female's room. CNA redirected resident out of the room. Resident cooperative. Will continue to monitor. A nursing note dated 08/03/25 at 1:37 pm stated, Informed by housekeeper she observed resident in female's room [room number] with his pants down and female bent forward. Removed resident from room and instructed not to go into female's rooms anymore. Started on 15 min checks. ADON notified of resident's inappropriate sexual behavior. Will continue to monitor. A nursing noted dated 08/18/25 at 10:11 am stated, Notified [PA] of resident increased sexual behavior in female resident room. Pending response. A nursing note effective 03/02/26 at 10:01 am, created 03/03/26 at 9:11 am, and struck out ( incorrect documentation) on 03/25/26 at 7:34 am by LVN B stated, Resident was caught by CNA after breakfast in a female resident's room with his pants down exposing himself to her and having her grab his penis. CNA intervened and redirected him and got him out of female's room. But after a while resident cont. to try and walk back towards that female's room and required constant redirection until he left to center. Cont. to monitor and redirect resident. A nursing note dated 03/03/26 at 9:11 am by LVN B stated, Resident was caught by CNA during breakfast in female resident's room with door closed and was exposing himself to her and had his penis in her mouth. CNA intervened and redirected him out of her room. Will continue to monitor. Notified psych services and RP has been notified of his behaviors. A nursing note dated 03/03/26 at 10:00 am by LVN B stated, Psych services re-evaluated his meds and n/o given. Increase back his abilify. Discontinue abilify 7.5mg QD to start 10mg QD. RP was notified. A nursing note dated 03/03/26 at 10:04 am by the ADON stated, ADON at nurse's station was called by CNA into female resident's room. Male resident had his pants up. Male resident was easily redirected out of female resident's room. Female resident was calm with no verbal refusal, no facial grimacing. Female resident had no signs of distress. Reported to ADM/DON/IDT. Will continue to monitor. A nursing note dated 03/03/26 at 8:20 pm stated, Resident continues with hypersexual behavior. Goes into females room, redirected PRN. Med as ordered. Will continue to monitor. A nursing note dated 03/14/26 at 4:35 pm stated, Resident continues going into female resident room. Redirected this shift and as needed. Will continue to monitor. In an interview on 03/24/26 at 3:30 pm, Resident #94 stated she did not have a boyfriend, and could not recall how old she was and was not able to answer if she felt fearful. In a phone interview on 03/24/26 at 3:41 pm, the RP of Resident #94 stated he would not have given consent for Resident #94 to be involved with any sexual activity. The RP stated Resident #94 had dementia and was incapacitated (made incapable of or unfit for normal functioning) and was not in her right mind. In an interview on 3/24/26 at 3:56 pm, the ADON stated she was at the nurse's station when CNA A started yelling out for her from the doorway of Resident #94's room. The ADON stated she went over and into Resident #94's room and saw Resident #15 with his pants up and standing next to the head of Resident #94's bed. The ADON stated CNA A informed her she saw Resident #15's penis in Resident #94's mouth. The ADON stated Resident #15 was redirected out of the room, and she immediately reported the incident to the ADM and DON. The ADON stated shortly after, Resident #15 left to the day habilitation center that he attends on Mondays, Tuesdays, and Thursdays. The ADON stated Resident #15 did not have a history of any sexual behaviors with any resident. The ADON stated Resident #94 was acting normal, not fearful or crying. The ADON stated Resident #94 had no facial grimacing, and she appeared to be comfortable. The ADON stated she did not recall if a head-to-toe assessment was done for the incident, but if there was not an assessment done, it would not have hurt to have done one. The ADON stated Resident #94's FM was seen talking to LVN B the next day, and the FM did not appear to be upset. The ADON stated Resident #94's FM said something along the lines of well she's been married 3 times, what do you expect. The ADON stated she could not recall if there was an IDT meeting with the family present after the incident. The ADON stated she could not recall what the doctor stated when notified about the incident. The ADON stated she did not witness any consent between Resident #15 and Resident #94, but when she walked into the room during the incident, it appeared consensual. The ADON stated Resident #15's BIMS was a 0 and meant he had severe cognitive impairment. The ADON stated she would have to look but was pretty sure Resident #94 had severe cognitive impairment as well. The ADON could not answer if both residents could consent. The ADON stated that to get consent it would have had to have been discussed through the IDT because the residents had rights. The ADON stated she did not feel comfortable answering if both Resident #15 and Resident #94 could consent since they both had severe cognitive impairment. The ADON stated she did not witness the actual incident, but from what she was told by CNA A, both residents appeared to be consenting due to not showing any fear. In an interview on 03/25/26 at 8:31 am, CNA A stated she was collecting breakfast trays when she went to check on Resident #94 and observed Resident #15 in the room. CNA A stated she observed Resident #94 sitting up in bed and Resident #15 was positioned at the head of the bed, making thrusting movements with his pelvis. CNA A stated she asked Resident #15 what he was doing, at which time he pulled away from the bed. CNA A reported that she then observed Resident #94 with her hands raised, in a grabbing position. CNA A stated she immediately called out for the ADON, who responded to the room and removed Resident #15. CNA A stated Resident #94 indicated she was okay but was unable to explain what had occurred. CNA A reported that, to her knowledge, Resident #94's family had not provided consent for the resident to engage in any sexual activity. In an interview on 03/25/26 at 8:44 am, LVN B stated she did not witness the incident but was informed of it by the ADON. LVN B stated that upon being notified, she contacted the doctor, the PA, and called Resident #94's RP. LVN B reported that she left a message for Resident #15's RP and called Resident #94's second contact. LVN B stated that after notifying the PA, the PA reviewed Resident #15's medications and made adjustments; however, LVN B could not recall the specific changes. LVN B reported that Resident #94's RP did not return her call. LVN B stated that on the day following the incident, 03/04/26, the FM of Resident #94 came to the facility, and she informed the FM of the incident that had occurred on the previous day. LVN B stated that the FM did not appear upset regarding the situation. LVN B stated she was not aware of any consent given by Resident #94's RP to have a sexual relationship. LVN B stated she could not determine whether Resident #15 and Resident #94 were able to consent. LVN B stated that the residents had rights. LVN B stated, as far as she knew, Resident #15 did not have any prior inappropriate sexual behavior. LVN B stated she struck out the nursing note that referred to an incident on 03/02/26 because she, documented the wrong incident. Not that there were two incidents- she just documented wrong. In a phone interview on 03/25/26 at 10:49 am, the FM of Resident #94 stated she was informed about an inappropriate incident that occurred with Resident #94 but was not given details about the incident. The FM stated she assumed a male resident was just wandering in Resident #94's room and the facility was keeping them apart. The FM stated she did not give consent to Resident #94 to have any sexual activity with any resident, and stated Resident #94 did not have the cognition to consent. In a phone interview on 3/25/26 at 10:28 am, the MD stated he was notified about the incident between Resident #15 and Resident #94 on 03/03/26. The MD stated he did not believe Resident #15 or Resident #94 had the capacity to consent to sexual activity and reported that Resident #94 was bed confined. The MD stated Resident #15 may require a transfer to an all-male facility due to his behaviors. The MD further stated Resident #15 had some type of autistic disorder or [NAME]-[NAME] disorder (rare genetic condition that leads to physical, mental and behavioral problems). The MD stated Resident #15 was not able to make independent cognitive decisions. The MD stated that the incident between Resident #15 and Resident #94 should have been reported to the state. The MD further stated he had not participated in an IDT meeting with the RP or FM of Resident #15 and Resident #94 regarding the incident. In a phone interview on 3/25/26 at 10:53 am, the PA stated she was aware of the incident involving Resident #15 and Resident #94 that occurred on 03/03/26. The PA stated she could not recall if she was notified the same day or the following day. The PA stated there had been changes to Resident #15's antipsychotic medication prior to the incident, including a GDR, and reported the incident occurred following the GDR. The PA stated she was upset regarding the situation. The PA stated both Resident #15 and Resident #94 had the cognitive ability of a child between approximately four and five years old and stated neither resident had the capacity to consent to sexual activity or make adult decisions regarding such activity. The PA stated she was not involved in an IDR meeting with Resident #15 and Resident #94's RP or FM, but she knew both families were notified. The PA stated she had not personally spoken to either family. The PA stated the incident should have been reported to the state. In an interview on 03/25/26 at 11:01 am, the DON stated she became aware of the incident on 03/03/26 at approximately 8:30 - 9:00 am, following breakfast. The DON reported that the ADON informed her and the ADM during the morning meeting that staff had reported Resident #15 was in Resident #94's room, and they were being inappropriate with each other. The DON stated after the meeting, CNA A reported she was collecting breakfast trays when she observed Resident #15 in Resident #94's room with his penis exposed and believed it was in Resident #94's mouth. The DON stated the ADON was at the nurse's station and was the first individual CNA A reported the incident to. The DON further stated the ADON reported she did not observe Resident #15's penis upon entering the room, as his pants were up at that time. The DON stated she and the ADM entered the room and spoke with Resident #94, who was in bed and did not appear to be in any distress. The DON reported Resident #94 was unable to recall the incident. The DON stated at that time Resident #15 was getting ready to leave to a day rehabilitation center. The DON stated that she and the ADM initiated staff interviews regarding the incident. The DON reported the MD and psychiatric services were notified, and Resident #15's medication was adjusted. The DON stated the resident's RP's were also notified. The DON stated at times Resident #15 had a history of behaviors, including exposing himself in his room; however, she could not recall any prior incidents involving another female resident. The DON reported the facility had previously sought out psychiatric services for Resident #15, and that medication adjustments and psychiatric interventions appeared to have improved his behaviors. The DON stated there was uncertainty regarding whether Resident #15 and Resident #94 had the capacity to consent to sexual activity and described the situation as a gray area. The DON stated she did not believe the incident constituted sexual abuse and stated that if the facility had determined the incident to be sexual abuse, it would have been reported. The DON stated both residents had similar cognitive impairments. The DON stated she was unsure whether a head-to-toe assessment was completed following the incident but acknowledged that such an assessment, along with safe/safety assessments, should have been conducted. The DON stated she could not recall any specific interventions implemented for Resident #94 following the incident. The DON further stated she was unaware of a history of similar behaviors for Resident #94 but did state she had called out to Resident #15 to go into her room. In an interview on 03/25/26 at 11:47 am, the ADM stated she became aware of the incident on the morning of 03/03/26 through the ADON. The ADM reported the ADON informed her that CNA A entered Resident #94's room and observed Resident #15 with his penis exposed and near Resident #94's mouth. The ADM stated she immediately went to assess Resident #94, who was in bed, did not appear [NAME] in distress, and denied that anything had occurred. The ADM stated Resident #15 also did not appear to be in distress. The ADM reported the ADON was in the process of notifying the MD, psychiatric services, and the family. The ADM stated Resident #15 had a history of exposing himself. The ADM stated she was not aware of prior incidents involving exposure to other female residents. The ADM reported staff would redirect Resident #15 away from female residents as needed. The ADM stated she believed Resident #15 and Resident #94 may have been able to consent to sexual activity but stated she was unsure how to determine whether either resident had the cognitive capacity to consent. The ADM stated the incident was not investigated as potential sexual abuse. The ADM further stated the facility determined the incident did not constitute sexual abuse, as neither resident appeared to be in distress and neither voiced concern. The ADM stated it appeared that both residents were willing participants. Record review of the facility's undated Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property Policy reflected in part: Preface- It is the policy of this facility to encourage and support all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse. Any nursing home employee or volunteer who becomes aware of abuse. shall immediately report to the Nursing Home Administrator. The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements. Centers for Medicaid and Medicare Services (CMS) - Definitions Definitions of Abuse and Neglect The following are the approved CMS definitions of abuse and neglect from the State Operations Manual Appendix PP effective November 28, 2016. a. