**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 out of 6 residents (Resident #1) reviewed for abuse/neglect. The facility failed to protect Resident #1 from physical abuse when LVN A forcefully dragged him to his bed on 05/26/2025 after an unwitnessed fall. An Immediate Jeopardy (IJ) existed from 05/26/2025 - 06/02/2025. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation. This deficient practice could place residents at risk of abuse, injury, and psychosocial harm. Findings included: Record review of Resident #1's admission record, dated 06/10/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Alzheimer's disease (brain disorder that causes memory loss), chronic kidney disease stage 3 (when your kidneys are damage and can't filter blood properly), muscle wasting and atrophy (decrease in size and wasting of muscle tissues), and lack of coordination (having difficulty controlling your movements and making them work together smoothly). Record review of Resident #1's Quarterly MDS assessment, dated 05/07/2025, reflected the resident had a BIMS score of 00, which indicated severe cognitive impairment. Resident #1 required partial/moderate assistance in the areas of toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear and personal hygiene. Record review of Resident #1's care plan, dated 06/05/2025, reflected Resident #1 was care planned for impaired cognitive function/dementia or impaired though processes with an intervention Communication: use resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated. Record review of Resident #1's nursing progress note, dated 05/26/2025, reflected resident had an unwitnessed fall in the resident room. Resident found with BM on him, the bed, chair, and all over the floor. Record review of Resident #1's nursing progress note, dated 05/26/2025, reflected fall follow up. Location of bruise: bilateral upper extremity size of bruise in cm: unknown blue/purple, Pain appears to be present: No, Intervention: Fall mat Record review of a written statement from CNA A, date 05/29/2025, reflected CNA A stated LVN A grabbed Resident #1 by the wrist and dragged him across the room so with me not knowing what to do I went under his arms and help him stand grabbing both sides of my arms to stay stable LVN A tried to take his hand away. I said no and help him to bed. From there LVN A took his vitals went out the room we assessed him saw elbow was bloody tried to tell LVN A she didn't respond. I then left to take care of my residents.[sic] Record review of a written statement from CNA B, date 05/29/2025, reflected CNA B stated LVN A grabbed Resident #1 by his wrist and proceeded to drag him back towards his bed. During an observation of Resident #1's room video surveillance, dated 05/26/2025, Resident #1 was observed laying on the floor unclothed. CNA A was observed attempting to clean Resident #1 when Resident #1 became combative. LVN A walked over to Resident #1 and stated that We are not going to do that today. Resident #1 then attempted to kick at LVN A. LVN A then grabbed Resident #1's right arm and pulled him up to a sitting position. LVN A then pulled Resident #1 by his right arm approximately three feet towards the resident's bed while CNA A & CNA B had his left arm. Resident #1 can be heard saying oh my arm and please don't during the improper transfer. Attempted to interview Resident #1 on 06/10/2025 at 11:30am., Resident #1 could not be interviewed due to his cognitive impairment. During an interview with the DON on 06/10/2025 at 2:45 PM, the DON stated Resident #1's RP showed the video of LVN A dragging Resident #1 towards his bed. The DON stated the incident is clearly abuse and that was not how staff were trained to assistance a resident from the floor after a fall. The DON stated the facility does not condone the behavior LVN A displayed and has referred her to the board of nursing. The DON stated that she expected for staff to report any witnessed or suspected abuse to ensure the residents' in the facility safety. During an interview with the ADM on 06/10/2025 at 3:00 PM, the ADM stated Resident #1's RP showed the video of LVN A dragging Resident #1 towards his bed. The ADM stated he considered the incident abuse because LVN A forcefully pulled the resident by his wrist/arm. The ADM stated that all staff have been inserviced on reporting abuse. The ADM stated that abuse would not be tolerated and expected for staff to report any witnessed or suspected abuse immediately. A record review of the facility's Abuse/Neglect policy, dated 09/09/24, reflected The resident has the right to be free of abuse neglect, and misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment or residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Definitions 1. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including caretaker, of good or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instance of abuse of all residents, irrespective of any mental or physical condition cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 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. This noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 05/26/25 and ended on 06/02/25. The facility had corrected the noncompliance before the survey began. The facility took the following actions to correct the non-compliance: - 05/29/25 LVN A, CNA A and CNA B and the ADM were suspended. - 05/29/25 All staff were in-serviced on ANE, trauma informed care, reporting allegations of abuse timely, pain management, notification in change of condition, fall prevention, fall risk, ambulatory, how to use Kardex, rounding Q2 hours, customer service, how to appropriately respond to a resident found on the floor initiated with nursing staff, safe surveys initiated with resident, skin assessment completed. - 05/29/25 All resident received a skin assessment. - 05/29/25 the facility held a QAPI meeting for ANE . - 05/29/25 - Gait Belt Transfer Skills Check list - 05/29/25 Family surveys - 05/29/25 ANE monitoring started and will continue from 6 weeks. - 05/30/25 Resident #1 had x-ray completed with no fractures. - 05/30/25 Administrator and DON inserviced on abuse and reporting. - 06/02/25 LVN A license was referred to the Texas Board of Nursing. During interviews with the 3 LVNs and 3 CNAs on 06/05/2025 from 10:22 AM - 2:14 PM, all staff stated they were inserviced on ANE, trauma informed care, reporting allegations of abuse timely, pain management, notification in change of condition, fall prevention, fall risk, ambulatory, how to use Kardex, rounding Q2 hours, customer service, how to appropriately respond to a resident found on the floor initiated with nursing staff, safe surveys initiated with resident, skin assessment completed. All staff interviews gave examples of abuse and who to report any suspected abuse to in a timely manner. Review of a police report, dated 05/26/25, reflected the ADM completed a police report for the incident with Resident #1. Review of the facility's Employee Disciplinary Report, dated 05/28/25, reflected LVN A, CNA A, and CNA B were terminated. Review of the facility's Ad Hoc QAPI Minutes, dated 05/29/25, reflected the ADM, DON, ADON, MD, SW, and ADO were in attendance. Review of witness statements, dated 05/29/25, reflected hand-written witness statements regarding the incident with Resident #1 from LVN A, CNA A, and CNA B. Review of a report of the residents' weekly skin assessments, dated 05/29/25, reflected all residents had a skin assessment completed with no new findings. Review of all resident Safe Surveys, dated 05/29/25, reflected all had been completed with no concerns. Review of an in-service, dated 05/29/25 - 05/30/25, reflected all staff from all shifts were in-serviced by the ADM on their Abuse and Neglect Policy. Review of Resident #1's x-ray results, results received 05/30/25, reflected no fractures or findings. An Immediate Jeopardy (IJ) existed from 05/26/2025 - 06/02/2025. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #1) of five (5) residents reviewed for abuse, in that: The facility failed to prevent Resident # 1 from becoming sexually assaulted by Resident #2, who had a history of sexually inappropriate behaviors, when Resident #2 blocked Resident #1 in the shower room on 5/17/2024 and touched her breast, kissed her and masturbated in front of her. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/20/2024. The IJ template was provided to the facility on 5/20/2024 at 5:17 pm. While the IJ was removed on 05/22/2024 at 4:00 pm, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of sexual abuse with potential for injuries, trauma, and hospitalization. Findings included: Review of Resident #1's face sheet dated 5/20/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included: Vascular Dementia (Memory disorder caused by circulation issues in the brain), Type 2 Diabetes Mellitus (blood sugar regulation disorder), Hypertension, Cognitive Communication Deficit (difficulty understanding and communicating), Aphasia (difficulty speaking), Dysphagia (difficulty swallowing), and Cerebrovascular Disease (brain circulation degeneration) Review of Resident #1's optional state assessment MDS dated [DATE] reflected a BIMS of 3 suggesting severe cognitive impairment. Review of Resident #1's care plan dated 4/30/2024 reflected: Resident #1 has impaired cognitive function/dementia or impaired thought processes r/t VASCULAR DEMENTIA. With intervention: o The resident needs (Specify: supervision/assistance) with all decision making. Date Initiated: 04/28/2023 Review of Resident #1's progress notes dated 5/17/2024 at 4:38 pm by the ADON reflected: Note Text: At approximately 235 pm this resident was found in C Hall shower room with another male resident. Resident immediately removed from shower room and taken to her room. Head to toe assessment completed. No obvious injuries noted. Resident unable to give statement on what occurred in shower room due to cognitive impairment. Male resident stated he told resident to come in shower room and while in there he touched her breast outside her clothing and kissed her and started to masturbate. Abuse coordinator present and notified. Law enforcement notified and currently in building. Male resident currently on one on one pending new orders. Review of Resident #1's progress notes dated 5/17/2024 at 5:09 pm reflected: Resident transported to ER for exam per [city name] Police Department. Family notified Review of Resident #1's progress notes dated 5/17/2024 at 11:57 pm reflected: Received a phone call from [state name]Health Resource [city and state name] stating that the patient was coming back shortly. She was put on Antibiotic for 7 days for STD prophylaxis . [Preventative measures] Review of Resident #1's progress notes dated 5/18/2024 at 12:26 am reflected: Patient arrived to the facility via a wheelchair with one assist. No distress noted at this time vital signs are within patient parameters. New orders of Doxycycline (antibiotic) 100mg Capsule for 7 days and Metronidazole (antibiotic) 500 mg tablet for 7 days. Will continue to monitor. Review of Resident #2's face sheet dated 5/29/2024 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Cerebral Infarction (stroke), Intermittent Explosive Disorder (mood regulation disorder), Type 2 Diabetes Mellitus (blood sugar regulation disorder), Hypertension, Hemiplegia (partial paralysis), and abnormalities of gait and mobility. Review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS of 11 suggesting a mild cognitive impairment. Review of Resident #2's current care plan dated 5/19/2024 reflected the following problem: Behavior: Sexually inappropriate: watching porn in public areas. Date initiated 3/15/2019. Interventions were as follows: IF RESIDENT IS WATCHING PORN IN PUBLIC AREAS INTERVENE AND REINFORCE THAT WATCHING PORN NEEDS TO BE DONE IN HIS ROOM AND NOT IN PUBLIC AREAS FOR OTHERS TO SEE; o Psychiatric Services consult as needed o Reinforce with staff that clear, firm limits are healthy and required when resident makes inappropriate gestures or statements; oReport incidents of target behavior to charge nurse; o Resident to be placed on secure unit due to sexual behaviors and safety; o Staff will be trained to respond, but not react to resident's behavior. Review of Resident #2's progress note dated 5/17/2024 at 2:45 pm by the ADON reflected: this resident was found in c hall bathroom with another female resident with door closed and was found and told staff he was masturbating in front of female resident and kissed her and touched her breast. The female resident did not show any signs of distress but is cognitively impaired and not able to consent to any of the above and was not able to give statement on event due to not remembering what happened. Immediately separated both residents, notified law enforcement, MD, both parties Family and Abuse Coordinator who is our admin. MD stated to send resident out for psych eval . During an interview on 5/18/2024 at 4:50 pm, the ADON stated she was working on 5/17/2024 when the incident between Resident #2 and Resident #1 occurred. She stated she had worked at the facility over a year and to her knowledge Resident #2 had never attempted to touch a female resident before. She stated he had made some inappropriate remarks to staff and female residents, but this was the first physical time. She stated Resident #2 was care planned for inappropriate sexual behavior. She stated Resident #2 had been moved to the male secure unit after the incident on 5/17/2024 pending placement at another facility. During an interview on 5/18/2024 at 5:06 pm, LVN A stated she was Resident #2's regular nurse and there had been an incident near the end of last year sometime between Resident #2 and another female resident. Resident #2 was found in bed in his room with a female resident