**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing and administering of all routine and emergency drugs and biologicals for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure that Resident #1's hospital discharge orders were followed to prevent rehospitalization due to hypoglycemia. 1. The facility failed to discontinue Resident #1's metformin and glyburide medications. 2. The facility failed to implement blood sugar monitoring for Resident #1. 3. The facility failed to start Resident #1 on the appetite stimulant (Mirtazapine) as ordered. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 02/10/2025 at 5:06 PM and an IJ template was given. While the IJ was removed on 02/11/2025 at 3:45 PM, the facility remained out of compliance at no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of exacerbation and/or deterioration of their health conditions which could result in rehospitalization and/or death. Review of Resident #1's face sheet reflected a [AGE] year-old woman re-admitted on [DATE] with initial admission date of 01/16/2025 with diagnoses of end stage renal disease (a medical condition where the kidneys have permanently lost their ability to function adequately), type 2 diabetes mellitus with unspecified complications (a diagnosis of type 2 diabetes where the specific complications are not detailed or identified), dysphagia (difficulty swallowing), dependence on renal dialysis (a condition where a person's kidneys have permanently lost their ability to adequately filter waste products from the blood, requiring regular treatments to remove these toxins and maintain life), cognitive communication deficit (a difficulty with communication caused by an impairment in cognitive processes), and other speech and language deficits following cerebral infarction (a range of communication impairments that can occur after a stroke). Review of Resident #1 MDS assessment dated [DATE] reflected a BIMS score of 13 and had an active diagnosis of diabetes mellitus. Review of Resident #1 active orders as of 1/27/2025 reflected resident had order for hemodialysis three times a week with an order date of 01/17/2025. Further review reflected an order for glyburide one time a day for diabetes mellitus and metformin tablet two times a day for diabetes mellitus with a start date of 01/17/2025. Review of Resident #1 progress note dated 01/22/2025 by the DON reflected dialysis center called to notify facility Resident #1 was sent to ER after treatment due to lower blood sugar of 27. Review of Resident #1 progress note dated 01/23/2025 by LVN A reflected Resident #1 returned to facility via ambulance. Progress note reflected Resident has no medications changes, no wounds. Review of Resident #1 progress note dated 01/25/2025 by RN B reflected Resident #1 refused to eat lunch and breakfast, and blood sugar obtained at 112 with no signs or symptoms of hypo/hyperglycemia. Review of Resident #1 hospital discharge instructions with date of 01/23/2025 reflected special instructions to follow up hospitalization for hypoglycemia (condition where the blood glucose level falls below normal) after discharge to SNF. Additional instructions reflected all diabetes medications now discontinued. Monitor blood sugar. Patient started on appetite stimulant. Discharge instructions included discharge medications which reflected metformin and glyburide were not included and mirtazapine was started on 01/22/2025. Review of Resident #1 orders active as of 01/27/2025 reflected no order for blood glucose checks or orders for appetite stimulant. Review of Resident #1 active orders at of 02/10/2025 reflected blood sugar checks before meals and at bedtime with a start date of 02/04/2025 and mirtazapine (appetite stimulant) by mouth at bedtime with a start date of 02/04/2025. Review of Resident #1 MAR reflected glyburide was administered on 1/24/2025, 01/25/2025 and 01/26/2025. Further review reflected metformin was administered once on 01/23/2025, twice on 01/24/2025, and twice on 01/26/2025. Review of Resident #1 change of condition evaluation dated 01/27/2025 reflected Resident #1 displayed altered mental status, abnormal vitals signs and signs of stroke. Resident #1 had a resting heart rate of 48 and blood glucose of 24 mg/dL. Review reflected change of condition was reported to the NP recommended to administer glucagon. Review of Resident #1's hospital notes dated 01/27/2025 reflected Resident #1's metformin and glyburide were discontinued and she was discharged back to the facility. Review reflected that, Resident #1 was found minimally responsive and blood sugar was 24 and did not improve after doses of glucagon. Review of hospital notes also reflected, Resident #1 had continued to receive metformin and glyburide. Review reflected Resident presented back with hypoglycemia, severe lactic acidosis and hyperkalemia. Further review reflected Resident #1 was seen in ICU. Review of Resident #1 hospital notes dated 02/01/2025 with admission date of 01/27/2025 reflected Resident #1 was readmitted to hospital on [DATE] with hypoglycemia which was corrected, and she was stopped on metformin and glyburide. Resident #1 was readmitted on [DATE] with hypoglycemia as she was restarted on her metformin and glyburide at the SNF. Further review reflected lactic acidosis (condition where the body builds up too much lactic acid) was felt secondary to metformin. During an interview on 02/10/2025 at 1:24 PM, RN C stated that he was familiar with Resident #1. RN C stated Resident #1 could be forgetful and may not recall everything. RN C stated that Resident #1 does get her blood sugar taken and that the nurse is responsible for taking blood sugar. He stated that her blood sugar that morning (02/10/2025) was 100 and that was within normal range. RN C stated that when residents get readmitted , the facility received a medication list from the hospital, and they call the medications into the on-call service to [NAME] the orders with the NP or MD or if the NP is in the facility, they could review it then. RN C stated if an order was discontinued, a resident should not have received the medication unless it was approved by the NP. RN C stated that the harm of receiving a discontinued medication depended on the type of medication that was received, and that if glyburide or metformin was given, it may lower the resident's blood sugar and could cause hypoglycemia. During a telephonic interview on 02/10/2025 at 1:55 PM, RN D stated she was familiar with Resident #1. RN D stated she was aware that Resident #1 went to the hospital two times, and she was the nurse that sent Resident #1 to the hospital the second time. RN D stated that she could not recall the date that Resident #1 went to the hospital. RN D stated that Resident #1 was unresponsive, and her blood sugar was really low. RN D stated she followed protocol and gave Resident #1 a shot of glucagon IM. RN D stated that she waited with Resident #1 for 15-20 minutes and when Resident #1's blood sugar did not go up, she called 911. RN D stated that when Resident #1 was being evaluated by EMS, her face started to droop. RN D stated that when a resident returns from the hospital, the facility received discharge orders and then they are verified with the NP. RN D stated that NP would clarify whether or not to keep or discontinue the medication. RN D stated she was not sure if Resident #1 received medication that was discontinued. RN D stated that there is not anyone else that verified orders received from the hospital. During a telephonic interview on 02/10/2025 at 2:11 PM, LVN A stated she was familiar with Resident #1. LVN A stated she readmitted Resident #1 on 01/23/2025. LVN A stated she could not recall if there were any medication changes for Resident #1. LVN A stated that at one point Resident #1 came back to the facility from the hospital and did not have any paperwork. LVN A stated she remembered she tried calling the hospital, and was left on hold and the line got disconnected. LVN A stated she went through some of Resident #1's paperwork in her room and looked for medication changes. LVN A stated she asked Resident #1 if they made any changes at the hospital and Resident #1 answered there were no changes. LVN A clarified that Resident #1 did not come back with any paperwork and EMS did not provide LVN A with any paperwork. LVN A stated that normally EMS gave her paperwork. LVN A stated that she asked EMS if there were any changes, and she was told no. LVN A stated she looked and found an envelope in Resident #1's closet and looked through it and did not see that there were any medication changes compared to the list the facility had. LVN A stated she did not recall the title of the paperwork because there were a lot of residents and a lot of things going on. LVN A stated, normally, the facility received paperwork from the paramedics and they would get a brief report and check a medication list that was brought in. LVN A stated that she would then call on-call and let them know a resident was readmitted and would provide medication names and doses. She stated if there were a discrepancy, she would call the hospital and get clarification. LVN A stated that Resident #1 could be forgetful. LVN A stated she left the paperwork with Resident #1 and did not take