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. ii. Sexual abuse is non-consensual sexual contact of any type with a resident. h. Immediately: means as soon as possible but ought not to exceed 24 hours after discovery of the incident, in the absence of a shorter State time frame requirement. Abuse Policy It is the policy of [Facility] that each resident will be free from Abuse. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse of any type will be tolerated and residents and staff will be monitored for Protection. Objective of Abuse Policy The objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention. B. Training Components Procedure: Staff and volunteers will receive education about resident mistreatment, neglect and abuse. upon first employment and annually after that, incorporating the following elements: Training on the abuse policies and procedures, Training about challenging behaviors and how to intervene, The definition of what constitutes resident mistreatment, neglect, or abuse. Review of facility abuse policies and procedures, Annual notification of covered individuals of their obligation to comply with reporting requirements. C. Prevention The facility leadership will assess the needs of the residents in the facility to be able to identify concerns to prevent potential abuse. Procedure: 1. Resident Assessment Every resident is unique and may be subject to abuse based on a variety of circumstances, including facility physical plant, environment, the resident's health, behavior or cognitive level. b. Upon admission and periodically after that, each resident will have a safety or vulnerability assessment completed which identifies potential vulnerabilities such as cognitive, physical, psychosocial, environment and communication concerns. c. The interdisciplinary team will identify the vulnerabilities and interventions on the resident care plan. 4. Population a. The facility's population presents the following factors, (May include, but not limited to) which could result in maltreatment of residents: The assessment, planning of care and services, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents who have behaviors such as entering other residents' rooms, wandering behaviors. socially inappropriate behaviors.residents with communications disorders. b. The facility will ensure a comprehensive dementia management program to prevent resident abuse. 5. Predatory Offender Provisions When assessing a person's risk of abusing other vulnerable adults, or if a predatory offender is seeking or has been admitted to the facility: The facility must notify other residents that a predatory offender has been admitted . If it is determined that notice to a resident not be appropriate because of the resident's medical, emotional, or mental status, the resident's next of kin or emergency contact (resident representative) must be notified. D. Identification Abuse policy requirements: It is the policy of this facility that all staff monitor residents and will know how to identify potential signs and symptoms of abuse. Occurrences, patterns, and trends that may constitute abuse will be investigated. Procedure: All staff will receive education about how to identify signs and symptoms of abuse. Residents will be monitored for possible signs of abuse. E. Investigation Abuse policy requirements: It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse.) are promptly and thoroughly investigated. Procedure: The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration. a. Investigation of abuse: When an incident of suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: i. Who was involved ii. Residents' statements a. For non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview resident first. If unable, observe resident, complete an evaluation of resident behavior, affect, and response to interaction, and document findings. IV. Involved staff and witness statements of events. v. A description of the resident's behavior and environment at the time of the incident. vi. Injuries present including a resident assessment. vii. Observation of resident and staff behaviors during the investigation. viii. Environmental considerations. Additional Investigation Protocols i. If the alleged perpetrator is a facility resident, the staff member will immediately remove the perpetrator from the situation and another staff member will stay with the alleged perpetrator and wait for further instruction from administration, if possible. ii. Examine, assess and interview the resident and other residents potentially affected immediately to determine any injury and identify any immediate clinical interventions necessary. iii. Social Services or designee should keep in frequent contact with the resident and or resident representative. iv. If the resident could be at risk in the same environment, evaluate the situation and consider options including a room change or roommate change. v. Notification of law enforcement and or State Agency. as indicated. F. Reporting and Response Abuse Policy Requirements: It is the policy of this facility that abuse allegations are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse. are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse.to the administrator of the facility and to other officials (including to the State Survey Agency.) in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility. Definitions (in accordance to the Elder Justice Act): Covered individual: A covered individual is defined as anyone who is an owner, operat

Based on interviews and record reviews, the facility failed to ensure the right to be free from abuse for two (Residents #15 and Resident #94) of 6 residents reviewed for abuse. The facility failed to ensure Resident #94 was free from sexual abuse on 03/03/26 when Resident #15, who had a history of sexual inappropriate behavior, was seen by CNA A putting his penis on or/in Resident #94's mouth. An Immediate Jeopardy (IJ) was identified on 03/25/26. The IJ template was provided to the facility Administrator on 03/25/26 at 5:42 pm. While the IJ was removed on 03/27/26 at 11:11 am, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to monitor and evaluate the effectiveness of the corrective systems. This deficient practice placed residents at risk of psychosocial harm and continued abuse. Findings included: Record review of Resident #15's admission record reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included moderate intellectual disabilities (developmental delays resulting in an average mental age of 6 to 9 years old), other frontotemporal neurocognitive disorder (also called frontotemporal dementia- a group of progressive brain diseases that cause neurons to die in the frontal and temporal lobes, causing early-onset dementia with symptoms such as loss of empathy, social inappropriateness, and language difficulties), cognitive communication deficit (difficulty with communication), and dementia with psychotic disturbance (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities with hallucinations or delusions). Record review of Resident #15's quarterly MDS dated [DATE] reflected a BIMS of 00 (severe cognitive impairment). Resident #15's functional abilities reflected independent for, sit to stand, sit to lying, chair/bed to chair-transfer and walking 10 - 50 feet. Resident #15 required setup or clean-up assistance with toileting and supervision or touching assistance for bathing.Record review of Resident #15's care plan revised on 09/25/25 reflected: Resident #15 resides in the secure unit and wanders into other residents' rooms. Resident #15 has acute confusional state characterized by; changes in consciousness, disorientation, environmental awareness, behavior related to: Moderate Intellectual Disabilities. Interventions Included: Assist to reorientation to room and facility Assure that staff are aware Resident #15 wanders Routine resident checks every 2 hours and locate Resident #15's whereabouts Record review of Resident #15's progress note dated 03/03/26 at 9:11 am reflected: resident was caught by [CNA A] during breakfast in female residents room with door closed and was exposing himself to her and had his penis in her mouth, [CNA A] intervened and redirected him out of her room. Will continue to monitor, notified psych services and [RP] has been notified of his behaviors. Record review of Resident #15 progress notes indicated: Resident #15's progress notes indicated he had previous inappropriate sexual behaviors on:8/3/25- Resident #15 in female's room with his pants down with the female in the room.7/19/25- Resident #15 was seen in T.V. room with his penis out and a female resident in the room.6/28/25- Resident #15 exposed genitals to female residents several times6/13/25- Resident #15 in another female resident's room with his hands in his pants while she slept.6/8/25- Resident #15 pulled his pants down in front of a female resident.5/22/25- Resident #15 continuously tried to enter a female resident's room with his penis exposed. 5/21/25- Resident #15 was seen standing in front of another resident's room with his pants down and his penis exposed.Record review of Resident #94's admission record reflected an [AGE] year-old female originally admitted to the facility on [DATE] and most recent admission was 01/03/24. Her diagnoses included Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), dementia (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities), major depressive disorder, recurrent (persistently low or depressed mood and a loss of interest in activities that creates significant difficulty in daily life, work, and social functioning), delusional disorder (a type of mental health condition in which a person can't tell what's real from what's imagined), anxiety disorder (mental disorder characterized by excessive and persistent worry, fear, or anxiousness which significantly interferes with daily life), and unspecified psychosis (psychotic symptoms not aligned with a specific psychotic disorder or mental illness). Record review of Resident #94's annual MDS dated [DATE] reflected a BIMS score of 3 (severe cognitive impairment). Record review of Resident #94's care plan dated 05/16/20 reflected: Resident #94 wanders in the nursing home and into other residents' rooms. DX: Dementia/Alzheimer's. Resident #94 resides in the secured unit. Resident #94 had cognitive loss; moderately impaired in decisions making; short term memory loss. DX: Alzheimer's/dementia Interventions included: Assist to reorientation to room and facility, assure that staff is aware that resident wanders, routine resident check Q 2Hrs and locate resident whereabouts. Assist in decision making by giving simple choices, assure that resident's wishes are understood by being patient, keep environment free of hazards In an interview on 03/24/26 at 3:30 pm, Resident #94 stated she did not have a boyfriend, and could not recall how old she was and was not able to answer if she felt fearful. In a phone interview on 03/24/26 at 3:41 pm, the RP of Resident #94 stated he would not have given consent for Resident #94 to be involved with any sexual activity. The RP stated Resident #94 had dementia and was incapacitated (made incapable of or unfit for normal functioning) and was not in her right mind. In an interview on 3/24/26 at 3:56 pm, the ADON stated she was at the nurse's station when CNA A started yelling out for her from the doorway of Resident #94's room. The ADON stated she went over and into Resident #94's room and saw Resident #15 with his pants up and standing next to the head of Resident #94's bed. The ADON stated CNA A informed her she saw Resident #15's penis in Resident #94's mouth. The ADON stated Resident #15 was redirected out of the room, and she immediately reported the incident to the ADM and DON. The ADON stated shortly after, Resident #15 left to the day habilitation center that he attends on Mondays, Tuesdays, and Thursdays. The ADON stated Resident #15 did not have a history of any sexual behaviors with