that lacked the capacity to consent to that behavior . Review of Resident #2's progress notes from 1/1/2023 to 05/19/2024 reflected no notes related to Resident #2 being found in his bed with a female resident. During an interview on 5/18/2024 at 7:48 pm, CNA B stated she had been working on 5/17/2024 and found Resident #2 in the shower room with Resident #1. She stated she had seen Resident #1 in the common area by the nurses station after lunch and told her she had to go down the other hall to take care of a resident but would come get her when she got back to take her to her room to lie down. She stated she was gone about 20 mins and when she came back, Resident #1 was not in the common area. She stated she started looking all around for her in the dining room, in her bedroom, tv room but could not find her. She stated she remembered walking past the shower room and the door was shut. She stated she alerted other staff that she was looking for Resident #1 and when she came back by the nurses station, she saw the door to the shower room cracked and she could see Resident #2 looking at her. She stated she went up to the shower room door and tried to push it open, but Resident #2 had his wheelchair against the door on the inside, blocking it from being opened. She stated she was able to get her head in and could see Resident #1 next to Resident #2, and behind the door on the inside. She stated she told Resident #2 to move out of the way or I was gonna shove the door open. She stated Resident #2 moved out of the way and she grabbed her wheelchair out of the bathroom and asked her if she was ok. She stated when she put her head in the door, Resident #2 had his hand on his private area over his clothes. She stated both residents were in their wheelchairs but Resident #1 was close enough to Resident #2 that he could touch her. She stated they both had all their clothes on, and she only witnessed Resident #2's hand on his lap on top his privates . She stated her and LVN A took Resident #1 to her room because she wanted to lie down. She stated LVN A checked Resident #1 over and she nodded her head that she was ok and stated she just wanted to lie down, so they changed her and put her to bed. CNA B stated Resident #2 made inappropriate comments that were very sexual towards her and other staff when they were showering him. She stated about 6-8 months ago there was another incident with Resident #2 where she had found him in bed laying right next to a female resident with their clothes on . She reported it to LVN A at the time and the AD. She stated she did not remember reporting it to the DON or ADON, but she thought LVN might have done it. She stated she thought the incident could have been prevented because he should have been gone already after the last incident. and this was a long time coming. She stated the previous incident happened before November of 2024 sometime and they just separated the residents but kept them on the same hall. She stated they kept an eye on [Resident #2] for a while. During an interview on 5/19/2024 at 9:19 am, LVN C stated she heard about the incident on 5/17/2024 with Resident #2 and felt it could have been prevented. She stated there was a previous incident with Resident #2 last year and if they had handled that situation better , the current incident could have been prevented. She stated she had witnessed Resident #2 talk to staff inappropriately in the past especially during his showers, but she had not witnessed any behaviors with other residents. During an interview on 5/19/2024 at 9:29 am, LVN A stated she had been working at the facility for 7 years and had been the weekend nurse on the hall for Residents #1 and #2 since Resident #2 was admitted last year. She stated after Resident #2 was found by CNA B in the shower room with Resident #1, they took Resident #1 to her room to assess her and make sure she was okay. Resident #1 could answer yes or no questions pretty well, but it took her a while to answer in a sentence. She stated Resident #1 denied any injury, could not remember what happened and stated she just wanted to go to bed and lie down. She stated Resident #2 had behaviors around female residents . She stated, We kind of watch him, he gets sexual in the shower. She stated, It's not every day, but they keep an eye on him around other female residents . She stated she caught Resident #2 in bed in his room with another resident last fall sometime. She stated they were both lying on top of the covers and had their clothes on but were not in there long enough to do anything. She stated the facility had talked to Resident #2 about his behaviors in the past, but the last AD decided he didn't have to go. She stated staff had refused to bathe him in the shower because of his inappropriate sexual remarks. She stated she reported it to the AD at the time but did not recall telling the DON or ADON. She stated she thought she had put a progress note in EMR but didn't remember. During an interview on 5/19/2024 at 11:01 am CNA D stated she had witnessed Resident #2's behavior. She stated, It starts by him fixating on a female resident. She stated Resident #2 would try to hold their hands and get close to them. She stated last week they were outside on the patio doing an activity and Resident #2 wanted her to bring Resident #1 up next to him to sit and she told him no and moved Resident #1 away from him. She stated the staff would just try to keep Resident #2 away from female residents. She stated she thought she said something to the nurse that day about the incident on the patio, but she didn't remember. She stated she felt the incident could have been prevented because we saw him grooming her. She stated Resident #2 had a history of seeking out females and was always wanting Resident #1 to sit with him or tried to come up next to her in his wheelchair. Every time they saw it they would move Resident #1 somewhere else. She stated, Everyone knew what was going on. She stated in the past she had witnessed Resident #2 grabbing another female resident's hand and putting it in his lap. She stated she believed the DON and ADON were aware of his behaviors. During an interview on 5/19/2024 at 11:14 pm, Resident #2 stated his room had been moved because something had happened and it was bad, bad, bad. He stated he was jacking off, kissing and titties and then he laughed. He stated it had happened in the bathroom with Resident #1 and that CNA E found them and came in the bathroom and took Resident #1 out. Resident #2 stated he was not hurt but the police came and talked to him. Resident #2 was observed in his room on the male, secure unit of the facility. During an interview on 5/19/2024 at 12:40 pm Resident #1's RP stated the facility called him on 5/17/2024 to tell him what had happened with Resident #1. He stated he came up to the facility and spoke to the police and Resident #1. He stated (Resident #1) had no idea what was going on and thought she had talked to the police because she left the store without paying. He stated he gave permission for them to send Resident #1 to the ED for an exam and testing. He stated once at the hospital they were able to swab Resident #1's neck and cheek, but he declined putting Resident #1 through the trauma of a SANE exam. He stated they discharged her from the ED with prescriptions for two antibiotics and she returned to the facility. He only agreed to her coming back to the facility because Resident #2 had been moved out of the general population. He stated he was told by a nurse that they found Resident #2 pleasuring himself and kissing Resident #1. The RP stated he put Resident #1 in the facility thinking she would be safe, and it made him very angry that the incident happened, that they didn't protect her. He stated fortunately with her memory issues, she didn't remember what happened but if she could, it would be a very traumatic event; it would be for anyone that experienced it and knew what was happening. He also said there was no telling what sort of trauma the event caused for her because she could not verbalize very well what happened. During an interview on 5/19/2024 at 1:46 pm, MDS E stated in the past Resident #2 had behaviors of watching porn videos in the main areas, so that was included in his current care plan. She stated she had opened up the intervention on his care plan on 5/17/2024 after the incident with him in the shower room, because they discussed moving Resident #2 to the secure unit. She stated she was getting ready to leave for vacation on Friday afternoon 5/17/2024 so she just opened that current problem for inappropriate sexual behavior on his care plan since they were moving Resident #2 to the secure unit pending placement at another facility and she had forgot to change the date showing it had been updated. During an interview on 5/19/2024 at 2:20 pm, the ADON stated she was not aware of a previous incident last year with Resident #2 when he was found in his room in his bed with another female resident. She stated that had not been reported to her. During an interview on 5/20/2024 at 12:17 am, the AD stated Resident #2 would remain on the secure unit until they had a placement for him. He stated the facility NP would be seeing the resident face to face that day and the facility Medical Director was completing a desk review of Resident #2's medications. The AD stated he had been at work on 5/17/2024 and had been in his office right off the common area near the shower room. He stated he saw Residents #1 and #2 together sitting in the common area. The AD stated then staff started looking for Resident #1 and they found her in the shower room with Resident #2. The AD stated Resident #2 had Resident #1 in the shower room for less than 10 minutes. He stated they had no video cameras in the building to record what had happened. The AD stated their policy was not to keep the shower room doors locked since they were right near the nurse's desk. He stated they had not had any problems in the past that he was aware of related to Resident #2 and inappropriate sexual behaviors, but he had only been at the facility about a month. During an observation and interview on 5/20/2024 at 12:29 pm with the AD and RGN revealed the shower room was noted to be just off the common area near the nurse's station. The shower room door was noted to have a locking mechanism on it on the inside. The AD and RGN remained inside the shower room and the Investigator locked the door from the inside and stepped outside the shower room. The door was observed to be locked and unable to be opened from the outside. It was observed there was a key slot on the outside of the door, but both the AD and the RGN denied knowing where the key was located. The RGN stated they would get the door rekeyed and start locking the shower room door. The RGN stated he had been the RGN since July of last year and was not aware of any incidents with Resident #2 watching porn or being in bed with another resident. During an interview on 5/20/2024 at 2:40 pm, the DON stated she was not aware of a previous incident from last year with Resident #2 where he had been found in bed in his room with another female resident. She stated the incident had not been reported to her and there was nothing in the progress notes about it for Resident #2 . During an interview on 5/20/2024 at 5:10 pm the RGN stated Resident #2's current care plan still had a problem on it for sexually inappropriate behavior. When asked why the area was still on the current care plan, the RGN stated he did not know. He stated he had updated Resident #2's care plan on 5/17/2024 to reflect he was being moved to the secure unit but was not sure why it did not show the revision date on the current care pan. During an interview on 5/21/2024 at 8:54 am, the former AD (FAD) stated he did not recall an incident from last year with Resident #2 being in bed with a female resident. He stated if there had been an incident like that he would have reported it. He stated there had been a couple incidents where he touched people - he touched other female residents by trying to hold their hands - - people that were incompetent at the time. He stated the touching incidents were a year or so ago an - he had completed a facility self-report. He stated he had had no concerns at that time with Resident #2 touching female residents in a sexual way. The FAD stated the interventions they put in place at the time were they sat down with him and told him he could not be with female resident unsupervised. He stated they thought about discharging him, but they had not seen any more behaviors at that time. He stated they had educated Resident #2 about his behaviors and tried to keep him in front of staff in the common area. He stated there was usually staff around the nurses desk in the common area and there had been no other incidents that he could recall. During an interview on 5/22/2024 at 3:13 pm, the AD stated everyone that worked at the facility was responsible for supervising and keeping an eye on the residents. Review of facility policy Preventing Resident Abuse dated June 2005 reflected: Our facility will not condone any form of resident abuse and will continually monitor our facilities policies procedures, training programs, systems, etc. to assist in preventing resident abuse. 1. The facility's goal is to achieve and maintain an abuse -free environment. 1j Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; 1k. assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues.1o Identifying areas within the facility that may make abuse and or neglect more likely to occur (e.g. secluded areas) and monitoring these areas regularly. The AD was notified on 5/20/2024 at 5:17 pm that an Immediate Jeopardy (IJ) had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 5/22/2024: On 5/20/24 an abbreviated survey was initiated at [facility name]. On 5/20/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: Facility Failed to provide supervision on 5/17/2024 to prevent Resident #1 from getting Resident #2 into the shower room alone. All items listed will be completed by 5:00PM on 5/21/24 with continued follow-up for scheduled staff. 