it with her. LVN A stated that she looked through Resident #1's paperwork because she could be forgetful and she wanted to double check if there were any changes. During an interview on 02/10/2025 at 2:47 PM, the NP stated she was a little familiar with Resident #1 as she was usually out to dialysis. NP stated she received something that there were no changes with Resident #1's medication and that the hospital did not send paperwork back and she resumed her medications. NP stated that Resident #1 then went out to the hospital again and they caught that there was an order to discontinue medication and that they were not discontinued. NP stated she saw Resident #1 when she admitted . NP stated she did not see Resident #1 when she returned from the hospital because she was not at the facility on Fridays and Resident #1 returned on 1/23/2025. NP stated if a resident returns during business hours staff will call her and let her know and they would review the medications. NP stated if a resident return in the evening, the facility staff would have called the on-call person and reviewed medications to the on-call staff. NP stated if a resident returned without a medication list or discharge instructions, she could usually call the doctor because he works at the hospital as well and get the doctor to send the medications. NP stated when she received a call about a resident that was readmitted to the facility, she would ask the facility staff if there were changes to previous medications and the nurse would clarify to resume or not. NP stated she would normally check the resident's admission the following day. NP stated she missed seeing Resident #1 because Resident #1 was either at dialysis or in the hospital. NP stated that Resident #1 was not a good historian and she did have some cognitive deficits. NP stated that glyburide and metformin were long-acting diabetic pills and were meant to lower blood sugar. She stated that if a resident was on an oral medication to control blood sugar, then blood sugar was not checked. NP stated it may be checked the first few days to get a trend and from there it would be checked every three months or if the Resident was symptomatic. NP stated that if Resident #1 was not eating, and with dialysis filtering her blood, it could contribute to her blood sugar lowering. NP stated that she was notified that the facility did not receive paperwork from the hospital and NP was not going to stop all medications just because the paperwork was not received. NP stated that normally, the following day, she would see the resident and reconcile medications, but she was not at the facility on 1/24/2025, and the MD saw her and they are unable to see a resident on the same day. During an interview on 2/10/2025 at 3:12 PM, RN E stated that Resident #1 was sent out from dialysis on 1/22/2025 due to low blood sugar. She stated Resident #1 was sent around 11:13 AM. RN E stated her blood sugar was 42 and did not increase after she was provided glucose gel. During an interview on 2/10/2025 at 3:35 PM, the ED stated that the admission assessment packet was the policy used for readmissions and medication reconciliation during readmissions. During an interview on 2/10/2025 at 3:36 PM, the DON stated the facility was not aware when Resident #1 returned without paperwork from the hospital. She stated LVN A said whoever brought Resident #1 back to the facility stated there were no changes to her medication, and Resident #1 stated she had no paperwork. DON stated LVN A tried to call the hospital because the hospital did not call for report. DON stated after Resident #1 was readmitted , the doctor called and said the medications should have been discontinued. DON stated she spoke with LVN A, and LVN A stated there was no paperwork. DON stated if a resident returned from the hospital with no paperwork, the nurse was supposed to call the ER and try to get a medication list. DON stated LVN A tried to get ahold of the hospital, but she was not able to get through. DON stated that Resident #1 was alert and orientated, and she said there were no changes. DON stated that it was the facility's responsibility to ensure there were no changes. DON stated she would have expected LVN A to document her attempts to try and get the medication list from the hospital, and any information she received that there were no changes. DON stated LVN A took EMS' word because nothing was sent with Resident #1 and assumed nothing had changed. DON stated Resident #1 went out to the hospital again on 1/27/2025 because her blood sugar had dropped again, and the nurse thought she was having a stroke because her heart rate was high and other symptoms. DON stated, initially, Resident #1 went to the hospital from dialysis. DON stated the admission packet was used for new admissions and readmissions after a 72-hour hospital stay. During an interview on 2/10/2025 at 3:51 PM, Resident #1 stated she had returned from dialysis and stated she was tired. Resident #1 stated she had been to the hospital a few times because her blood glucose dropped. Resident #1 stated when that happened, she felt dizzy. Resident #1 was unable to remember if she had paperwork when she returned from the hospital or the nurse that was working. Review of undated admission assessment packet reflected no guidance on medication reconciliation. Review of the facility's policy titled Medication Administration dated June 2022 reflected it is the policy of this facility that medications shall be administered as prescribed by the attending physician. The ED and DON were notified on 2/10/2025 at 5:00 PM that an IJ had been identified. An IJ template was provided and a POR was required. The following POR was approved on 02/11/2025 at 1:09 PM and indicated: Immediate Plan of Removal The facility submits this Plan of Removal to address the Immediate Jeopardy identified, on 2/10/2025. Identification of Others Affected by Alleged Deficient Practice: All admissions and re-admissions have the potential to be affected by this alleged deficient practice. Summary: On 2/10/2025 an abbreviated survey was initiated at [facility]. On 2/10/2025 the surveyor provided an Immediate Jeopardy (IJ) 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 (IJ) states as follows: F755- The facility failed to ensure pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals. The facility failed to ensure that Resident #1's hospital discharge orders were followed to prevent rehospitalization due to hypoglycemia. Action: Medical Director notification Start Date: 2/10/25 Completion Date: 2/10/25 Responsible: Executive Director Action: Audit all admissions/readmissions from 1/23/25 to present to ensure all medications were correctly verified. Start Date: 2/10/25 Completion Date: 2/10/25 Responsible: DON/Designee/Clinical Resource Action: Inservice DON on admission requirements to verify orders. If the sending facility (hospital, SNF, etc.) does not provide discharge summaries or orders: a. The admitting nurse will call the hospital and/or facility resident is returning from to obtain discharge orders. b. In the event orders are unable to be obtained, the NP/DON/ADON/MD will be notified by the admitting nurse to assist in retrieving discharge summaries/orders. c. These steps will remain in the permanent admission/readmission protocol. Start Date: 2/10/25 Completion Date: 2/10/25 Responsible: Clinical Resource Action: Inservice Nursing and Nursing Leadership staff on admission requirements to verify orders. If the sending facility (hospital, SNF, etc.) does not provide discharge summaries or orders: a. The admitting nurse will call the hospital and/or facility resident is returning from to obtain discharge orders. b. In the event orders are unable to be obtained, the NP/DON/ADON/MD will be notified by the admitting nurse to assist in retrieving discharge summaries/orders. c. These steps will remain in the permanent admission/readmission protocol. Start Date: 2/10/25 Completion Date: 2/11/25 Responsible: DON/Designee Action: Ad hoc QA1 meeting. Attendees will include ED, DON, Clinical Resource, Cluster Partners, Medical Director. Meeting will include the Plan of Removal and inventions. Start Date: 2/10/25 Completion Date: 2/10/25 Responsible: Executive Director Action: Admissions Coordinator inservice on notification of pharmacy consultant of all admissions/readmissions for medication review. Start Date: 2/11/25 Completion Date: 2/11/25 Responsible: DON Systemic Change to Prevent Re-Occurrence: DON/Designee will ensure admitting nursing staff verify admission/readmission orders. If the sending facility (hospital, SNF, etc.) does not provide discharge summaries or orders: d. The admitting nurse will call the hospital and/or facility resident is returning from to obtain discharge orders. e. In the event orders are unable to be obtained, the NP/DON/ADON/MD will be notified by the admitting nurse to assist in retrieving discharge summaries/orders. f. These steps will remain in the permanent admission/readmission protocol. Monitoring to Ensure Ongoing Compliance: DON/ Designee will audit order listing report daily to include admissions and readmissions. Will include trends of verification of orders upon admissions during QAPI meeting x 90 days. Surveyor monitored the