any resident. The ADON stated Resident #94 was acting normal, not fearful or crying. The ADON stated Resident #94 had no facial grimacing, and she appeared to be comfortable. The ADON stated she did not recall if a head-to-toe assessment was done for the incident, but if there was not an assessment done, it would not have hurt to have done one. The ADON stated Resident #94's FM was seen talking to LVN B the next day, and the FM did not appear to be upset. The ADON stated Resident #94's FM said something along the lines of well she's been married 3 times, what do you expect. The ADON stated she could not recall if there was an IDT meeting with the family present after the incident. The ADON stated she could not recall what the doctor stated when notified about the incident. The ADON stated she did not witness any consent between Resident #15 and Resident #94, but when she walked into the room during the incident, it appeared consensual. The ADON stated Resident #15's BIMS was a 0 and meant he had severe cognitive impairment. The ADON stated she would have to look but was pretty sure Resident #94 had severe cognitive impairment as well. The ADON could not answer if both residents could consent. The ADON stated that to get consent it would have had to have been discussed through the IDT because the residents had rights. The ADON stated she did not feel comfortable answering if both Resident #15 and Resident #94 could consent since they both had severe cognitive impairment. The ADON stated she did not witness the actual incident, but from what she was told by CNA A, both residents appeared to be consenting due to not showing any fear. In an interview on 03/25/26 at 8:31 am, CNA A stated she was collecting breakfast trays when she went to check on Resident #94 and observed Resident #15 in the room. CNA A stated she observed Resident #94 sitting up in bed and Resident #15 was positioned at the head of the bed, making thrusting movements with his pelvis. CNA A stated she asked Resident #15 what he was doing, at which time he pulled away from the bed. CNA A reported that she then observed Resident #94 with her hands raised, in a grabbing position. CNA A stated she immediately called out for the ADON, who responded to the room and removed Resident #15. CNA A stated Resident #94 indicated she was okay but was unable to explain what had occurred. CNA A reported that, to her knowledge, Resident #94's family had not provided consent for the resident to engage in any sexual activity. In an interview on 03/25/26 at 8:44 am, LVN B stated she did not witness the incident but was informed of it by the ADON. LVN B stated that upon being notified, she contacted the doctor, the PA, and called Resident #94's RP. LVN B reported that she left a message for Resident #15's RP and called Resident #94's second contact. LVN B stated that after notifying the PA, the PA reviewed Resident #15's medications and made adjustments; however, LVN B could not recall the specific changes. LVN B reported that Resident #94's RP did not return her call. LVN B stated that on the day following the incident, 03/04/26, the FM of Resident #94 came to the facility, and she informed the FM of the incident that had occurred on the previous day. LVN B stated that the FM did not appear upset regarding the situation. LVN B stated she was not aware of any consent given by Resident #94's RP to have a sexual relationship. LVN B stated she could not determine whether Resident #15 and Resident #94 were able to consent. LVN B stated that the residents had rights. LVN B stated, as far as she knew, Resident #15 did not have any prior inappropriate sexual behavior. In a phone interview on 03/25/26 at 10:49 am, the FM of Resident #94 stated she was informed about an inappropriate incident that occurred with Resident #94 but was not given details about the incident. The FM stated she assumed a male resident was just wandering in Resident #94's room and the facility was keeping them apart. The FM stated she did not give consent to Resident #94 to have any sexual activity with any resident, and stated Resident #94 did not have the cognition to consent. In a phone interview on 3/25/26 at 10:28 am, the MD stated he was notified about the incident between Resident #15 and Resident #94 on 03/03/26. The MD stated he did not believe Resident #15 or Resident #94 had the capacity to consent to sexual activity and reported that Resident #94 was bed confined. The MD stated Resident #15 may require a transfer to an all-male facility due to his behaviors. The MD further stated Resident #15 had some type of autistic disorder or [NAME]-[NAME] disorder (rare genetic condition that leads to physical, mental and behavioral problems). The MD stated Resident #15 was not able to make independent cognitive decisions. The MD stated that the incident between Resident #15 and Resident #94 should have been reported to the state. The MD further stated he had not participated in an IDT meeting with the RP or FM of Resident #15 and Resident #94 regarding the incident. In a phone interview on 3/25/26 at 10:53 am, the PA stated she was aware of the incident involving Resident #15 and Resident #94 that occurred on 03/03/26. The PA stated she could not recall if she was notified the same day or the following day. The PA stated there had been changes to Resident #15's antipsychotic medication prior to the incident, including a GDR, and reported the incident occurred following the GDR. The PA stated she was upset regarding the situation. The PA stated both Resident #15 and Resident #94 had the cognitive ability of a child between approximately four and five years old and stated neither resident had the capacity to consent to sexual activity or make adult decisions regarding such activity. The PA stated she was not involved in an IDR meeting with Resident #15 and Resident #94's RP or FM, but she knew both families were notified. The PA stated she had not personally spoken to either family. The PA stated the incident should have been reported to the state. In an interview on 03/25/26 at 11:01 am, the DON stated she became aware of the incident on 03/03/26 at approximately 8:30 - 9:00 am, following breakfast. The DON reported that the ADON informed her and the ADM, the Abuse Coordinator, during the morning meeting that staff had reported Resident #15 was in Resident #94's room, and they were being inappropriate with each other. The DON stated after the meeting, CNA A reported she was collecting breakfast trays when she observed Resident #15 in Resident #94's room with his penis exposed and believed it was in Resident #94's mouth. The DON stated the ADON was at the nurse's station and was the first individual CNA A reported the incident to. The DON further stated the ADON reported she did not observe Resident #15's penis upon entering the room, as his pants were up at that time. The DON stated she and the ADM entered the room and spoke with Resident #94, who was in bed and did not appear to be in any distress. The DON reported Resident #94 was unable to recall the incident. The DON stated at that time Resident #15 was getting ready to leave to a day rehabilitation center. The DON stated that she and the ADM initiated staff interviews regarding the incident. The DON reported the MD and psychiatric services were notified, and Resident #15's medication was adjusted. The DON stated the resident's RP's were also notified. The DON stated at times Resident #15 had a history of behaviors, including exposing himself in his room; however, she could not recall any prior incidents involving another female resident. The DON reported the facility had previously sought out psychiatric services for Resident #15, and that medication adjustments and psychiatric interventions appeared to have improved his behaviors. The DON stated there was uncertainty regarding whether Resident #15 and Resident #94 had the capacity to consent to sexual activity and described the situation as a gray area. The DON stated she did not believe the incident constituted sexual abuse and stated that if the facility had determined the incident to be sexual abuse, it would have been reported. The DON stated both residents had similar cognitive impairments.The DON stated sexual abuse was any unwanted sexual activity by either person and was when one person forces one person to do a sexual act that the other person does not want or consent to. The DON further stated, it appeared like both residents were engaging in the act. The DON stated she was unsure whether a head-to-toe assessment was completed following the incident but acknowledged that such an assessment, along with safe/safety assessments, should have been conducted. The DON stated she could not recall any specific interventions implemented for Resident #94 following the incident. The DON further stated she was unaware of a history of similar behaviors for Resident #94 but did state she had called out to Resident #15 to go into her room. In an interview on 03/25/26 at 11:47 am, the ADM stated she became aware of the incident on 03/03/26 that morning through the ADON. The ADM reported the ADON informed her that CNA A entered Resident #94's room and observed Resident #15 with his penis exposed and near Resident #94's mouth. The ADM stated she immediately went to assess Resident #94, who was in bed, did not appear [NAME] in distress, and denied that anything had occurred. The ADM stated Resident #15 also did not appear to be in distress. The ADM reported the ADON was in the process of notifying the MD, psychiatric services, and the family. The ADM stated Resident #15 had a history of exposing himself. The DON stated she was not aware of prior incidents involving exposure to other female residents. The ADM reported staff would redirect Resident #15 away from female residents as needed. The ADM stated she believed Resident #15 and Resident #94 may have been able to consent to sexual activity but stated she was unsure how to determine whether either resident had the cognitive capacity to consent. The ADM stated the incident was not investigated as potential sexual abuse. The ADM further stated the facility determined the incident did not constitute sexual abuse, as neither resident appeared to be in distress and neither voiced concern. The ADM stated it appeared that both residents were willing participants. Record review of the facility's undated Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property Policy reflected in part: Preface- It is the policy of this facility to encourage and support all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse. Any nursing home employee or volunteer who becomes aware of abuse. shall immediately report to the Nursing Home Administrator. The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements. Centers for Medicaid and Medicare Services (CMS) - Definitions Definitions of Abuse and Neglect The following are the approved CMS definitions of abuse and neglect from the State Operations Manual Appendix PP effective November 28, 2016. a. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. ii. Sexual abuse is non-consensual sexual contact of any type with a resident. h. Immediately: means as soon as possible but ought not to exceed 24 hours after discovery of the incident, in the absence of a shorter State time frame requirement. Abuse Policy It is the policy of [Facility] that each resident will be free from Abuse. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse of any type will be tolerated and residents and staff will be monitored for Protection. Objective of Abuse Policy The objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention. C. Prevention The facility leadership will assess the needs of the residents in the facility to be able to identify concerns to prevent potential abuse. Procedure: 1. Resident Assessment Every resident is unique and may be subject to abuse based on a variety of circumstances, including facility physical plant, environment, the resident's health, behavior or cognitive level. c. The interdisciplinary team will identify the vulnerabilities and interventions on the resident care plan. 4. Population a. The facility's population presents the following factors, (May include, but not limited to) which could result in maltreatment of residents: The assessment, planning of care and services, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents who have behaviors such as entering other residents' rooms, wandering behaviors. socially inappropriate behaviors.residents with communications disorders. b. The facility will ensure a comprehensive dementia management program to prevent resident abuse. 