1. R#2 received MD order to be placed on All Male Secure Unit Placement 2. R#1 was provided a Head-to-Toe Assessment on 5/17/24 with no injuries identified 3. Emotional Distress Assessment completed for R#1 on 5/17, 5/18, 5/19 with no issues identified 4. R#2's Care Plan was updated by MDS Nurse 5. On 5/18/24 Administrator/DON completed 100% Incident/Accident Audit on every resident in facility to ensure no incidents of sexual inappropriate behavior were documented without any interventions. No other residents were identified as having sexually inappropriate behavior. Safe surveys were completed all female residents not residing on the secure unit. 6. Administrator/DON initiated Staff in-service for ALL STAFF on 5/20/24 on Resident Accidents/Supervision, Resident Supervision/Safety, Resident Rights, and Abuse and Neglect. Administrator/DON trained by Regional Clinical Director prior to start of in-service on 5/20/2024. If staff are unable to attend any of the in-services, they will be required to complete the in-service before starting their assigned shift. Any agency will be in-serviced prior to the beginning of their shift. Any new hires will be in-serviced on hire, prior to working a shift. The Medical Director was first made aware of the Immediate Jeopardy 5/20/24 at 7:00PM and has been involved in developing the Plan of Removal. These conversations are considered a part of the QA process. A QAPI meeting was held on 5/20/2024 with attendance of the Administrator, Director of Nursing, Assistant Director of Nursing and Regional Clinical Director. This plan was initially implemented 5/20/24 and will be monitored through completion by corporate and regional staff. Plan of Removal completion date is 5/21/24 by 5:00 pm with continuation of oncoming staff and follow up. A Surveyor monitored the POR on 5/22/2024 as followed: 05/22/2024 12:16 PM Observation of shower room (room in which incident occurred) door with handle which did not lock on the inside or outside of shower room. All shampoo and any supplies needed that could contain chemicals were locked in a cabinet and no residents could access them. 05/22/2024 12:22 PM Interview with Resident #2, he stated he was doing ok, and the staff were taking good care of him. He stated he felt safe in the facility, and he had been moved to the secure unit because of something bad he had done. He stated he had been jacking off, kissing, and titties. He stated that had never happened before and he was not sure if the other resident wanted to do it or not, but she was his friend and he liked her. He stated she never said no. Resident #2 was observed in secure unit in his room with call light in reach. Resident was dressed appropriately and in no sign of pain or distress. 05/22/2024 12:26 PM Interview with Resident #1, she shook her head yes when asked if she was doing ok and if she felt safe in the facility. Resident was sitting in her wheelchair in the dining room at the table visiting her family member. Resident appeared clean and was dressed appropriately. Resident was in no sign of pain or distress and smiled when meeting and talking with surveyor. 05/22/2024 12:28 PM Interview with FM, he stated he is doing well, and he is aware of the incident that occurred with the other resident. He stated his only concern is making sure resident is supervised correctly and that he is fine if the other resident remains in the secure unit, bit he is not sure about how he would feel if the resident was out of the secure unit. He stated resident is confused at times and she does not recall the incident. 05/22/2024 1:15 PM Interview with MA-F she stated she had worked in the facility for about 6 years, and she worked the day shift. She stated she was in-serviced on resident accidents/supervision, resident supervision/safety, resident rights, and abuse and neglect on this past Monday and Tuesday. She stated staffing was ok. She stated she felt as though she could meet the needs of her residents. She stated she had not had any residents complain to her about any inappropriate sexual behavior from any other residents. She stated an example of abuse was cursing at a resident and she had never witnessed abuse in this facility. She stated if she suspected abuse, she would have reported it to her charge nurse and the Administrator, which was the Abuse Coordinator. 05/22/2024 1:19 PM Interview with LVN - G, she stated she had worked in the facility for about 3 years and she worked the day shift. She stated she was in-serviced on resident accidents/supervision, resident supervision/safety, resident rights, and abuse and neglect on this past Monday, and they always have different materials for them to read. She stated staffing was generally ok and they make it work. She stated she felt as though she could meet the needs of her residents. She stated she had not had any residents complain to her about any inappropriate sexual behavior from any other residents. She stated an example of abuse was pulling a resident roughly and she had never witnessed abuse in this facility. She stated if she suspected abuse, she would have reported it to the Administrator, which was the Abuse Coordinator. 05/22/2024 1:27 PM Interview with LVN - H, she stated she had worked in the facility for about 4 years and she worked the day shift. She stated she was in-serviced on resident accidents/supervision, resident supervision/safety, resident rights, and abuse and neglect on yesterday. She stated staffing was ok. She stated she felt as though she could meet the needs of her residents. She stated she had not had any residents complain to her about any inappropriate sexual behavior from any other residents. She stated an example of abuse was involuntarily secluding a resident and she had never witnessed abuse in this facility. She stated if she suspected abuse, she would have reported it to the Administrator, which was the Abuse Coordinator. 05/22/2024 1:30 PM Interview with CNA - I, she stated she had worked in the facility for about 4 months, and she worked the day shift. She stated she was in-serviced on resident accidents/supervision, resident supervision/safety, resident rights, and abuse and neglect today. She stated this was her first day back since the weekend and she was off on Monday and Tuesday. She stated she was in-serviced prior to getting on the floor to work. She stated staffing was ok. She stated she felt as though she could meet the needs of her residents. She stated she had not had any residents complain to her about any inappropriate sexual behavior from any other residents. She stated an example of abuse was hitting a resident and she had never witnessed abuse in this facility. She stated if she suspected abuse, she would have reported it to the Administrator, which was the Abuse Coordinator. 