POR on 2/11/2025 as followed: Review of the facility's in-service training report dated 02/10/2025 and titled admission process verification of medication on admission and readmission reflected it was provided to the DON by Clinical resource. Review of facility in-service titled notification of pharmacy consultant of all admission and readmission for medication review dated 02/11/2025 reflected in-service was provided to admission coordinator. Review of facility in-service dated 02/10/2025 titled Admission/Verification of Meds reflected it was completed with 25 nurses. Review reflected any admission will have medication verification against discharge orders. If a resident did not bring orders, hospital needed to be called and attempts needed to be made to get orders. If unable to do so, documentation needed to be noted in the resident's charge. Notification to DON/ADON/NP was to be made to attempt to get discharge orders and staff should pass along on the 24-hour report. Review of admission medication orders audit for admissions on 1/23/2025 included 23 residents. No discrepancies were listed. Review of QAPI sign-in sheet dated 02/10/2025 reflected a meeting was conducted and included the ADM, DON, NP, and Medical Director. During interviews on 02/11/2025 between 2:27 PM and 3:30 PM, with 2 RNs and 4 LVNs, it was revealed that staff received an in-service either 2/10/2025 or prior to their shift on 2/11/2025 by the DON or Clinical resource. Staff stated that the in-service included to ensure orders were received for any new admission and if the resident did not come with paperwork then the staff should try to contact the hospital and if they are unable to get through then they should notify the DON/ADON. Staff stated this information should be written on the 24-hour report and document all that was done and who was notified in management and attempts made to get the orders. Staff stated the NP should also be called and notified that a patient was sent with no orders. Staff stated if a resident was still at the hospital at midnight then they would be considered a new admission and all orders should have been discontinued and all new orders would be put in as if they were a new patient. Staff stated that if a resident was sent out with low blood sugar, they would want to check the resident's blood sugar when they returned and may ask the NP if they wanted to initial blood sugar checks and felt that was standard nursing care. During an interview on 02/11/2025 at 3:36 PM, the DON stated in-service was provided to her on 02/10/2025 by clinical resource. DON stated nurses were in-serviced prior to beginning their shift of if they were present yesterday (02/10/2025). DON stated the process was updated and for any admission staff was to ensure they received discharge orders. If they were not received, then they should call the sending facility that discharged the residents. DON stated if staff could not get ahold of the facility, then it should be communicated with the DON/ADON/NP and with the oncoming shift. DON/ADON would then attempt to get ahold of the MD to get discharge orders. DON stated if the resident was not back in the facility by midnight, then their medications should be discontinued, and the medications would have to be entered again like a new admission. DON stated that ADONs would pull an order listing from the report daily and cross reference the information with discharge paperwork and what is in PCC. DON stated order listing report will also be discussed during QAPI and during IDT meetings. The ED was notified on 02/11/2025 at 3:45 PM that the IJ had been removed. While the IJ was removed, the facility remained out of compliance at a level of no actual harm that was not immediate jeopardy at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #2) of three residents reviewed for accidents and hazards, in that: The facility failed to ensure Resident #2 (who was a high-elopement risk) did not elope from the facility on 03/26/24 at 12:50 PM when the Receptionist used her remote-control door opener to unlock the front door. He was located over 24 hours later at a bus stop approximately 12 miles from the facility. The noncompliance was identified as PNC. The IJ began on 03/26/24 and ended on 03/27/24. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk for unsafe elopements, falls, injuries, dehydration, and hospitalization. Findings included: Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), hypertension (high blood pressure), type II diabetes, and frontal lobe and executive function deficit following cerebral infarction. Review of Resident #2's admission MDS assessment, dated 03/06/24, reflected a BIMS of 11, indicating a moderate cognitive impairment. Section GG (Functional Abilities and Goals) reflected he ambulated independently. Section P (Restraints and Alarms) reflected he required no physical restraints or alarms. Review of Resident #2's admission care plan, dated 02/26/24, reflected he was an elopement risk/wanderer related to impaired safety awareness with an intervention of providing structured activities. Review of Resident #2's Elopement/Wandering Evaluation, dated 02/27/24, reflected he was a high risk for elopement. Review of Resident #2's nursing progress notes, dated 03/26/24 at 7:35 PM and documented by LVN C, reflected the following : [Resident #2] reported missing to charge nurse around 5PM charge nurse was on 200 hall. [Resident #2] is aox2-3 and has a hx of attempting to elope. [Resident #2] usually goes to smoke break at regular intervals. Informed DON, ADMIN, ADON. All staff began searching entire facility for [Resident #2] . police called. Review of Resident #2's nursing progress notes, dated 03/27/24 at 9:50 PM and documented by LVN C, reflected the following : [Resident #2] brought back to facility via private vehicle with staff member. No new orders given from hospital . Sitter at bedside. During an interview on 03/28/24 at 9:32 AM with the ADM and DON, the ADM stated around 5:00 PM on 03/26/24, a MA notified the charge nurse that he could not find Resident #2 when he went to administer his medication. The ADM stated upon review of the video footage, Resident #2 attempted to push the front door open around 12:50 PM and the alarm went off. The ADM stated the Receptionist looked up and immediately pressed the button that turns the alarm off and unlocks the door. The ADM stated Resident #2 then pushed open the door and walked out. He stated his expectations were that all staff, including the Receptionist, were to verify residents before allowing them to exit the facility. The ADM stated the Receptionist was fully aware Resident #2 was an elopement risk and he was even in the elopement binder that was kept at the Receptionist's desk and the nurses' station. The ADM stated all residents that were a high risk of wandering/eloping had their picture in the binder, along with their face sheet, and the elopement process. The ADM stated the Receptionist had been suspended and would not be returning. The ADM stated they had more than 20 people searching for Resident 32 around the clock and he was found at a bus station around 4:22 PM on 03/27/24 by a sister facility's ADM. The ADM stated they took him to the hospital for an evaluation and other than mild dehydration, he had a good bill of health and was taken back to the facility. The ADM stated he did not remember what he did the day before but was now on 1:1 around-the-clock until they found alternate placement. On 03/28/24 at 10:40 AM, a telephone call was made to the Receptionist. A return call was not received prior to exiting. During an observation and interview on 03/28/24 at 11:53 AM, revealed Resident #2 was in his bed sleeping. HSK B was sitting in his room. She stated she worked in the housekeeping department but today was sitting with Resident #2 due to his elopement incident. She stated he had not exhibited any exit-seeking behaviors and when she asked him what he did yesterday (03/27/24), he stated he went to the store for groceries. She stated before her shift she was in-serviced on the elopement policy, exit-seeking behaviors, and about verifying residents in the elopement binders at the front desk and nurses' station before every letting a resident leave. During an interview on 03/28/24 at 11:59 AM, LVN C stated she was in-serviced before working her shift on elopements, the elopement binders, checking the binders if a resident was trying to leave, and ensuring you put eyes on each of their residents at the beginning of their shift, frequently, and end of their shift. During an interview on 03/28/24 at 12:08 PM, the MDSC stated she had been in-serviced the day Resident #2 eloped. She stated the in-services included their elopement policy, the elopement binders, and exit-seeking behaviors. She stated at every morning meeting she was told if someone was a high-elopement risk she was responsible for ensuring their care plan had interventions in place. During an interview on 03/28/24 at 12:59 PM, the SC stated she had been in-serviced on the elopement binders, if a resident was a high-risk of elopement and wanted to go outside, to go out with them and ensure to bring them back inside. She stated she was also in-serviced on redirecting residents that wandered. During