5. Predatory Offender Provisions When assessing a person's risk of abusing other vulnerable adults, or if a predatory offender is seeking or has been admitted to the facility: The facility must notify other residents that a predatory offender has been admitted . If it is determined that notice to a resident not be appropriate because of the resident's medical, emotional, or mental status, the resident's next of kin or emergency contact (resident representative) must be notified. D. Identification Abuse policy requirements: It is the policy of this facility that all staff monitor residents and will know how to identify potential signs and symptoms of abuse. Occurrences, patterns, and trends that may constitute abuse will be investigated. E. Investigation Abuse policy requirements: It is the policy of this facility that reports of abuse (mistreatment, neglect, or abuse.) are promptly and thoroughly investigated. Procedure: The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration. a. Investigation of abuse: When an incident of suspected incident of abuse is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: i. Who was involved ii. Residents' statements a. For non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview resident first. If unable, observe resident, complete an evaluation of resident behavior, affect, and response to interaction, and document findings. IV. Involved staff and witness statements of events. v. A description of the resident's behavior and environment at the time of the incident. vi. Injuries present including a resident assessment. vii. Observation of resident and staff behaviors during the investigation. viii. Environmental considerations. Additional Investigation Protocols i. If the alleged perpetrator is a facility resident, the staff member will immediately remove the perpetrator from the situation and another staff member will stay with the alleged perpetrator and wait for further instruction from administration, if possible. ii. Examine, assess and interview the resident and other residents potentially affected immediately to determine any injury and identify any immediate clinical interventions necessary. F. Reporting and Response Abuse Policy Requirements: It is the policy of this facility that abuse allegations are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse. are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse.to the administrator of the facility and to other officials (including to the State Survey Agency.) in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility. Initial reporting of allegations: If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency. A follow-up investigation will be submitted to the State Agency within five (5) working days. Law Enforcement: All reports of suspected crime and or alleged sexual abuse must be immediately reported to local law enforcement to be investigated. Facility staff will fully cooperate with the local law enforcement designee. The Administrator or Designee will inform the resident or resident's representative of the report of an incident and that an investigation is being conducted. Covered individuals are obligated to comply with reporting requirements. If uncertain whether to report an incident, call the State Agency for further direction. Informing the Resident and or Responsible Party: The Administrator or designee will inform the resident and or responsible party the results of the investigation. This was determined to be an Immediate Jeopardy (IJ) on 03/25/26 at 5:25 pm. The ADM and DON were notified on 03/25/26 at 5:42 pm. The ADM was provided with the IJ template on 03/26/26 at 3:26 pm. The following Plan of Removal submitted by the facility was accepted on 03/26/26 at 8:04 pm. Plan of Removal for Immediate Jeopardy Problem: F600 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation Interventions: On March 25, 2026, the facility reviewed the BIMS of all admitted Residents on the secured memory unit and determined there were 20 female residents with severe cognitive impairment and 16 males with severe cognitive impairment. -Verified on 03/27/26 through record review and interview with the ADM. Training: Conducted on 3/24/26: The facility Administrator and Director of Nursing were in-serviced on reportable incidents. -Verified on 03/27/26 through in-service record review and interview with ADM and DON. Training: Conducted on 3/25/26: The facility Administrator and Director of Nursing were in-serviced by the Corporate Nurse on implementing the company Abuse policy, with emphasis that the policy should be followed for any type of abuse. -Verified on 03/27/26 through in-service record review and staff interviews from various shifts. Training: Conducted on 3/25/26: The facility Administrator and Director of Nursing were in-serviced by the Corporate Nurse on the reporting timeframe for allegations of abuse utilizing PL 2024-14. -Verified on 03/27/26 through in-service record review and interviews with the Corporate Nurse, ADM, and DON. Training: Conducted on 3/25/26: The facility Administrator and Director of Nursing were in-serviced by the Corporate Nurse that all allegations of abuse must be investigated, and notification of the allegation details must be made to the Resident's Responsible Party. -Verified on 03/27/26 through in-service record review and interviews with the Corporate Nurse, ADM, and DON. Staff interviews from various shifts beginning on 03/27/26 at 8:00 am, revealed the ADM, DON, ADON, MDS, CNA A, LVN B, RNVC, LVN D, RN E, CNA F, LVN G, CNA H, CNA I, CNA J, LA, CMA K, CMA L, LVN M, LVN N, CNA O, HK, RN R, the AD, and RN T were able to identify the different types of abuse, neglect and who the Abuse Coordinator was. Staff stated regardless of the resident's cognition, all suspected abuse/sexual abuse would be stopped and reported to the ADM immediately. All staff were able to identify the yellow dot program and where it would be located. All CNA's were able to state in addition to the yellow dot being located on the resident's name plate outside of their room, those residents would also be listed on their shower sheets. Training: Will be completed by 3/26/26 as follows: All staff in-servicing on: what is abuse utilizing a combined definition of reportable incidents for the THHS and CMS definitions. what is sexual abuse; and reporting of all sexual abuse and/or sexual behaviors to the Administrator. (This includes all incidents regardless of a Resident's diagnosis and/or cognitive status as the Administrator will then follow the new procedure outlined below). a Resident's cognitive status influences their ability to consent. all instances of staff encounters with Resident sexual behaviors, especially those Residents with dementia, will be stopped, Resident's separated, Resident safety ensured, and immediate report made to the Administrator. Residents will be kept separated and monitored while Administrator makes a determination on ability to consent of Resident(s). Administrator and/or Designee will ensure continuity of transfer of information to staff between shifts. immediate reporting to Administrator of any suspected instances of abuse. going forward, any Residents with a diagnosis of dementia and an occurrence of inappropriate sexual behaviors with another Resident and place a yellow dot on the Resident's nameplate to identify to staff 1) the Resident has the diagnosis and inappropriate sexual behavior with another Resident, and 2) to be more vigilant in monitoring the Resident's location. All newly admitted Residents will be reviewed for a diagnosis of dementia and a history of inappropriate sexual behaviors; any Residents who meet these criteria will have a yellow dot added to their nameplate. In-service sign in sheets will be cross referenced with employee roster. New Procedures: Effective 3/25/26: The Administrator and DON were verbally educated that all instances of sexual activity, sexual contact, sexual behaviors, and/or sexual abuse will be called to the Corporate Nurse for review. The review will include use of Attachment 2: How to Report Abuse, Neglect, Exploitation (ANE), Other Incidents and Sexual Activity included with PL 2024-14. The review process will involve the Resident's physician, and Resident and/or the Resident's Responsible Party. The Administrator will keep a log of all reported instances along with the outcome of the call. Special emphasis will be placed on any Resident(s) with BIMS of 12 or below. Going forward, the Facility will identify Residents with a diagnosis of dementia and an occurrence of inappropriate sexual behaviors with another Resident and place a yellow dot on the Resident's nameplate to signify to staff 1) the Resident has the diagnosis and inappropriate sexual behavior with another Resident, and 2) to be more vigilant in monitoring the Resident's location. All newly admitted Residents will be reviewed for a diagnosis of dementia and a history of inappropriate sexual behaviors; any Residents who meet these criteria will have a yellow dot added to their nameplate. The DON and/or Designee will be responsible for ensuring the yellow dot is placed on the Resident's nameplate in a timely manner. Quality Assurance Performance Improvement: On March 25, 2026, the Quality Assessment and Assurance Committee members to include the Medical Director (via telephone), Administrator, Director of Nursing, Assistant Director of Nursing, Social Worker, and Corporate Nurse met to review and approve this plan. Verified on 03/27/26 through in-service record review and interviews with ADM, DON, and ADON. The Administrator and/or Designee will provide a copy of the log of instances of reported sexual activity, sexual contact, sexual behaviors, and/or sexual abuse to the Corporate Nurse for a second review weekly for 2 months. Verified on 03/27/26 through an interview with the Corporate Nurse. The results of the Administrator and/or Designee reviews will be presented to the Quality Assessment and Assurance Committee for review of trends and/or negative findings and further recommendations during the scheduled meetings for 2 months. The committee will make recommendations for further education as warranted and develop further performance improvement plans as necessary. Verified on 03/27/26 through interview with the ADM and DON. The ADM was informed that the Immediate Jeopardy was removed on 03/27/26 at 11:11 am. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, record review, and interview the facility failed to store all drugs and biologicals in locked compartments on 2 of 8 medication carts (RN C's medication cart and the wound care cart) reviewed for storage of drugs. The facility failed to ensure RN C's medication cart located by the nurse's station in the 300 hall was locked when not in use.The facility failed to ensure the wound care cart located by room [ROOM NUMBER] was locked when not in use. This failure could place residents at risk of having access to unauthorized medications and lead to an increased risk of drug diversion, or harm due to accidental ingestion of unprescribed medications.Findings included: During an observation on 03/24/26 at 2:23 PM, a medication cart by the nurse's station in the 300 hall was unlocked and unattended. This surveyor opened all drawers having access to medications in bulk bottles and blister packs easily assessable for removal. RN C was walking from a nearby hall to the medication cart and identified herself as being responsible for the unlocked medication cart.In an interview on 03/24/26 at 2:24 PM, RN C stated she just walked away for a moment and forgot to lock the medication cart. RN C stated the cart should be locked at all times because there was medication in the cart and any resident could get into the medication cart and get medication that was not prescribed to them. RN C stated residents could have complications if a medication was taken that was not prescribed to them.During an observation on 03/25/26 at 9:20 AM, a wound care cart by room [ROOM NUMBER] was unlocked and unattended. LVN D was walking nearby and when questioned about the cart, LVN D was able to open the drawers without needing to unlock the cart. In an interview on 03/25/26 at 9:20 AM, LVN D stated the wound care cart was supposed to always be locked. LVN D stated there was no designated wound care nurse as the charge nurses were responsible for wound care. LVN D stated he did not know who used the wound care cart last. LVN D stated the cart should be locked at all times because the residents could get into the cart and get medications or supplies. LVN D stated the nurses were in charge of locking the carts. In an interview on 03/27/26 at 10:45 AM, the DON stated the medication and wound care carts should always be locked to prevent others, including residents, from getting medications and supplies. The DON stated if the carts were unlocked, then anybody could get into the carts, and they could steal medications and/or take them when not prescribed. Record review of the facility's Medication Labeling and Storage policy, dated February 2023, reflected - Policy: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. 4. 