05/22/2024 1:35 PM Interview with AD and RGN, they stated they had in-serviced staff regarding resident accidents/supervision, resident supervision/safety, resident rights, and abuse and neglect. They stated there may be some staff that have not been in-serviced as of yet, but they will not be allowed to work until they have received the in-services. They stated 85% of staff have been in-service so far and there were only a few staff that had not been in-serviced yet. They stated the RN weekend supervisor was the one responsible for ensuring staff on the weekends have been in-serviced prior to working. They stated staffing was adequate to meet the resident's needs. They stated they felt as though their staff could meet the needs of their residents. They stated they were not aware of any residents that had complained about any inappropriate sexual behavior from any other residents. They stated an example of abuse was sexual a resident and they had never witnessed abuse in this facility. They stated if staff suspected abuse, they should have reported it immediately to Administrator which was the Abuse Coordinator. They stated Resident #2 would remain in the secure unit unless they had to staff available to perform one on one supervision. They stated they are actively trying to have resident placed at a different facility which is more suitable for him, but each facility has denied resident admitting so far and they may also suggest family taking him home. 05/22/2024 2:17 PM Interview with LVN - J, she stated she had worked in the facility for about 2 months, and she worked the 2-10 shift. She stated she was in-serviced on resident accidents/supervision, resident supervision/safety, resident rights, and abuse and neglect on Monday. She stated she was in-serviced prior to getting on the floor to work. She stated staffing was good. She stated she felt as though she could meet the needs of her residents. She stated she had not had any residents complain to her about any inappropriate sexual behavior from any other residents. She stated an example of abuse was cussing at a resident and she had never witnessed abuse in this facility. She stated if she suspected abuse, she would have reported it to the Administrator, which was the Abuse Coordinator. 05/22/2024 2:22 PM Interview with MA- K, he stated he had worked in the facility for about a year and a half, and he worked the 2-10 shift. He stated he was in-serviced on resident accidents/supervision, resident supervision/safety, resident rights, and abuse and neglect on Monday and Tuesday. He stated he was in-serviced prior to getting on the floor to work. He stated staffing was decent. He stated he felt as though he could meet the needs of his residents. He stated he had not had any residents complain to him about any inappropriate sexual behavior from any other residents. He stated an example of abuse was a resident-to-resident altercation and he had never witnessed abuse in this facility. He stated if he suspected abuse, he would have called and reported it to the Administrator, which was the Abuse Coordinator. 05/22/2024 Reviewed in-servicing which includes attendance forms with staff signatures dated 05/20/2024 given by the RGN for DON and AD over accidents and incidents, abuse and neglect, safety and supervision of residents, and resident rights. Reviewed in-servicing which includes attendance forms with staff signatures dated 05/20/2024 given by the DON over accidents and incidents, abuse and neglect, safety and supervision of residents, and resident rights. 05/22/2024 Reviewed documentation on QAPI meeting held 05/20/2024 regarding prevent reoccurrence and continued safety for all residents in which the DON and Administrator both attended. 05/22/2024 Reviewed documentati[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the need of 1 (Resident # 1) of 5 residents reviewed for pharmacy services. The facility failed to follow the physician orders when administering Resident # 1's medications causing the resident to aspirate, have labored breathing and being sent to the hospital and being admitted due to aspiration. An (IJ) Immediate Jeopardy was identified on 8/24/2023 at 7:26pm. While the (IJ) Immediate Jeopardy was removed on 8/26/2023 at 5:00pm, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed all residents at risk for inadequate therapeutic outcomes, and a decline in health. Findings included: Record review of Resident #1 face sheet dated 8/24/2023, reflected Resident # 1 was an 85- year- old man, admitted to the facility on [DATE]. Resident # 1 was diagnosed with ATHEROSCLEROTIC HEART DISEASE (damage or disease in the hearts blood vessels), DYSPHAGIA (difficulty swallowing foods or liquids) FOLLOWING CEREBRAL INFARCTION (disrupted blood flow to the brain due to problems with the blood vessels that supply it.) Record review of Resident # 1's care plan dated 6/27/2023, reflected Resident # 1 had a swallowing problem. Record review of Resident # 1's swallowing assessment reflected he required (Reg diet pureed texture, pudding thick consistency for fluids) Record review of Resident # 1 significant change MDS dated [DATE] reflected a BIMS- high level of cognitive functioning. In the MDS section K swallowing/nutritional status reflected; pureed textured, thickened liquids therapeutic diet. Record review of Resident # 1 physician orders dated 2/14/2023 reflected- Pureed texture, pudding consistency, for fortified at breakfast and an order dated 8/22/2023 reflected- Crushed medications and mix with food/fluids due to swallowing disorder, every shift related to Dysphagia, Oropharyngeal Phase. In an interview on 8/24/2023 at 1:07pm with LVN A, revealed on 8/22/2023 the MA admitted he administered Resident #1 medications without crushing and without thickened liquids. LVN A stated when she asked the MA were Resident # 1's medications administered crushed he stated no were they supposed to be? When asked if the medications were given with water not a thickened liquid he stated yes. She stated these medications were not administered as prescribed in the orders. LVN A stated Resident # 1 was coughing and had labored breathing. She stated they sent Resident # 1 was sent for further evaluation and treatment. In a phone interview on 8/22/2023 at 1:28pm with Resident # 1, revealed he had a choking incident on 8/22/2023, the resident was able to state he was feeling fine today. He stated on Tuesday he was not feeling very well. The resident stated he was not able to remember all of what happened but stated something was wrong. In a phone interview on 8/22/2023 with (RP) at 1:30pm, revealed she was contacted by the facility and advised that that Resident # 1 