an interview on 03/28/24 at 1:06 PM, CNA A stated she was in-serviced before her shift the day before, 03/27/24. She stated the in-services were about elopements, the elopement binder, knowing residents that were a high-risk of eloping, who to notify, and to check on the residents every two hours and ensure you lay eyes on them. During a telephone interview on 03/28/24 at 1:18 PM, CNA D stated she worked on Resident #2's hall on the day he eloped. She stated when she made her initial rounds at 2:00 PM, he was not in his room, but that was not unusual for him because he was rarely in his room as he liked to walk around the facility and sit in the dining room or living room area. She stated she knew she had made a mistake. She stated she had been in-serviced on ensuring they lay your eyes on your residents at the start of each shift and every two hours. She stated there were elopement binders at the front desk and the nurses' stations which identified residents that were high risk. Observation on 03/28/24 from 1:57 PM - 2:04 PM revealed three staff members getting in-serviced by the DON and taking a written elopement quiz in the front lobby before clocking in for their shifts. During an interview on 03/28/24 at 2:08 PM, the new Receptionist stated if a resident wanted to leave the facility, she would first check the elopement binder to ensure they were not a high elopement risk. Review of the facility's Suspension document, dated 03/26/24, reflected the Receptionist was suspended pending the full investigation. Review of the facility's Elopement Timeline for Resident #2, from 03/26/24 - 03/27/24, reflected the following: [Resident #2] (Elopement) 3/26/24 Timeline: 5:15 PM- Med Aide, looked to provide meds to resident and saw they were not in their room. Resident often would sit in other resident's rooms or be in other places of the building, but upon looking for him, it was determined resident may be missing. 5:45 PM- ED and DON were notified that resident was not able to be found after staff had searched the facility and other resident rooms. Immediate code was called to search for the resident. Reviewed Cameras: 12:45 PM- It was observed that [Resident #2] left his room and per his roommate's statement was going to go and purchase or find some cigarettes. 12:50 PM- [Resident #2] approached front door and attempted to open the door. The door alarm sounded, and the resident pulled back from the door. Receptionist looked and noticed someone wanting to exit and pushed the button to release the door alarm and [Resident #2] was able to leave the facility. 6:28 PM- Notified cluster and market to create search party in the local area- reaching out to hospitals, potential places resident may have gone to, metro bus routes were contacted, reached out to point of contacts. POC on file has not had any contact with him and asked that we stop reaching out as he does not want involvement with the resident. 7:10 PM- Police were called after initial search and resident not returned. Case #240861143- Officer [name] #8755. 7:00 PM-11:00 PM- Search parties drove surrounding neighborhoods, called hospitals every couple hours, spoke with local patrons of convenient stores/gas stations/stores providing pictures of the resident. 3/27/24 6:30 AM- Searching began again: 6:30 AM- Local Hospitals called. 7:22 AM- All bus stops from (street) to (street) 7:27 AM- (homeless shelter) searched 7:32 AM- (two major retailers), 2 Homeless [NAME] near (major highway) 8:04 AM- Parks and Churches in area around facility 8:27 AM- Gas stations from (street) to (street) 8:27 AM- (fast-food restaurant) on (intersection) stated they would review their cameras for us this morning 8:34 AM- (apartment complex) just west of the facility 8:38 AM- (neighborhood) east of facility 8:58 AM- (neighborhood) cleared 9:00 AM- (DON from sister facility) contacted (bus) company to ask for any sign on bus routes. From 4PM 3/26 to 4 AM 3/27, there were not sightings of the resident. 9:13 AM- (public park) cleared 9:17 AM- (fast-food restaurant) stated they would review cameras for us and get back to us later 9:47 AM- (neighborhood) 10:20 AM- (grocery store) 10:24 AM- (ED from sister facility) spoke with police department to see if they can trace bank information, they are unable to do that due to time to do that and not being next of kin, but did identify a [family member] that we can try and contact but did not have contact information 11:33 AM- Calls to hospitals and transits again 11:54 AM- (fast-food restaurant) staff member saw the silver alert and would look out 12:07 PM- (transit company) searched as well as (nearby church) 12:15 PM- (grocery store) at (intersection) searched again 12:22 PM- (fast-food restaurant) confirmed they did not see him on Camera 12:23 PM- two gas stations searched 12:35 PM- (three retailers) 12:55 PM- All hospitals called again 1:09 PM- Flyer created based on silver alert to provide to vendors, stations, community 2:00 PM- Huddle with staff- in-serviced staff on Elopement Risk, Elopement Policy, Resident Monitoring and Residents walking along driveway 2:30 PM- Regrouped- Mapped out more regions and sent teams to additional grids of [city name]- some interviewed current residents to see if they would have additional insight to where he may go- one resident made recommendations more into downtown [city name] 3:50 PM- Security company across from facility shared that they had video of resident from prior day heading east towards (major highway) 4:22 PM- [Resident #2] was found at a bus stop- was willing to go with (two EDs from sister facilities), who took him to (hospital) evaluation 4:48 PM- Called Police Department to give update on resident being located 5:23 PM- Submitted Self Report to HHSC 5:30 PM- QAPI Meeting completed with IDT and Medical Director regarding elopement risk, root cause and interventions and next steps 6:00 PM- Present- Continue inservicing staff Review of an in-service entitled Elopement Process, from 03/26/24 - 03/27/24, reflected staff from all shifts were in-serviced on the following: Where are the elopement binders? Who is in the binders? Elopement Policy and Procedure Review of the facility's Interdisciplinary Committee Meeting (QAPI) agenda, dated 03/27/24, reflected the MD, DON, ADM, MDSC, SW, SC, BOM, and other corporate individuals were in attendance. The problem areas discussed reflected the following: Ad hoc QAPI meeting discussing elopement, process and procedure during an elopement, RCA and training going forward. Searches and grids were created and were searched in a 5-mile radius. [Resident #2] mentioned to roommate the was wanting some cigarettes. Searching places triggered gas stations. Different people were assigned in searching on 3/26 and this morning. [Resident #2] was found. Interventions: elopement risk assessments completed at 100%, in-serviced started on #1 elopement assessments, #2 notifying leadership team when someone is noted leaving the facility, #3 monitoring of residents upon start of shift, #4 no one is to be outside unsupervised if they are in the elopement binder. Elopement drill completed. Self-report submitted this afternoon. Care plan for elopements interviewed [sic]. We will continue to monitor for completion of in-services. Review of the elopement binder at the Receptionist's desk, on 03/28/24, reflected residents with a high-elopement risk had a face sheet and picture in the binder. Resident #2's information was included in the binder. Review of the facility's Elopement/Unsafe Wandering Policy, revised 12/2023, reflected the following: It is the policy of this facility to provide a safe environment, as free of accidents as possible, for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintain the least restrictive manner for those at risk of elopement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the resident(s) environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents, for 1 of 4 residents (Resident #72) reviewed for accident hazards and supervision, in that; 1.Resident #72 had 2 unauthorized, unchaperoned elopement events on 10/03/2022 and 01/03/2023, without the facility providing adequate safety interventions to prevent further elopement risks. An IJ was identified on 09/01/2023. The IJ template was provided to the facility on [DATE] at 05:30 PM. While the IJ was removed on 09/03/2023, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on elopement risk residents. The findings included: A record review of Resident #72's admission record, dated 08/31/2023, revealed an admission date of 12/10/2021 with diagnoses which included Alzheimer's disease [a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment] and cognitive communication deficit [a difficulty with thinking and how someone uses language]. A record review of Resident #72's quarterly MDS, dated [DATE], revealed Resident #72 was a [AGE] year-old female admitted for long term care. Further review revealed Resident #72 needed supervision and or touching assistance while walking outdoors., Functional Abilities and Goals .mobility .Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel .1 step (curb): The ability to go up and down a curb and/or up and down one step .Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as Resident completes activity. Assistance may be provided throughout the activity or intermittently. A record review of Resident #72's IDT-BIMS assessment, dated 10/04/2022, revealed a score of 04 out of a possible 15, which indicated severe cognitive impairment. A record review of Resident #72's care plan dated 08/31/2023, revealed Resident #72 had eloped on 10/03/2022, at risk for elopement related to her independence in mobility and her dementia .[Resident #72] will be safe while ambulating about the facility and around the facility . reorient her to the facility and the surroundings .encourage her to tell staff when she is going for a walk . continue with stop alarm at exit doors . continue to have door alarm on at all times . complete elopement assessment . assess for any changes . activity program set up through speech therapy and activities to go on assisted walks. A record review of Resident #72's nursing progress note dated 10/03/2022 authored by LVN H at 06:07 PM, revealed Resident #72 was seen walking 0.7 miles away down a busy 5 lane road by a person who was familiar with Resident #72. The note reflected, pt [Resident #72] noted wandering off of the property. pt [Resident #72] was noted walking down the highway towards [named] grocery store. nurse and cna left property and noted pt [Resident #72] walking back toward property. pt [Resident #72] stated that she just wanted to go for a walk and see the people. pt's [Resident #72] [family member] has been notified. MD .has been notified. pt [Resident #72] has been fully assessed and has no s/s of distress no c/o pain no injuries noted. 135/82/118-20-98.2-96% room air. pt [Resident #72] is in dining area at this time ax0 2-3 eating dinner. A record review of Resident #72's nursing progress note dated 01/03/2023 authored by LVN I at 02:34 AM, revealed Resident #72 eloped and was returned to the facility by a kind stranger, around 06:00 PM, who discovered Resident #72 0.8 miles away at a convenience store. The note reflected At 1839 [06:38 PM], resident [#72] was returned to facility. The gentleman that brought resident back to facility states she was at [named] corner store. DON and NP aware of elopement. DON attempted to call [family member] X2 and left message, no return call this noc [nocturnal / night]. Q 1hr checks per order. Labs ordered. WCTM. A record review of the google maps website, https://www.google.com/maps/place/3200+W+Slaughter+Ln,+Austin,+TX+78748/@30.1828935,7.8431987,17z/data=!3m1!4b1!4m6!3m5!1s0x865b4c68be837171:0x9764e07399760efb!8m2!3d30.1828889!4d-97.8406238!16s%2Fg%2F11bw3ybj_j?entry=ttu , accessed August 31, 2023, revealed the facility had a 1000-foot driveway from the 5 lane road where the facility was located. Further review revealed a convenience store 0.8 miles away from the facility accessed only by crossing the 5-lane road. Further review revealed the grocery store was located 0.7 miles away from the facility. During multiple observations from 08/29/2023 through 09/03/2023 of the route from the facility to the convenience store and the grocery store revealed the facility had a 1000-foot driveway before reaching the road, several isolated wooded areas, numerous commercial businesses, and an apartment complex. The route was adjacent to a 5-6 lane road with a 45 mile an hour speed limit. During an interview on 08/31/2023 at 10:02 AM LVN H stated she was on working the evening on October 03, 2022, and was responsible for Resident #72's care when she received a telephone call, around 06:00 PM, from a person who was familiar with Resident #72 and the facility. The person stated Resident #72 was seen walking to the local grocery store along the busy road. LVN H stated she immediately alerted the staff to the elopement and initiated the elopement protocol. LVN H stated she and a fellow CNA went in their vehicles and searched for Resident #72. LVN H stated she had observed Resident #72 walking back to the facility. LVN H stated she had assessed the resident without any injuries, alerted the previous DON, reported the elopement to the doctor, and made a nursing note . During an interview on 08/31/2023 at 05:32 PM the facility's Community Liason [CL] stated she, by chance, had been outside of the facility's front door on 08/30/2023 when she observed Resident #72 walking out of the front door behind a visitor who was exiting the facility. The CL stated she redirected Resident #72 back into the facility. The CL stated she recognized Resident #72 maybe should not be outdoors due to her own experience and had not received any training to identify residents who were elopement risks. During an interview on 9/1/2023 at 10:37 AM the Administrator stated he began as the Administrator in January of 2023 and had not received a report from the previous Administrator and/or the previous DON [CSC RN] of any elopement events for any residents. The Administrator stated Resident #72 had eloped on 01/03/2023 however he believed the elopement was the first elopement and without any previous history of elopements. The Administrator stated had he known that was her second elopement he may have explored a discharge for Resident #72 to a facility which had more infrastructure for residents who were elopement risks. The Administrator stated the IDT met in January 2023 and implemented elopement risk interventions for Resident #72, to include staff to monitor Resident #72's elopement seeking, documentation of elopement seeking, and interventions for Resident #72 to have the opportunity to walk outside with staff and family. The Administrator stated Resident #72 had several attempts for elopement and has been redirected back into the facility due to staff monitoring Resident #72. During an interview on 09/01/2023 at 11:46 AM the DON stated she had been the DON since December 2022 and had not received any report for elopements for any residents. The DON stated she had received a report from the facility nurses on 01/03/2023 that Resident #72 had eloped and was returned to the facility by a person who discovered her at the convenience store down the road from the facility. The DON stated she had no clear idea how long Resident #72 was gone or how she eloped. The DON stated she had reported the elopement to the Administrator and the elopement resulted in an IDT meeting where the elopement was reviewed. The DON stated Resident #72 had since been redirected from elopement seeking by staff who utilized the facility's all alarmed doors secured by access codes and electromagnetic locks. The DON stated the risk to Resident #72's elopement could have been severe injury. The DON stated if she had been aware that the elopement had been the second time the interventions could have been more intense to include a discharge to a facility which could meet her needs for elopement risk. The DON stated the facility was not equipped for wander guards used for residents who were elopement risks. During an interview on 09/01/2023 at 04:38 PM the CSC RN stated she was the previous DON from October 2022 up to December 2022 when the current DON accepted the position. The CSC RN stated she recalled Resident #72 had a practice of safely ambulating outside of the facility unsupervised and unchaperoned and in early October 2022 she was discovered to have eloped. The CSC RN stated at the time she did not recognize the event as an elopement due to her regular practice of walking outdoors around the facility to include her walks to the store. The CSC RN stated staff were still learning the residents since the facility recently accepted ownership of the facility. The Surveyor reminded the CSC RN Resident #72's BIMS was a 4 at the time of the elopement in October 2022, the facility's driveway was 1000 feet long, the main road at the end of the driveway leading to the grocery store was a 5-6 lane busy road. The Surveyor asked again if the CSC RN still believed the event was not an elopement and the CSC RN stated Resident #72 had that practice and she had not recognized the event as an elopement . A record review of the facility's Elopement / Unsafe Wandering policy, dated June 2018, revealed, It is the policy of this facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. Wandering is defined as random or repetitive locomotion and can be either goal directed or non-goal directed/aimless. Elopement is when a resident leaves the facility premises or a safe area without authorization; an order for discharge or leave of absence, and or any necessary supervision to do so. This was determined to be an Immediate Jeopardy (IJ) on 09/01/2023 at 05:30 PM. The Administrator was notified. The Administrator was provided with the IJ template on 09/01/2023. The following Plan of Removal verification was accepted on 09/03/2023 at 01:17 PM. Removal of Immediacy Plan: Wandering and Elopement Date/Time presented to Surveyors: 09/01/23, 08:00 PM Identified here are the steps and immediate actions [The Facility] will take to address the non-compliance and provide residents with proper assessments to meet resident needs and safety concerns. IMMEDIATE ACTION The Medical Director was notified of immediate jeopardy. 