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 provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one of two residents observed during medication pass. (Resident #4) RN T left a cup containing Resident #4's medications on top of medication cart while she went inside the room to don gown. This failure could affect the 2 residents who received medications from RN T by placing them at risk for medication errors and receiving less than therapeutic benefits from medications. Findings Included: Observation of resident #4's room on 3/25/26 at 7:56am revealed a medication cup left in top of medication cart by RN T while she was donning gown inside room. The cup contained Levothyroxine (ordered for treatment of hypothyroidism). Record review of Resident #4's face sheet dated 3/25/26 revealed an [AGE] year-old female admitted to the facility of 6/25/21. Pertinent diagnosis include hypothyroidism (a common condition where the thyroid gland fails to produce enough thyroid hormones, slowing down the body's metabolism). Record review of Resident #4's MDS assessment, dated 12/30/25, revealed severe cognitive impairment. During an interview with RN T on 3/25/26 at 8:10 a.m. revealed she did not normally leave medications in top of medication cart, but she forgot to take the medication into the room with her. RN T said that the negative outcome could be that any resident could grab the medication and take it. During an interview on 3/26/26 at 4:30 p.m. DON stated confirmed medications scheduled to be administered should not be left unattended. DON said that the negative outcome was that any resident or visitor could take the medication and could have an adverse reaction. Record review of facility's policy titled Administering Medications with a revised date April, 2019, revealed: No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one of two residents observed during medication pass. (Resident #4) The facility failed to ensure RN T did not leave a cup containing Resident #4's medications on top of the medication cart, when she went in Resident #4's room to put a gown on. This failure could place residents at risk for medication errors and receiving medications that are not prescribed for them. Findings Included: Observation of resident #4's room on 3/25/26 at 7:56 am, revealed a medication cup left in top of medication cart by RN T while she was donning (putting on protective personal equipment) gown inside room. The cup contained Levothyroxine (ordered for treatment of hypothyroidism). Record review of Resident #4's face sheet dated 3/25/26, revealed an [AGE] year-old female admitted to the facility of 6/25/21. Diagnosis included hypothyroidism (a common condition where the thyroid gland fails to produce enough thyroid hormones, slowing down the body's metabolism). Record review of Resident #4's MDS assessment, dated 12/30/25, revealed a BIMS score of 2 (severe cognitive impairment). During an interview on 3/25/26 at 8:10 a.m., RN T said she did not normally leave medications on top of the medication cart, but she forgot to take the medication into the room with her. RN T said that the negative outcome could be that any resident could grab the medication and take it. During an interview on 3/26/26 at 4:30 p.m., the DON stated medications that were scheduled to be administered should not be left unattended. The DON said the negative outcome would bet any resident or visitor could take the medication and could have an adverse reaction. Record review of facility's policy titled Administering Medications with a revised date April, 2019, revealed: No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 of 5 residents (Resident #1 and Resident #2) reviewed for pharmacy services in that:The facility failed to ensure that a multidose vial of Ativan (a medication used to treat anxiety, agitation, and sometimes seizures), that had not been dated when opened, was not administered after the recommended 28 days from opening to Resident #1 on [DATE], [DATE], and [DATE], and Resident #2 on [DATE].These failures could place residents at risk for non-therapeutic responses to medications.Findings included:1. Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old male with an initial admission date of [DATE] and a current admission date of [DATE]. The pertinent diagnosis included Dementia with behavioral disturbances (a condition which affects memory, thinking, and the ability to perform daily activities, as well as could include symptoms such as agitation, aggression, delusions, and/or hallucinations). Record review of Resident #1's physician orders dated [DATE] revealed Ativan 2 MG/ML, inject 0.5 ML intramuscularly (administered within a muscle) one time only for aggression and combativeness. The physician order dated [DATE] revealed Ativan 2 MG/ML, inject 2 MG intramuscularly one time only for severe aggression, and the physician order dated [DATE] revealed Ativan 2 MG/ML, inject 0.5 ML intramuscularly one time only for aggression and combativeness.Record review of Resident #1's February 2026 MAR revealed IM Ativan was administered on [DATE] (by LVN-C), [DATE] (by RN-D), and [DATE] (by LVN-E).2. Record review of Resident #2's face sheet dated [DATE] revealed an [AGE] year-old female with an admission date of [DATE]. The pertinent diagnoses included Dementia with anxiety (a condition which affects memory, thinking, and the ability to perform daily activities, as well as could include symptoms such as anxiety), and Generalize Anxiety Disorder (nagging feelings of worry or anxiety). Record review of Resident #2's physician orders dated [DATE] (by LVN-C) revealed Ativan 2 MG/ML, give 0.5 ML one time only for aggression and combativeness. Record review of Resident #2's February 2026 MAR revealed Ativan 0.5 ML was administered on [DATE].In an observation on [DATE] at 11:29 AM, a multidose vial of Ativan was observed to be approximately 1/3 full with no written open date or initials on either the vial or the packaging. The vial expiration date was [DATE], but the vial had been opened on [DATE] (as noted on the Ativan Narcotic Count log that coincided with the vial of Ativan). In an interview on [DATE] at 2:15 PM, ADON-A stated multidose vials of medication should be dated and initialed on the vial by the nurse opening it as soon as it was opened. She also stated once the vial had been opened it was good for 28 days, then had to be discarded. ADON-A also stated the ADONs audit the controlled medication logs usually every couple of weeks, so she was not sure how the medication got missed. She also said the nurses were supposed to verify a medication was not expired prior to giving any medication because if the medication was expired it could make a resident sick, or the medication could be less effective. In an interview on [DATE] at 2:27 PM, LVN-C stated multidose vials of medication were supposed to be dated and initialed by the nurse who opened it, but the vials should be checked for expiration by every nurse who administered it, and he stated he had administered on the dates specified on the MAR and on the Ativan log. He stated he was not sure how long the vial was good for once it had been opened. LVN-C also stated he had not checked to see if the vial was expired prior to using it because he was busy this day, and there were so many things going on at one time. He stated if a medication was expired it could be less effective or even caused a resident harm. In an interview on [DATE] at 3:10 PM RN-D stated she had not check the Ativan for an opened by or expiration date prior to administration. She stated she believed the medication was good for 28 days from the date is had been opened or punctured. RN-D stated residents could have a reaction to the expired medication or it may not work properly if it is expired. RN-D stated the person who opened the vial should date it when it was opened, but any nurse giving the medication should be checking to make sure the medication was not expired prior to giving it. In an interview on [DATE] 3:28 PM, LVN-E stated she had not checked the opened by or expiration date on the Ativan, but she knew she was supposed to because the medication was only good for so many days after opening. LVN-E stated residents could have a possible reaction or the medication could be less effective if given after it has expired. LVN-E stated the nurse who opened the vial was the one who dated it, but every nurse that administered it should check to see if it had expired. In an interview on [DATE] at 10:55 AM, the DON stated multiuse vials of medication were dated and initialed when they were opened, and they were good for 28 days once opened. She stated since the Ativan was initially opened on [DATE], it would have expired on [DATE] and should have been discarded appropriately at the time. The DON also stated every nurse who administered the medication should have checked to see when it was opened and if it was expired because medication could lose its efficacy after expiration or could even have caused harm to a resident. Record review of the Ativan 20 MG / 10 ML multidose vial narcotic log/record, dated [DATE], revealed Ativan was signed out for Resident #1 on [DATE], [DATE], and [DATE]. The log also revealed Ativan was signed out for Resident #2 on [DATE].Record review of the facility's Medication Administration policy, revised [DATE], revealed .12. When opening a multi-dose container, the date opened is recorded on the container. The expiration/beyond use date on the medication label is checked prior to administering.Record review of the facility's Medication Labeling and Storage policy, Revised February 2023, revealed .5. Multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on observation, interview, and record review, the facility failed to ensure the resident was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #1) of 7 residents reviewed for dignity and respect, in that: LVN A spoke to Resident #1 in front of other residents, in the dining room, about Resident #1 sitting in the dining room in his underwear, making Resident #1 feel embarrassed. This failure could place residents at risk for embarrassment, isolation, and possible depression.The findings include: Record review of Resident #1's Face Sheet dated 09/30/25 documented a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of: Muscle Wasting and Atrophy(The loss of skeletal muscle mass.) , Heart Failure (A chronic condition in which the heart doesn't pump blood as well as it should.), Type 2 Diabetes (A chronic condition in which the body does not use insulin properly or does not produce enough insulin), Hypertension (a condition where the force of blood against the artery walls is consistently too high.), Chronic Obstructive Pulmonary (disease a group of lung diseases that cause airflow obstruction and breathing problems). Record review of Resident #1's Care Plan Dated 09/30/25 revealed requires assistance with activities of daily life, is at risk for shortness of breath related to Chronic Obstructive Pulmonary Disease, at risk for injury related to alteration in vision, at risk for falls, being treated for my hyperlipidemia and encourage to exercise and the resident is encouraged to participate in activities that will not depend on major physical exertion and encourage to get out of bed daily. Record review on 09/30/25 of Resident #1's MDS dated [DATE] revealed resident had a BIMS score of 15 which indicated intact cognition, meaning the individual's cognitive function, including memory and orientation, appears normal and unimpaired according to the scale's criteria. The Functional Abilities section indicated resident was independent no need for assistance. Record Review of Resident #1's progress note dated 09/06/25 revealed CNA B was concerned with Resident #1's sadness and depressed demeaner so CNA B asked Resident #1 what was wrong and Resident #1 stated he did not want to discuss anything with CNA B. The weekend manager was the SSA and she was notified of the incident that occurred between LVN A and Resident #1 that day. The incident involved LVA A who told Resident #1 in front of the other residents that he was wearing underwear briefs to bingo and needed to go change. The SSA was prompt in addressing the incident so it could be further investigated. In an interview on 09/30/25 at 2:30 PM with the Abuse Coordinator/ Administrator she stated Resident #1 was approached by a LVN A and Resident #1 was asked if he knew he had no pants on. The AC/Admin stated LVN A preceded to ask Resident #1 if he could go put on some clothes over his underwear briefs because there were female residents present in the dining room playing bingo. Resident#1 was helped to his room, and he never returned to the dining room that day. The AC/Admin stated she followed up on Resident#1 the next day to see if he had any issues with the way he was approached and he stated he had forgotten about it and was water under the bridge. The AC/Admin Stated she went a second time to follow up on the resident and he was fine and had no issues with staff or facility. In an Interview on 09/30/25 at 2:51 PM LVN A she stated the residents were playing bingo and Resident #1 was sitting playing in his underwear. LVN A stated she went up to Resident #1 and asked him if he knew that he had no pants. LVN A stated Resident #1 said he knew he did not have pants. LVN A asked Resident #1 if he could go put some pants on. LVN A stated Resident #1 was escorted to the room, and he never came back. LVN A stated she told him there were female resident in the dining room and Resident #1 said he did not care. LVN A stated she probably should have told him in a more privately manner instead of in front of the whole table. LVN A said she had not approached another resident in that manner again since the one incident in the dining room with Resident #1. LVN A stated she has a good rapport with Resident#1 and there was no ill will between them. The last time they had a training on Resident Rights was about 4 to 6 months ago. In an interview 09/30/25 4:41 PM with the Social Services Assistant she was the manager