started choking and wasn't recovering well, continuing to cough and complain of chest pains so they sent him to the hospital to ensure that he did not aspirate. She stated when he got to the hospital, he was still having some choking problems and was not able to formulate his words. In an interview on 8/24/2023 at 5:53pm with MDS revealed, the MA administered the following medications to Resident # 1 without crushing or thickened liquid. The medications were as follows: Lodipine 10mg, Aspirin 81mg, Cholecalciferol 125mg 1 tablet, Clopidogrel Bisulfate tablet 75mg 1 tablet, Ferrous sulfate Iron 200mg 1 tablet, Finasteride tablet 5mg 1 tablet, Lactobacillus Capsule 1 caplet, Lasix tablet 20mg 1 tablet, Tamsulosin HCI Capsule 0.4 mg, Zinc tablet 50mg, buspirone HCI tablet 15mg 1 tablet, Metoprolol Tartrate tablet 25mg, Oxcarbazepine tablet 600mg, and Zanaflex tablet 4mg 1 tablet. Interview on 8/24/2023 at 1:54pm with hospital staff revealed, Resident # 1 was admitted to the hospital on [DATE] for aspirations and shortness of breath. In an interview on 8/24/2023 at 2:23pm with the DON revealed, on 8/22/2023 a CNA (unknown) walking down the hall advised her that Resident # 1 was choking. She stated when she entered the room LVN C was already in the room assisting Resident # 1. She stated that's when she learned that the MA had given Resident # 1 his medications not crushed or with thickened liquids. She stated Resident #1 complained of his chest hurting really bad and that he stated he was choking. The DON stated she never spoke with the MA herself but did advise the nursing staff to in-service the MA before he administered medication to any of the other residents. The DON stated the nurses were responsible for ensuring that all agency staff are trained on the care needs for the residents. She stated Resident # 1 was sent to the hospital for further evaluation and possible aspiration. The DON stated Resident # 1 could have aspirated due to not having his medications crushed and administered with thickened liquids according to the orders. In an interview on 8/24/2023 at 12:30pm with the ADM revealed, the incident happened on 8/22/2023 and he has not yet completed his five -day report. He stated he was advised that the MA gave Resident # 1 his medications without them being crushed. He stated when a person is not given their medication according to the orders the Resident could have an adverse reaction and could be terminal. He stated he contacted the staffing agency and advised that the agency staff should be placed on the DNR (do not return) list and advised that they could make a referral on the staff's certification. Record review of facility progress note dated 8/22/2023 reflected, Resident # 1 was sent to the hospital on 8/22/2023 for aspirating. Record review of hospital records dated 8/22/2023, reflected Resident # 1 was admitted to the hospital for aspiration. Record review of facility Administering Medications policy dated April 2019, reflected Medications are administered in a safe and timely manner, and as prescribed. This was determined to be an (IJ) Immediate Jeopardy (IJ) on 78/24/2023 at 7:26pm. The ADM was notified. The ADM was provided with the IJ template on 8/24/2023 at 7:26pm. A Plan of Removal was first submitted by the ADM on 8/25/2023 at 9:14am. The Plan of removal accepted on 8/26/2023 at 12:18pm. Re: Plan of Removal of Immediate Jeopardy The following is a plan of removal, which has been immediately implemented for the facility to remedy the immediate jeopardy which was imposed 8/24/23 at 7:26pm for F-755 facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the need of resident 1. MA administered residents 1 medication whole and with water instead of the order which stated to crush all medications and serve with thicken liquids due to swallowing issues. All residents could potentially be affected by deficient practice. All items listed will be completed by 8/25/23 with continued follow up for scheduled staff. 1. Resident #1was assessed by LVN#1 post the event and sent to the hospital for evaluation. The initial radiological exam showed no obstructions or complications. Local Hospital is providing a higher level of care in place for this resident continues. 8-24-2023 thru 8-25-2023 2. All residents will be reviewed by DON for correct medication administration order that includes liquid administration order type. 8-25-2023 thru 8-25-2023 3. All residents were assessed by the DON/ADON regarding medication administration for crushed medication orders and/or the need for crushed medications due to diagnosis documented swallowing disorders. 8-24-2023 thru 8-25-2023 4. All residents' orders were reviewed by DON/ADON/MDS for crushed medication and orders for thickened liquids accuracy including order communication to EMAR (electronic medication administration record) regarding order. 8-24-2023 thru 8-25-2023 5. All residents requiring crushed mediations and thickened liquids care plans were reviewed by MDS/DON/ADON. 8-24-2023 thru 8-25-2023 6. All Medication aides and nurses were in-serviced by the DON/ADON regarding medication administration policy and procedure with a special focus regarding order for crushed medications and those residents requiring thickened liquids. 8-24-2023 thru 8-25-2023 7. Regional Director of Care in -serviced DON/ADON/Admin on physician orders for crushed medication and thickened liquids. All staff were in-serviced by the Admin/DON/ADON regarding following physician orders for crushed medications and thickened liquids. 8-24-2023 thru 8-25-2023 8. A medication observation will be conducted by the DON/ADON 3 times a week randomly for 3 weeks. All negative findings will be immediately corrected and forwarded to QAPI for intervention change. 8-24-2023 thru 9-8-2023 9. Contracted pharmacy consult was contacted regarding the medication administration error and involvement in QAPI process/interventions, to schedule Inservice for September 4,2023 8-24-2023 thru 8-25-2023. All residents' potential to be affected by this deficient practice. If staff are unable to attend any of the in-services, they will be required to complete before starting their assigned shift. Staff will sign the Inservice sheet for each service that will be kept at the nurses station in a binder. All PRN and Agency Staff will be in-service before the start of shift by the DON/ADON/designee. The Medical Director was initially made aware of the immediate jeopardy 8/24/23 at 10:11pm and has been involved in the development of the plan to removal. These conversations are considered a part of the QA process. To monitor for compliance the Administrator and/or designee will review all residents with swallowing disorders and medication administration passes as above with follow up if warranted for the next 30 days. The IDT will review and assess the orders in place to determine what further actions if needed are necessary. Members