1. Resident #72 a. On 9/1/23, Resident #72 was assessed by a nurse with head-to-toe assessment for injury. b. On 8/30/23 at 10 am Resident #72 was placed on one-on-one line-of-sight supervision. Supervision will continue until [a] safe transition to a secure healthcare facility. c. On 09/01/23 Family/RP and physician were notified of elopement and elopement risk. 2. All other Residents a. On 9/1/23, elopement assessments [were] completed on all Residents. b. By 09/02/23, all Residents at high risk of elopement will be reviewed by [the] IDT to ensure a safe environment. Care plans will be updated to reflect elopement risk and person-centered care interventions. c. On 9/1/23, DON or designee placed all high-risk Residents in an elopement binder. 3. In-servicing/audits a. DON or designee will in-service licensed nurses on completing elopement assessments accurately. In-servicing started on 9/1/23 of [with] licensed nursing staff on completing the elopement assessment at admission, quarterly, and at change of condition. Staff re-educated to notify DON or designee when a Resident triggers high risk for elopement. All nurses will receive this in-servicing prior to next shift worked at the facility. DON or designee will check weekly to ensure assessments are being completed. b. In-servicing started on 9/1/23 of all staff on elopement policy and procedure. In-services to be completed for each staff prior to the next shift worked. c. On 9/1/23 all exit doors checked for integrity + proper functionality. 4. The abuse coordinator will provide a summary of elopement incidents and Residents at high risk for elopement to monthly QAPI meeting. Submitted by: The Administrator Plan of Removal Verification Plan of Removal Verification 09/02/2023 Removal of Immediacy Plan: Wandering and Elopement Date/Time presented to Surveyors: 09/01/23, 08:00 PM Identified here are the steps and immediate actions [The Facility] will take to address the non-compliance and provide residents with proper assessments to meet resident needs and safety concerns. IMMEDIATE ACTION The Medical Director was notified of immediate jeopardy. Interview: A phone interview with the Medical Director on 09/2/2023, at 12:15 PM, revealed he was notified of immediate jeopardy on 09/01/23 at 05:00 PM. Record review of the facility POR binder dated 09/01/23 revealed that the medical director was notified of IJ elopement on 09/01/23 and 4 residents were assessed as at a high risk for elopement (Resident #72, Resident #80, Resident #34, and Resident #141.) 1. Resident #72 a. On 9/1/23, Resident #72 was assessed by a nurse with head-to-toe assessment for injury. i. Record review of resident #72's electronic medical record revealed a progress noted dated 09/02/23 revealed a head to assessment was completed on 09/01/2023 with no injuries noted. b. On 8/30/23 at 10 am Resident #72 was placed on one-on-one line-of-sight supervision. Supervision will continue until [a] safe transition to a secure healthcare facility. i. Observation on 09/02/23 at 12:22 p.m. of resident #72 at the entrance of 300 hall revealed she was sitting next to her family member, reminiscing about how they met. ii. Interview on 09/02/2023 at 12:28 p.m. with Staffing Coordinator A assigned to 1:1 with Resident #72. She stated she was assigned to 1:1 and hanging out with resident, ensuring she did not elope. Staffing coordinator A confirmed she was in-serviced on elopement this morning prior to starting her shift. c. On 09/01/23 Family/RP and physician were notified of elopement and elopement risk. i. Record review of Resident #72's electronic medical record dated 09/01/23 at 4:11 p.m. revealed that the family member was made aware that resident #72 was an elopement risk, and he agreed to seek placement due to safety. ii. During an interview on 09/02/2023 at 12:15 PM the Medical Director stated that the Interdisciplinary committee recommended Resident #72 be discharged to a facility that could meet her needs. 2. All other Residents a. On 9/1/23, elopement assessments [were] completed on all residents. i. During an interview on 09/02/2023 at 10:29 a.m., the DON stated all elopement risk assessments were completed by nurses assigned to corresponding residents on 09/01/2023. ii. All census, 97 residents, were reviewed for elopement risk assessments. Record review of all 97 residents electronic medical records on 09/02/23 revealed elopement risk assessments had been completed on 09/01/23. iii. A sample of 10 were selected for the document record review. iv. Record review of Resident #76; revealed an elopement risk assessment was completed on 09/01/23. v. Record review of Resident #65; revealed an elopement risk assessment was completed on 09/01/23. vi. Record review of Resident #75; revealed an elopement risk assessment was completed on 09/01/23. vii. Record review of Resident #32; revealed an elopement risk assessment was completed on 09/01/23. viii. Record review of Resident #87; revealed an elopement risk assessment was completed on 09/01/23. ix. Record review of Resident #84; revealed an elopement risk assessment was completed on 09/01/23. x. Record review of Resident #72; revealed an elopement risk assessment was completed on 09/01/23. xi. Record review of Resident #37; revealed an elopement risk assessment was completed on 09/01/23. xii. Record review of Resident #61; revealed an elopement risk assessment was completed on 09/01/23. xiii. Record review of Resident #49; revealed an elopement risk was completed on 09/01/23. b. By 09/02/23, all residents at high risk of elopement would be reviewed by [the] IDT to ensure a safe environment. Care plans would be updated to reflect elopement risk and person-centered care interventions. i. During an interview on 09/02/2023 at 10:29 AM, the DON stated all residents who were assessed as a high risk of elopement had been reviewed by IDT to ensure a safe environment. Care plans were updated to reflect elopement risks and person-centered care interventions. ii. The facility identified four residents (Residents #72, #34, #80 and #141) as elopement risks. iii. Record review of Resident #72's care plan, dated 08/31/2023, revealed an intervention see elopement binder at the nurse's station, dated 08/31/2023 iv. Record review of Resident #34's care plan dated 09/01/2023 revealed an intervention: 09/01/23 IDT team met MDS resource, CNA, DON, Clinical resource, ED, on residents' high risk for elopement. currently resident wanders around facility aimlessly but is not exit seeking. v. Record review of Resident #80's care plan dated 09/01/2023 revealed an intervention: 09/01/23 IDT team met MDS resource, CNA, DON, Clinical resource, ED, on residents' high risk for elopement. currently resident wanders around facility aimlessly but is not exit seeking. vi. Record review of Resident #141's care plan dated 09/01/2023 revealed an intervention: 09/01/23 IDT team met MDS resource, CNA, DON, Clinical resource, ED, on residents' high risk for elopement. currently resident wanders around facility aimlessly but is not exit seeking. c. On 9/1/23, DON or designee placed all high-risk Residents in an elopement binder. i. Record review of the facility's elopement binder, located at the nurse's station on 09/02/2023 revealed the elopement policy, pictures and face sheets for the four residents (Residents #72, #80, # 34, and #141) identified as high risk for elopement. 3. In-servicing/audits a. The DON or designee will in-service licensed nurses on completing elopement assessments accurately. In-servicing started on 9/1/23 of [with] licensed nursing staff on completing the elopement assessment at admission, quarterly, and at change of condition. Staff re-educated to notify the DON or designee when a resident triggers high risk for elopement. All nurses will receive this in-servicing prior to next shift worked at the facility. The DON or designee will check weekly to ensure assessments are being completed. i. A record review of the facility's nursing roster dated 09/01/2023 revealed 1 DON and 1 ADON and an additional 18 nurses and 44 CNA's. As of 09/03/2023 the DON and the ADON and 13 of the 18 nurses and 34 of the 44 CNA's were interviewed. ii. A record review of the facility's elopement in-service records dated 09/01/2023 and 09/02/2023 revealed the DON, the ADON and the additional 18 nurses received the elopement in-service training. Further review of the training records revealed 30 of the 44 CNA's received the elopement in-service training. iii. During an interview on 09/03/2023 at 11:30 AM the Administrator stated the DON and himself would monitor all shifts and ensure any staff member that had not received the in-service training would not be allowed to accept CNA duties prior to receiving the elopement in-service with a return demonstration of the understanding of the training. iv. A record review of the facility's in-service, Elopement and Unsafe Wandering dated 09/01/2023, revealed, the regional clinical RN and the DON provided the training. The in-service revealed, It is the policy of this facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. Wandering is defined as random or repetitive locomotion and can be either goal directed, or non-goal directed or angle. Elopement is when a resident leaves the facility premises or a safe area without and or any necessary supervision to do so . procedures . residents with high risk factors identified on an elopement wandering evaluation are