on duty that day doing rounds the CNA B had a concern with the Residents #1 and a LVN staff member. CNA B stated LVN A yelled at Resident #1 about him not wearing pants in the dining room with other residents playing bingo. The SSA stated Resident #1 told her about what LVN A had done and LVN A was just doing her job. The SSA stated the other residents in the dining room thought they were shorts and had no problem with him in the dining room dressed that way. The SSA stated Resident#1 told her he felt belittled after the LVN A spoke to him, so he went to his room. The SSA stated Resident #1 told her he had no clothes that fit him at the time of the incident and had called a family member to bring him clothes that fit. The SSA stated the Resident #1 might have thought he was wearing shorts and thought it was ok to wear. The SSA stated only the LVN nurse realized he was wearing was underwear in the dining room, but no one playing bingo had a problem with what he was wearing. The SSA stated no other incidents had occurred with LVN A and other residents being spoken to in this manner. The SSA stated Resident#1 was only staying in the facility for a short time for skilled nursing and had since moved to his apartment. The SSA could not say if he ever did activities again but was around the facility walking in the halls. The SSA stated no mental anguish, or distress was noted from the residents several days after the incident occurred. In an interview on 09/30/2025 at 5:02 PM CNA B he stated when he went to Resident's #1's room and he notices that everything was dark in the room, and he was upset. Resident #1 told him the LVN A told him in the dining room in front of other residents from across the table he needed to leave because he was not fully dressed. CNA B stated Resident #1 was not hard of hearing and maybe could have whispered it to him more privately. CNA B stated normally the resident was a very outgoing person and could tell the resident was upset. CNA B stated the next two days Resident #1 was not coming out of his room and then he got covid, so he had to stay in his room until he was out quarantine for 7 days. CNA B stated he did not know of any other incidents with the LVN A involved in the incident or the resident with any other resident or staff member. CNA B stated he Received dignity training on 09/22/25 along with other staff members. In an interview 10/01/25 at 9:06 PM with the Activities Assistant (AA) he stated the residents were playing bingo and the nurses were coming in to check vitals for some residents and because of this did not realize the incident with Resident#1 was in underwear and he thought they were shorts. The AA stated Resident #1 stated to him the nurse told him from across from across the table in front of other residents about how he was dressed. The AA stated he saw Resident #1 leave immediately after LVN A spoke to the resident and the resident never returned. The AA stated after some time had passed CNA B was pulled aside asked if he had observed what had occurred and he stated to the Administrator and DON that he did not observe or know what had occurred. The AA stated none of the residents had made a comment about what he was wearing. The AA stated Resident #1 mannerism before the incident was good. The AA observed Resident #1 was being social, taking to residents and playing bingo. The AA stated when Resident #1 left and did not say anything about what occurred with the LVN A. The AA stated she did not see Resident#1 after the incident because Resident #1 tested positive for covid. The AA said if he would have known what was occurring, he would have gone to the activity's director and the administrator Immediately to report the incident. The AA stated his last training on resident's rights was one month ago when he was hired. The AA was able to identify the abuse coordinator as the administrator. The AA was able to describe the different types of abuse and what the steps are to report abuse. In an interview on 10-01-25 at 9:41 AM with Resident #1 he stated he was playing bingo and the LVN A was going to do finger stick to check his blood sugar when she asked him in front of the whole table why was he in his underwear in the dining room. Resident #1 stated after the LVN A said this I felt like crap! Resident #1 stated none of the resident's playing bingo complained about what he was wearing or even realized he was in his underwear. Resident#1 stated he just felt comfortable in what he was wearing and maybe he should not have gone to the dining room dressed this way. Resident #1 stated he did not want to get anyone in trouble, and he had put it past him and had a great stay in the facility. Record review of the facility's policy titled, Quality of Life - Dignity, revised 08/2009, revealed: 1. Residents shall be treated with dignity and respect at all times.

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 2 of 5 residents (Residents #1 and #2) reviewed for pharmacy services. 1. The facility failed to administer Resident #1's Losartan per the recommended and prescribed blood pressure parameters in July and August of 2025. 2. The facility failed to administer Resident #2's Isosorbide per the recommended and prescribed blood pressure parameters in July and August of 2025. These failures could place residents at risk for complications, as well as jeopardize their health and safety.Findings included: Record review of Resident #1's face sheet, dated 08/26/2025, revealed a [AGE] year-old female with an original admission date of 04/17/2018, and a current admission date of 11/02/2023. Pertinent diagnoses included Alzheimer's Disease (progressive decline in memory, thinking, and behavior), cognitive communication deficit (difficulty in communication which arises from impaired cognitive functions), Dementia (a group of symptoms affecting memory, thinking, and social abilities), and Essential Primary Hypertension (high blood pressure which occurs without an identifiable medical condition causing it). Record review of Resident #1's Quarterly MDS assessment, dated 08/12/2025, revealed a BIMS score of 01, which revealed severely impaired cognition. MDS also revealed an active diagnosis of Hypertension. Record review of Resident #1's care plan, last reviewed 08/23/2025, revealed a care plan for potential for hyper/hypotensive episodes related to Hypertension and antihypertensive medications. Interventions included give medications as ordered, and/or report abnormal blood pressures to doctor. Record review of Resident #1's active physician orders, started 03/29/2025, revealed an order for Losartan Potassium (a medication used to treat high blood pressure) 50 MG, give one tablet by mouth twice per day related to Hypertension; Hold for systolic blood pressure less than 120. Record review of Resident #1's July 2025 MAR revealed Losartan Potassium 50 MG, give one tablet by mouth twice per day related to Hypertension; Hold for systolic blood pressure less than 120. Dates when Losartan was given outside of parameters included: 07/05/2025 7:00 AM B/P 113/65 Administered 07/11/2025 6:00 PM B/P 119/70 Administered07/13/2025 7:00 AM B/P 106/68 Administered07/22/2025 7:00 AM B/P 110/75 Administered07/27/2025 6:00 PM B/P 102/66 Administered07/28/2025 6:00 PM B/P 102/78 Administered Record review of Resident #1's August 2025 MAR revealed Losartan Potassium 50 MG, give one tablet by mouth twice per day related to Hypertension; Hold for systolic blood pressure less than 120. Dates when Losartan was given outside of parameters included: 08/11/2025 7:00 AM B/P 116/60 Administered08/16/2025 7:00 AM B/P 110/60 Administered08/16/2025 6:00 PM B/P 118/62 Administered08/23/2025 7:00 PM B/P 117/66 Administered Record review of Resident #2's face sheet, dated 08/27/2025, revealed an [AGE] year-old male with an original admission date of 04/03/2024. Pertinent diagnoses included Alzheimer's Disease (progressive decline in memory, thinking, and behavior), cognitive communication deficit (difficulty in communication which arises from impaired cognitive functions), Dementia (a group of symptoms affecting memory, thinking, and social abilities), and Essential Primary Hypertension (high blood pressure which occurs without an identifiable medical condition causing it). Record review of Resident #2's Change in Condition MDS assessment, dated 07/27/2025, revealed a BIMS score of 07, which revealed severely impaired cognition. MDS also revealed an active diagnosis of Hypertension. Record review of Resident #2's care plan, last reviewed 08/06/2025, revealed a care plan for medication to treat hypertension. Interventions included give medications as ordered and monitor blood pressures as ordered and notify doctor if results are high or low. Record review of Resident #2's active physician orders, started 03/05/2024, revealed an order for Isosorbide Mononitrate (a medication used to treat high blood pressure) 60 MG, give one tablet by mouth daily; Hold if systolic blood pressure was less than 120. Record review of Resident #2's active physician orders, started 09/15/2024, revealed an order for Losartan Potassium 25 MG, give one tablet by mouth twice daily for hypertension; Hold if systolic blood pressure was less than 120. Record review of Resident #2's July 2025 MAR revealed Losartan Potassium 25 MG, give one tablet by mouth twice per day related to Hypertension; Hold for systolic blood pressure less than 120. Dates when Losartan was given outside of parameters included: 07/01/2025 7:00 AM B/P 115/64 Administered 07/12/2025 6:00 PM B/P 107/61 Administered Record review of Resident #2's July 2025 MAR revealed Isosorbide Mononitrate 60 MG, give one tablet by mouth daily; Hold if systolic blood pressure was less than 120. Dates when Losartan was given outside of parameters included: 07/01/2025 7:00 AM B/P 115/64 Administered 07/12/2025 7:00 AM B/P 107/61 Administered Record review of Resident #2's August 2025 MAR revealed Losartan Potassium 25 MG, give one tablet by mouth twice per day related to Hypertension; Hold for systolic blood pressure less than 120. Dates when Losartan was given outside of parameters included: 08/01/2025 7:00 AM B/P 118/81 Administered 08/06/2025 7:00 AM B/P 119/75 Administered08/11/2025 7:00 AM B/P 110/66 Administered08/15/2025 7:00 AM B/P 116/76 Administered08/22/2025 7:00 AM B/P 119/79 Administered Record review of Resident #2's August 2025 MAR revealed Isosorbide Mononitrate 60 MG, give one tablet by mouth daily; Hold if systolic blood pressure was less than 120. Dates when Losartan was given outside of parameters included: 08/01/2025 7:00 AM B/P 118/81 Administered 08/04/2025 7:00 AM B/P 119/71 Administered08/06/2025 7:00 AM B/P 119/75 Administered08/11/2025 7:00 AM B/P 110/66 Administered08/15/2025 7:00 AM B/P 116/76 Administered08/22/2025 7:00 AM B/P 119/79 Administered In an interview on 08/27/25 at 12:12 PM, LVN-B stated he thought he got confused and probably messed up while administering blood pressure medication since there were multiple medications with multiple different parameters. He stated he always checked the residents' blood pressures when they got blood pressure medication, and then he always checks parameters for the medication, but he must have gotten confused. LVN-B stated the blood pressure was checked to make sure it was within range, because if they give a medication for hypertension when the blood pressure was already low, it could continue to drop, and the patient could bottom out. If the blood pressure dropped too low it could cause the resident serious harm. LVN-B denied having any residents experience hypotensive crisis or episodes in the past couple of months. He stated he had been educated and in-serviced regarding administering blood pressure medications, as well as taking vital signs. In an interview on 8/27/25 at 1:25 PM, RN-C stated she always checked the parameters in the orders, but thought she just missed some because the blood pressures taken were close to the ordered parameters. She stated she should have been more careful and paid more attention. RN-C stated the blood pressure was assessed to see if it was too high or too low. RN-C stated if antihypertensive medication was given when the blood pressure was already low, it could cause the resident to have a hypotensive crisis. She stated she had not seen any residents have any signs or symptoms of hypotension in the past couple of months. RN-C stated the blood pressure should always be checked and compared to the parameters prior to administering any blood pressure medication so a resident was not harmed. In an interview on 8/27/25 at 1:49 PM, LVN-D stated nurses should always check the parameters in the orders prior to administering a blood pressure medication because if it was given outside of parameters, it could cause harm, or even death, to a resident. He stated he did not remember the last time he was in-serviced regarding blood pressure medications or vital sign parameters, but he thought it was around two years ago. Record review of the facility's Administering Medications policy, revised April 2019, revealed Medications are administered in a safe and timely manner, and as prescribed. 11. The following information is checked/verified for each resident prior to administering medications: b. Vital signs, if necessary.