of this meeting are to include the Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Social Worker, and Therapy Representative. Any negative findings will be forwarded to the Administrator and the QA committee. This plan was initially implemented 8/24/23 and will be monitored through completion. It will be monitored thereafter 30 days by the regional director of care and regional director of operations. Plan of Removal completion date is 8/25/23 by with continuation of oncoming staff and follow up. The Surveyor monitored the Plan of Removal on 8/26/2023 as follows: 3:00pm Entrance of facility 3:10pm Entrance Conference with ADM and advised her the reason for the visit due to POR (Plan of Removal) monitoring. ADM was given a list of information needed. She stated the census is 58. Review of nurse's progress dated 8/22/2023 reflected the resident had been assessed prior to going to hospital. The note reflected that the resident continued to have coughing and breathing problems, so the resident was sent to the hospital for further evaluation. The resident returned to the facility on 8/25/2023 late evening. Review of nurse's progress note dated 8/26/2023 reflected Resident # 1 was assessed upon return to the facility. Record review reflected that the ADM and DON were in-serviced by the regional director of Operations on abuse/neglect dated 8/25/2023 In an interview on 8/26/2023 at 3:30pm with the DON revealed she went through each resident's chart and reviewed their medications and orders to verify that they are current and correct for each resident. The DON stated she reviewed all orders for crushed medications and thickened liquids she stated she completed this on 8/26/2023. Record review of medication log for residents with crushed medications developed and placed on each medication cart for staff to review on every resident with crushed medications, thickened liquids and how to administer to resident. Record review 8/26/2023 of resident roster will all residents who have a diagnosis of swallowing disorder, the facility had 47 residents with swallowing disorder. The DON stated she completed this task during the medication pass with the MA to ensure that all residents received the correct medication in the form required to take. Records reviewed reflected all 47 residents with swallowing disorders, care plan and orders had been updated in PCC system The DON stated she reviewed all orders for crushed medications and thickened liquids she stated she completed this on 8/26/2023. In an interview with MDS on 8/26/2023 at 4:00pm, revealed she updated all care plans to reflect how to administration the medication and how to cleanse the resident's pallet. She stated she also developed a medication log that is kept placed on each medication cart that shows each resident with crushed medications and how they are to be administered, the log is updated daily to ensure all residents with crushed medications are listed and how to administer according to the order to help ensure that when giving medications the form is reviewed and checked off for each resident. Record review of in-services reflected 3 agency staff have completed the following in-services: Medication administration, crushing medications, Abuse/Neglect, Choking dated 8/26/2023. Record review reflected 4 agency staff completed the in-service on Where to find and read Physician orders dated 8/25/2023. Record review reflected 31 facility staff completed the following in-services Dysphagia dated 8/25/2023, 27 facility staff completed the in-service for Choking and Abuse/ Neglect dated 8/25/2023, 15 facility staff completed the in-service on Where to find and read physicians orders, crushing medications, and Medication administration dated 8/25/2023. Record review of in-service Physicians orders, crushed medications and thickened liquids dated 8/26/2023 completed by the regional director. Record review of two staff observations were completed by the DON administering medications. The staff were observed going through each step before administering to verify correct dosage, correct resident, and administered in the correct manner for, 1 MA and LVN on 8/25/2023 and 8/26/2023 Beginning at 3:56pm - Interview with 3 CNA's (agency staff) 6am to 6pm shift. Stated they have been in-serviced on where to find the care needs for the residents in PCC. Stated they have been in-serviced on abuse/neglect stated the protocol is to report immediately if they see or suspect abuse/neglect. Stated they have never seen or suspected abuse/neglect at this facility. Stated they have been trained on choking and protocols to take when a resident may choke, stated they do not pass medications. Beginning at 4:10pm -MA B (facility) doubles on the weekends 6am to 10pm. Stated she has been in-serviced on abuse/neglect, dysphagia, choking, crushed medications, medication administration and physician orders. She stated she looks in the MAR to verify what medication a resident requires the dosage, and how it is to be administered. She stated the protocol for abuse/neglect is to report immediately to the admin. who is the abuse/neglect coordinator, stated she has never seen or suspected abuse/neglect at this facility. Beginning at 4:34pm Interview with RN weekend supervisor double weekends (facility), LVN weekend nurse 6am- 10pn (facility) Stated they have been trained on abuse/neglect, physician orders, medication administration, crushed medications. Stated staff are to report if there is any discrepancy or error made when medications are administered. She stated a log has been placed on each medication cart as an added way for MA, and nurses will know which residents require crushed medications and thickened liquids, but they should still check the MAR. 4:40pm Interview with LVN B (facility staff) weekend nurse 6am- 10pm Stated they have been trained on abuse/neglect, physician orders, medication administration, crushed medications. Stated they check the medication log posted on the medication cart is one way to know and look in the MAR on the PCC system to see how medication is administered for the resident. 4:49pm Interview with Resident # 4 stated she as ok, stated she had no concerns at this time and stated she felt safe. 4:50pm Observation of Resident #1, appeared he was sleeping, did not appear to be in any pain or distress during this observation 5:00pm interview with Resident # 5 stated he was doing fine, stated he felt safe and had no concerns at this time. 4:53pm- Interview with ADMN. Stated it was his expectation that staff follow all the training and protocols they have been given to provide the resident with the care needs they require that will allow them to have the best quality of life possible. The ADM was informed that Immediate Jeopardy was removed on 8/26/2023 at 5:00pm. The facility remained out of compliance at the severity level of potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.