considered at risk and will have an individualized care plan developed that includes measurable objectives and time frames . staff shall promptly report any resident who is trying to leave the premises or suspected of being missing to the charge nurse or supervisor to elevate the need for further interventions. If a resident is missing it is a facility wide emergency. The missing resident procedures will be initiated . if the resident is unaccounted for after a thorough search of the building and grounds immediately notify, the Administrator . v. During an interview on 09/02/2023 at 04:09 PM RN C stated her shift was the 06:00 AM to 02:00 PM shift. RN C stated on 09/01/2023 and again on 09/02/2023, received in person and computer training to reflect residents who have been assessed as elopement risks, elopement prevention and elopement safety protocols. RN C stated she had received her training from the DON. vi. Record review of the facility's elopement assessment in-service dated 09/01/2023, and computerized elopement prevention and safety protocol training dated 09/02/2023, revealed RN C had received the elopement assessment and prevention training and completed the computerized elopement prevention and safety protocol training. vii. During an interview on 09/02/2023 at 05:28 PM CNA D stated her shift was the 06:00 AM to 02:00 PM shift. CNA D stated she received an in-person and computerized training. CNA D stated the training included the implementation of an Elopement Binder which she could refer to, to identify residents who were a high risk for elopement. She stated the binder was kept at the nurse's station. CNA D stated she had received the training from the DON. viii. Record review of the facility's elopement assessment in-service dated 09/01/2023, revealed CNA D had received the elopement assessment and prevention training. ix. During an interview on 09/02/2023 at 05:25 PM CNA E stated her shift was the 06:00 AM to 02:00 PM shift. CNA D stated she received an in-person and computerized training. CNA D stated the training included the implementation of an Elopement Binder which she could refer to, to identify residents who were a high risk for elopement. She stated the binder was kept at the nurse's station. x. Record review of the facility's elopement assessment in-service dated 09/01/2023, revealed CNA E had received the elopement assessment and prevention training and prevention training and completed the computerized elopement prevention and safety protocol training. xi. During an interview on 09/02/2023 at 05:38 PM LVN J stated her shift was the 06:00 AM to 06:00 PM shift. LVN J stated on 09/01/2023 and again on 09/02/2023, she received in person and computer training to reflect residents who have been assessed as elopement risks, elopement prevention and elopement safety protocols. LVN J stated she had received her training from the DON. xii. Record review of the facility's elopement assessment in-service dated 09/01/2023, and computerized elopement prevention and safety protocol training dated 09/02/2023, revealed LVN J had received the elopement assessment and prevention training and completed the computerized elopement prevention and safety protocol training. xiii. During an interview on 09/02/2023 at 01:58 PM LVN E stated her shift was the 02:00 PM to 10:00 PM shift. LVN E stated on 09/01/2023 and again on 09/02/2023, she received in person and computer training to reflect residents who have been assessed as elopement risks, elopement prevention and elopement safety protocols. LVN E stated an Elopement Safety binder was implemented to assist staff to recognize residents who were assessed an elopement risk and had a need for safety. LVN E stated she had received her training from the DON. xiv. Record review of the facility's elopement assessment in-service dated 09/01/2023, and computerized elopement prevention and safety protocol training dated 09/02/2023, revealed LVN E had received the elopement assessment and prevention training and completed the computerized elopement prevention and safety protocol training. xv. During an interview on 09/02/2023 at 02:38 PM CNA K stated her shift was the 02:00 PM to 10:00 PM shift. CNA K stated on 09/01/2023 and again on 09/02/2023, she received in person and computer training to reflect residents who have been assessed as elopement risks, elopement prevention and elopement safety protocols. CNA K stated an Elopement Safety binder was implemented to assist staff to recognize residents who were assessed as an elopement risk and had a need for safety. CNA K stated she had received her training from the DON. xvi. Record review of the facility's elopement assessment in-service dated 09/01/2023, and computerized elopement prevention and safety protocol training dated 09/02/2023, revealed CNA K had received the elopement assessment and prevention training and completed the computerized elopement prevention and safety protocol training. xvii. During an interview on 09/02/2023 at 02:13 PM CNA L stated his shift was the 02:00 PM to 10:00 PM shift. CNA L stated on 09/01/2023 and again on 09/02/2023, he received in person and computer training to reflect residents who have been assessed as elopement risks, elopement prevention and elopement safety protocols. CNA L stated an Elopement Safety binder was implemented to assist staff to recognize residents who were assessed aa an elopement risk and had a need for safety. CNA L stated he had received his training from the DON. xviii. Record review of the facility's elopement assessment in-service dated 09/01/2023, and computerized elopement prevention and safety protocol training dated 09/02/2023, revealed CNA L had received the elopement assessment and prevention training and completed the computerized elopement prevention and safety protocol training. xix. During an interview on 09/02/2023 at 05:27 PM LVN M stated her shift was the 06:00 PM to 06:00 AM shift. LVN M stated on 09/01/2023 and again on 09/02/2023, she received in person and computer training to reflect residents who have been assessed as elopement risks, elopement prevention and elopement safety protocols. LVN M stated an Elopement Safety binder was implemented to assist staff to recognize residents who were assessed as an elopement risk and had a need for safety. LVN M stated she had received her training from the DON. xx. Record review of the facility's elopement assessment in-service dated 09/01/2023, and computerized elopement prevention and safety protocol training dated 09/02/2023, revealed LVN M had received the elopement assessment and prevention training and completed the computerized elopement prevention and safety protocol training. xxi. During an interview on 09/02/2023 at 04:19 PM LVN N stated her shift was the 06:00 PM to 06:00 AM shift. LVN J stated on 09/01/2023 and again on 09/02/2023, she received in person and computer training to reflect residents who have been assessed as elopement risks, elopement prevention and elopement safety protocols. LVN N stated an Elopement Safety binder was implemented to assist staff to recognize residents who were assessed as an elopement risk and had a need for safety. LVN N stated she had received her training from the DON. xxii. Record review of the facility's elopement assessment in-service dated 09/01/2023, and computerized elopement prevention and safety protocol training dated 09/02/2023, revealed LVN N had received the elopement assessment and prevention training and completed the computerized elopement prevention and safety protocol training. xxiii. During an interview on 09/02/2023 at 05:26 PM CNA O stated her shift was the 06:00 PM to 06:00 AM shift. CNA O stated on 09/01/2023 and again on 09/02/2023, she received in person and computer training to reflect residents who had been assessed as elopement risks, elopement prevention and elopement safety protocols. CNA O stated an Elopement Safety binder was implemented to assist staff recognize residents who were assessed a elopement risk and had a need for safety. CNA O stated she had received her training from the DON. xxiv. Record review of the facility's elopement assessment in-service dated 09/01/2023, and computerized elopement prevention and safety protocol training dated 09/02/2023, revealed CNA O had received the elopement assessment and prevention training and completed the computerized elopement prevention and safety protocol training. xxv. During an interview on 09/02/2023 at 04:46[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one (Resident #1) of 15 residents reviewed for resident-to-resident abuse. The facility failed to prevent Resident #2, who had a history of hypersexual behaviors, from touching Resident #1 in a sexually inappropriate manner on 12/04/2022. LVN B failed to identify Resident #2's unwanted touching of Resident #1's breast area as sexual abuse. The facility failed to protect Resident #1, who had a history of sexual assault as a child, from being sexually abused by Resident #2. These failures placed Resident #1 at serious risk of reliving trauma, mental anguish, decreased psychosocial well-being and mental health, and increased anxiety. On 12/09/2022 at 5:40 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12/11/2022, the facility remained out of compliance at a severity level of actual harm that was not an Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings included: A record review of the facility's abuse and neglect prohibition policy dated 7/10/2019 and provided on 12/08/2022 at 10:01 a.m. reflected the following: Long-Term Care Regulatory Provider Letter Number: PL 19-17 (Replaces PL 17-18) Title: Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility (NF) Must Report to the Health and Human Services Commission (HHSC) Provider Types: Nursing Facility (NF) Date Issued: July 10, 2019 1.0 Subject and Purpose This letter provides guidance for reporting incidents to HHSC and: o Adds Attachment 1, describing reporting requirements and providing examples to help determine what constitutes a reportable incident. o Adds Attachment 2, a flow chart to assist in decisions about making reports. o Deletes guidance on resident-resident sexual activity and incorporates that guidance into the flow chart in Attachment 2. 