Based on interview, record review and observation, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #100), reviewed for care plans. The facility failed to implement and ensure Resident #100 had 2 beveled mats on floor as care planned dated 10/25/24. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and implementing personalized plans developed to address their specific needs. The Findings included: Record review of Resident #100's face sheet dated 1/15/25 reflected a [AGE] year-old-male with an original admitted [DATE]. Diagnoses included Dementia (decline in cognitive abilities that affects a person's ability to perform everyday activities), hypertension (high blood pressure), and unsteadiness on feet. Record review of Resident #100's care plan dated 10/25/24 stated Resident #100 was at risk for falls due to unsteadiness on feet. Interventions included 2 beveled mats. Record review of Resident #100's annual MDS dated [DATE] reflected a BIM score of 2 (severe cognitive impairment), utilized a wheelchair, and required partial/moderate assistance with sitting/standing and chair/bed transfers. During an observation on 01/14/25 at 02:55 PM Resident was asleep in bed with one floor mat noted to right side of the bed. During an observation on 01/15/25 at 01:50 PM Resident was in bed. One floor mat noted to right side of the bed. In an interview on 01/15/25 at 01:52 PM LVN C stated Resident #100 should have had two floor mats at bedside for fall precautions as Resident #100 had a history of sliding himself off the bed. LVN C stated she was not sure why Resident #100 did not have two floor mats but would immediately get another floor mat to have at Resident #100's bedside. LVN C stated Resident #100 needed two floor mats at bedside to prevent possible injury in case of a fall. In an interview on 01/15/25 at 01:54 PM CNA D stated Resident #100 was supposed to have two floor mats for fall precautions. CNA D stated if she saw only one floor mat at Resident #100's bedside, she would have reported it to the nurse immediately. CNA D stated she did not notice there was only one floor mat as that side of the bed is was closer to the wall and she usually assists Resident #100 on the right side of the bed. CNA D stated she was not sure why Resident #100 only had one floor mat but was going to get another one. CNA D stated Resident #100 needed a floor mat at each side of the bed to help prevent possible injury in case of a fall. In an interview on 01/15/25 at 04:35 PM the DON stated Resident #100 should have had two floor mats at bedside due to having a care plan that was person centered and should be followed for the resident's safety. The DON stated by not having two floor mats then Resident #100 could potentially have an injury if he sustained a fall. The DON stated the nursing managers are responsible for making sure care plans are implemented and followed. The DON stated she was going to in-service staff immediately on implementation of care plans. Record review of facility's Care Plans, Comprehensive Person-Centered Policy dated 3/2022 stated: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;

Based on observation, interviews and record reviews, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 residents (Resident #67) reviewed for pharmacy services. The facility failed to ensure Resident #67's physician order for Latanoprost Opthalmic Solution (eye drops) were administered at bedtime as ordered. This failure could place residents at risk for non-therapeutic responses to medications. Findings included: Record review of Resident #67's face sheet dated 01/16/25 revealed a [AGE] year-old female with an initial admitted [DATE] and a current admitted [DATE]. Pertinent diagnoses included dementia and glaucoma (fluid buildup in the front part of the eye, causing increased pressure and damage to the optic nerve). Record review of Resident #67's Comprehensive MDS assessment section C, cognitive patterns, dated 11/09/24 revealed a BIMS score of 1 (severe impairment). Record review of Resident #67's care plan revised 11/14/24 revealed the focus I have impaired vision r/t diabetes and glaucoma. I wear glasses. I am at risk for injury r/t decreased visual field. DX: Glaucoma. Interventions listed for the focus included: - Administer eye drops as ordered (if ordered); - Encourage independence of ADL's and provide support as needed; - Keep environment free from small objects on floor, very hot liquids, and other hazardous items; - Monitor for eye pain/discomfort & report to MD. Record review of Resident #67's order summary revealed an active order dated 11/03/23 for Latanoprost Ophthalmic Solution 0.005% (Latanoprost). Instill 1 drop in both eyes one time a day for glaucoma. During an observation of medication administration at 7:39 AM on 01/15/25, this state surveyor observed MA A instill 1 drop of Latanoprost Opthalmic Solution 0.005% in both eyes of Resident #67. The pharmacy label on the Latanoprost read as follows: Instill 1 drop into both eyes at bedtime. Wait 3-5 minutes between drops. In an interview with MA A at 7:41 AM on 01/15/25, MA A stated she did not notice that the label on the medication stated to give the eyedrops at bedtime. MA A stated she had given the eyedrops to Resident #67 in the morning for as long as she could remember. MA A stated she compared the name of the resident, the name of the drug and the number of drops on the label to what was written on her computer and those all matched. MA A stated it was important to follow orders as written by the doctor. MA A stated when she saw a label was mismatched with what the computer showed then she would inform her nurse about the discrepancy. In an interview with RN B at 9:23 AM on 01/15/25, RN B stated it was important to follow doctor's orders as prescribed for the safety and health of the resident. RN B stated if the MA saw a discrepancy between the label on the medication and the order in the computer then they should hold the medication and inform the nurse. RN B stated if there was any discrepancy in an order, she would call the doctor to verify what the proper dose, route, and timing of the medication was. RN B stated she would put a change in direction sticker on the pill package to correct the error. In an interview with the DON at 9:43 AM on 01/16/25, the DON stated before any medication was administered, the employee should make sure the label matched what the order showed in the computer. The DON stated if the MA saw a discrepancy from the label to what the computer showed they should notify the nurse. The DON stated the nurse should then look into the resident's chart to see if they could determine which order was correct and notify the physician to clarify. The DON stated the nurse should instruct the MA to put a change in direction sticker on the label of the medication and call the pharmacy to order a new label or new medication. The DON stated medications were prescribed for a reason and for it to be effective it needed to be administered how the physician asked it to be. The DON stated the nurse that received the order copied it into the computer. The DON stated they reviewed new orders every day in their morning meetings. Record review revealed the facility policy titled Administering Medications revised April 2019 stated the following: Medications are administered in a safe and timely manner, and as prescribed. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to keep accurate temperature and chemical logs 2. The facility failed to label and date items in the nutrition rooms 3. The facility failed to discard and replace dented pans 4. The facility failed to maintain cleanliness in the ice machine 5. The facility failed to maintain cleanliness of the floor These failures could place residents at risk of foodborne illnesses. Findings include: Initial tour of the kitchen on [DATE] beginning at 10:20 a.m. with the DM revealed the high-temp wash log was missing documentation per DW A. DW A stated the kitchen staff sometimes did not document and he had to get on them for it. DW A stated there was no excuse other than that sometimes they (staff) just don't do it. There was a dented metal colander hanging on the pan rack. The ice machine had a black fuzzy substance on the ice chute, identified as mold and removed with a paper towel by the DM. There was a large dark-brown liquid substance on the floor behind the stove. The DM stated she did not know what it was, and that something must have spilled and never got cleaned up. The DM stated they used a cleaning sheet, but they did not always follow it. Interview with DW B on [DATE] at 03:42 p.m. stated his co-workers told him to fill in the shifts he worked. He stated he only filled in the shifts he had worked. DW B stated he did not fill in the log every day because he was too busy. DW B stated he did not know why accurate logs were important. DW B would not reveal the co-worker's names, only that they were a boy and a girl. Observation of the nutrition room in the 200 Hall on [DATE] at 2:40 p.m. revealed 1 unlabeled, open, and half-eaten dill pickle, 1, 64 oz. of honey thick-it water expired [DATE], and 1 unlabeled 6-pack of 5.5 oz. of green Jell-O. Observation of the nutrition room in the 100 Hall on [DATE] at 2:44 p.m. revealed 1 unlabeled full quart container of sherbet, 6 unlabeled 3 oz. containers of sherbet, 1 unlabeled and open pint of ice cream, and 3 unlabeled ice cream treats. An interview with the ADON on [DATE] at 2:42 p.m. stated that residents who got the expired honey-thickened water could be affected because the thickened water could lose its thickness and they could aspirate it and get pneumonia and depending on the severity, could end up in the hospital and be put on antibiotics. An interview with the RM on [DATE] at 2:47 p.m. stated items in the refrigerator and freezer should be labeled because staff needs to know who the food belongs to, so no one gets the wrong thing, like a diabetic might get someone else's sugary treat and get sick. An interview with DW C on [DATE] at 06:45 a.m. stated she was trained by two other dishwashers, not the DM. DW C stated she did not know if hot water was used to sanitize the dishes, but the water was super hot. DW C stated she thought the temperature of the water should be 150F. An interview with the DM on [DATE] at 08:55 a.m. stated she trained the staff on the dishwasher and chemical testing, and that she should stay on top of it (the logs) to make sure they do it. The DM stated she threw the dented colander away because it needed to be thrown away because bacteria or bits of food could get stuck in the dents and crevasses and come off in the food and make someone sick or break a tooth because it was metal. The DM stated she was responsible for checking and replacing dented pans. The DM stated the dented colander was an oversight and it should have been thrown away sooner. An interview with MSA (maintenance supervisor assistant) on [DATE] at 11:00 a.m. revealed not sure what type the washer was but thought it was a high-temperature washer. He did not know what temperature the washer should run at. Record review of the dishwasher logs dated [DATE]-[DATE] and interview with the DM on [DATE] at 3:12 p.m. revealed all blanks on the washer temperature and chemical strip log had been filled in with black marker-like ink for the following dates: [DATE] -[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE], [DATE], [DATE], [DATE], [DATE] -[DATE]. Interview with the DM on [DATE] at 3:13 PM, she stated she did not know who would have done that. The DM stated DW B had worked some of the days where there was no documentation, and she would tell him when he came to work that day. Record review of the facility policy titled, Dishwashing Machine Use revised ,d+[DATE] revealed Policy Statement: Food service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. 7. The operator will check the temperature using the machine gauge with each dishwashing machine cycle and will record the results in a facility-approved log. The operator will monitor the gauge frequently during the dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately. A record review of in-services and training for the kitchen staff revealed all had completed a computerized Texas Food Handler Safety; one had expired on [DATE]. [DATE]-Diets, snacks, drinks, green sticker program, diet roster. [DATE]-Food high MSG. [DATE]-All diets will be liberalized on all diets upon admission, and all NAS (No Added Salt) and NCS (No Concentrated Sweets) will be discontinued. Textures will stay the same. Exceptions will be renal diets. [DATE]-Renal Diets. [DATE] Handwashing; must wash hands for 20 seconds, explained when handwashing is needed, must wash hands when you change your gloves, after bathroom, entering or leaving a room, after eating food, etc. [DATE]-Temperature logs, Temperatures must be logged in real-time with exact temperature. Review of References: TAC 228.111 (p) Warewashing equipment (three-compartment-sink) determining chemical sanitizer concentration: concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. Figure: 25 TAC 228.111(n)(1) Sanitizer Concentration range: ,d+[DATE] ppm, when the minimum temperature is 150 degrees Fahrenheit.

Based on Observation, interviews, and record reviews, the facility failed to maintain essential equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating equipment: 1. The meat freezer was not sealing properly 2. The ice machine had jagged edges These failures could place residents at risk of foodborne illnesses and injury. Findings included: An initial tour of the kitchen on 10/23/23 beginning at 10:20 a.m. and interview with the DM revealed the outsides of the ice machine were heavily rusted and becoming detached from the machine creating a hazard of sharp rusted metal. The seals on the meat freezer doors had ice on them, breaking the seals away from the freezer and melting. The doors to the meat freezer were not closing properly because of the bad seals. The DM stated it had been that way for a couple of weeks, and she had told maintenance. The DM stated kitchen staff checked the meat freezer often to make sure it was still running and not thawing the items inside. There was no documentation for the extra checks of the meat freezer. The items inside were cold and hard to the touch. An interview with the MSA on 10/26/23 at 11:00 a.m. revealed he did not know about the meat freezer or the ice machine in the kitchen. The MSA stated the kitchen staff or the MS did not inform him of everything that goes on in the kitchen. The MSA stated he did not make regular rounds in the kitchen and only went in there if the MS needed help. A phone interview with the MS on 10/26/23 at 2:00 p.m. stated he had straightened out the seal on the meat freezer yesterday. The MS stated he had the meat freezer repaired not too long ago, that a wire was loose and kept tripping the breaker, and the meat freezer was holding temperature, so we (the repairmen) did not look at it. The MS stated he did not know how long the meat freezer had been that way until this surveyor pointed it out. The MS stated he saw the rusted sides on the ice maker bin but could not give an estimated time for how long it was like that-for a while I guess. The MS stated he was about to get bids for the freezer part(s). The MS stated it was important to maintain kitchen equipment to avoid catastrophes, such as it was not possible to know when the freezer could go out, and all that food would be ruined. The MS stated if the seal in the meat freezer should shift because of melting ice, it would make a big mess and the residents would not get the meats and nutrition they should. The MS stated he did not make regular rounds in the kitchen and only went in there to fix things as needed and when they (the kitchen staff) told him about it. The MS stated the kitchen staff was responsible for overseeing the kitchen. A record review of the only Maintenance logs provided revealed several pages from 2016.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for 1 of 1 kitchen reviewed for pests. The facility failed to treat gnats in the kitchen This failure could affect all residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life. Findings were: An initial tour of the kitchen on 10/23/23 at 10:20 a.m. with the DM revealed gnats in all of the general kitchen areas. Observation of the kitchen on 10/26/23 at 6:40 a.m. revealed a swarm of gnats in the kitchen near the dishwasher machine area, and in all of the general kitchen areas. Interview with DW B on 10/23/23 at 03:42 p.m. stated he had seen gnats in the kitchen, but they came and went-they were not constantly there. An interview with DW C on 10/26/23 at 06:45 a.m. stated she had seen gnats everywhere in the kitchen. She stated she had not told anyone about the gnats because everyone knew about them. An interview with the DM on 10/26/23 at 06:50 a.m. stated she got a shipment of a solution about 3 days ago that took care of the gnats. The DM stated kitchen staff poured the solution into the kitchen drains at night so it could sit, and it did a good job of killing the gnats. The DM stated kitchen staff used the solution for the first time last night since they received the shipment of the solution. The DM did not answer why the kitchen did not use the solution right away or on a regular basis. An interview with the MSA on 10/26/23 at 11:00 a.m. revealed he knew about the gnats in the kitchen. The MSA stated the kitchen staff treated it at night when there was no food around and the water was settled because it goes in the drain. The MSA stated he did not know if the kitchen staff was using the solution to rid the gnats on a regular basis. A phone interview with the MS on 10/26/23 at 2:00 p.m. revealed he had worked at the facility for 6 years and no one ever told him about any gnats. The MS stated the facility had regular pest control. An interview with the ADM on 10/26/23 at 4:00 p.m. revealed she was aware of the gnats in the kitchen and knew the kitchen staff was treating the gnats on an as-needed basis. The ADM was unaware of the potential for gnats to cause cross-contamination and illness. A record review of the only Maintenance logs provided revealed several months from 2016. A record review of the facility pest control logs dated 2023 revealed regular montly pest control, but not for gnats.

Based on record review, observation, and interviews, the facility failed to provide a safe, functional, and comfortable environment to include fire extinguishers throughout the buildings were regularly inspected and maintained for 1 of 4 portable fire extinguishers inspected throughout the facility. One of four portable fire extinguishers that were observed for monthly quick checks were not inspected monthly. This failure could result in undetected impairments of the portable fire extinguishers delaying suppression of fires exposing residents and staff to smoke inhalation and other fire related injuries resulting in more than minimal harm. Findings included: Record review of portable fire extinguisher quick check tags revealed 1 of 4 fire extinguishers were not inspected monthly. Observations on 10/26/2023 at 12:00 PM revealed 1 portable fire extinguisher in the laundry area did not have any indication that monthly quick checks were performed since June 15th, 2023. In an interview on 10/26/2023 at 12:00 PM Housekeeper A said she worked in the laundry and did not know when the fire extinguishers should be inspected. In an interview on 10/26/2023 at 12:25 PM with the Administrator and maintenance worker B they said the fire extinguishers should be checked monthly to ensure proper operation. The Administrator and maintenance worker B observed the fire extinguisher was last inspected June 15th, 2023. No explanation was given why the fire extinguisher had not been inspected since then. Maintenance worker B said the fire extinguishers are inspected by the maintenance department. The Administrator said not having a working fire extinguisher could endanger the lives of the staff and residents. Record review of facility Fire Extinguishers policy dated 2001 and revised April 2008 indicate The facility has placed fire extinguishers strategically throughout the facility and shall keep them operable at all times.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 9 residents (R #1), reviewed for care plans in that: The facility failed to develop a comprehensive person-centered care plan for R #1, use of anticoagulant medication. These deficient practices could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. Findings included: Record review of R #1's Face Sheet revealed a [AGE] year-old female, with an original admitted [DATE]. Diagnosis included, Type 2 diabetes ( insufficient production of insulin in the body), Dysphasia (difficulty swallowing), Alzheimer's Disease (neurodegenerative disease that affects a person's cognitive in daily activities including memory, thought control, and language), Heart Failure, Pulmonary Embolism (blockage of an artery in the lungs), Fracture of Lower Leg, including Ankle, TIA (transient ischemic attack, similar to a stroke), and Cerebral Infarction (type of stroke caused by impaired blood flow to the brain). Record review of R #1's Quarterly Minimum Data Set, dated dated dated [DATE] revealed R #2 has a BIMS (Brief Interview Mental Status) of 10 (Moderately Impairment) and requires Extensive Assistance with, bed mobility, transfers, Dressing, Toilet use and Personal Hygiene. Record review of R #1's Care Plan dated 7/14/2023 revealed no care plan for anticoagulants. Had an actual fracture to right tibia and right fibula and fracture to left ankle. Record review of R #1's orders stated; -Plavix Tablet 75 MG (Clopidogrel Bisulfate) Give 1 tablet by mouth one time a day for CAD dated 7/12/2023 -Eliquis Oral Tablet 5 MG (Apixaban) Give 5 mg by mouth two times a day related to PULMONARY EMBOLISM (I26) dated 8/23/2023 - Monitor for blood in stools or urine, bleeding gums, or excess bleeding with minor injuries, check if any signs or symptoms present, notify MD immediately and document dated 7/12/2023 Interview on 8/24/2023 at 2:57pm DON stated, anticoagulants such as Plavix should be care planned as it was person-centered and direct care staff need to be able to identify any adverse effects of anticoagulants. Interview on 8/24/2023 at 3:15pm MDS Coordinator stated, Plavix should be care planned and must have missed it by mistake. MDS Coordinator stated it is important to care plan anticoagulants so nurses and staff are aware R #1 is on this type of medication so they can be looking for signs and symptoms of bruising, bleeding, or complications, especially since R #1 had fractures. MDS Coordinator stated he would update R #1's care plan immediately. Record review of Care Plan, Comprehensive Person-Centered Policy dated December 2016 stated; A comprehensive, person-centered care plan that includes measurable objectives, and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The care planning process will: g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; m. aide in preventing or reducing decline in the resident's functional status and/or functional levels; o. Reflect currently recognized standards of practice for problem areas and conditions. 12. The comprehensive, person-centered care plan is developed within seven days of the completion of the required comprehensive assessment (MDS). 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.