2.0 Policy Details & Provider Responsibilities 2.1 Incidents that a NF Must Report to HHSC and the Time Frames for Reporting A NF must report to HHSC the following types of incidents, in accordance with applicable state and federal requirements: o Abuse A review of PL 19-17 reflected abuse (with or without serious bodily injury) was a type of incident that needed to be reported immediately, but not later than two hours after the incident occurred or was suspected. Attachment 1 of PL 19-17 reflected what HHSC rules defined abuse as, which reflected sexual abuse, including involuntary or nonconsensual sexual conduct that would constitute an offense under Penal Code §21.08 (indecent exposure) or [NAME] Code Chapter 22 (assaultive offenses), sexual harassment, sexual coercion, or sexual assault. Attachment 1 of PL 19-17 reflected CMS's definition of abuse which reflected that instances of abuse of all residents, irrespective of any mental or physical condition, caused physical harm, pain or mental anguish. Attachment 2 of PL 19-17 reflected a flowchart with guidance on reporting resident-resident sexual activity. The flowchart reflected the following: The facility becomes aware of, or receives, and allegation of suspected abuse, neglect, exploitation or another reportable incident --> Does it involve resident-to-resident sexual activity? --> YES --> Take immediate action to prevent further potential ANE pending investigation --> Can all residents involved in the sexual activity consent to participation? --> NO --> Report the incident within two hours --> Complete an internal investigation of the incident --> Take appropriate corrective action --> Report the investigation findings within 5 working days from the initial report to HHSC on Form 3613-A --> Maintain evidence demonstrating results of all incidents for no less than three years after the reported allegation A record review of the facility's policy on abuse and neglect prohibition dated 11/28/2016 and provided on 12/10/2022 at 4:22 p.m. reflected the following: Policy: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents must 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 resident, resident representative, families, friends, or other individuals. Prevention - The employees of our facility will take action to protect and prevent abuse and neglect from occurring within the facility by: Staff has knowledge of the individual residents' care needs Supervision of staff to identify inappropriate behaviors (i.e., derogatory language, rough handling, ignoring residents while giving care. Etc.) Assess, care plan, and monitor residents with history of aggressive behaviors, behaviors such as entering other residents'' rooms, self-injurious behavior, communication disorders, totally dependent on staff Identification of Abuse - Identify events, such as but not limited to, suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction for the investigation. 2. Episodes of resident to resident altercation, willful or accidental, with or without injury. 3. Occurrences, patterns and trends will be assessed by Licensed staff and/or Interdisciplinary Team to determine the direction of the investigation. Protection - If a resident incident is reported, discovered or suspected, where the health, welfare or safety of the residents is involved, this facility will take the following steps to prevent further potential abuse while the investigation is in progress; 1. If the suspected perpetrator is another resident: a. Separate the residents so they do not interact with each other until circumstances of the reported incident can be determined b. If a room change is appropriate, advise residents'' families of the change and room location Reporting/Response - All alleged violations will be reported via phone or in writing within 24 hours to the State Licensing Agency. The facility shall follow-up to the State Licensing Agency in writing the findings and results of the completion of the investigation within 5 days. The facility will analyze occurrences and determine what change are needed, if any, to the policies and procedures to prevent further occurrences. Definitions - 483.13(b) and (c) To assist the facility's staff members in recognizing incidents of abuse, the following definitions are provided o Abuse - 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. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual abuse - is non-consensual sexual contact of any type with a resident. A record review of Resident #1's undated face sheet reflected an [AGE] year-old female admitted on [DATE] with diagnoses of Alzheimer's disease (brain disorder that causes problems with memory, thinking and behavior), hypertension (high blood pressure), peripheral vascular disease (condition affecting blood vessels), hyperlipidemia (high cholesterol), generalized anxiety disorder, recurrent depressive disorders (depression), and unspecified dementia. A record review of Resident #1's care plan last revised on 12/06/2022 reflected Resident #1 had impaired thought process related to Alzheimer's Disease and had potential for psychosocial well-being problem related to recent resident to resident interaction. Interventions included that staff were to allow the resident time to express feelings and emotions as needed, anticipate and meeting her needs and redirect as necessary, assess for any changes in behavior, encourage residing to sit in common areas and socialize with her peers as able, and provide comfort and reassurance. Resident #1's care plan did not reflect any history of sexual assault or trauma. Resident #1's care plan reflected a diagnosis of anxiety, however, this was not listed as a focus area no interventions for anxiety were reflected. A record review of Resident #1's MDS assessment dated [DATE] reflected a BIMS score of 00, which indicated severe cognitive impairment. A review of Section G (Functional Status) reflected Resident #1 required extensive assistance and one person physical assist with bed mobility and transfers. Section G also reflected Resident #1 required a wheelchair and was only able to stabilize with staff assistance when moving from seated to standing, moving on and off toilet, and transferring from bed to wheelchair. Resident #1's face sheet reflected she resided in room [ROOM NUMBER]-A. A record review of Resident #2's undated face sheet reflected an [AGE] year-old male admitted on [DATE] with diagnoses of unspecified dementia, type 2 diabetes (uncontrolled blood sugar), hypertension (high blood pressure), chronic obstructive pulmonary disease (trouble breathing). Resident #2's face sheet reflected he resided in room [ROOM NUMBER]-A. A record review of Resident #2's care plan created by MDS Resource and revised on 10/11/2022 reflected he had a behavior problem including hypersexual tendencies related to cognitive impairment. Interventions for this behavior reflected that staff were to educate family and/or caregivers on successful coping and interaction strategies, administer medications as ordered, discuss resident's behavior and explain/reinforce why behavior was inappropriate and/or unacceptable to the resident, stop and talk with resident when passing by, and intervene as necessary to protect the rights and safety of others. A record review of Resident #2's MDS assessment dated [DATE] reflected a BIMS score of 6, which indicated severe cognitive impairment. A review of Section G (Functional Status) reflected Resident #1 required only supervision and set up help with bed mobility and transfers. Section G also reflected Resident #1 required a wheelchair but could stabilize without staff assistance when moving from seated to standing, moving on and off toilet, and transferring from bed to wheelchair. This indicated Resident #2 had higher functional ability than Resident #1. A record review of Resident #3's undated face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of major depressive disorder (depression), hyperlipidemia (high cholesterol), cognitive communication deficit (difficulties with communication), dementia, and anxiety. Resident #3's face sheet reflected she resided in room [ROOM NUMBER]-B. A record review of Resident #3's care plan revised on 11/08/2022 reflected she was at risk for psychosocial well-being related to the pandemic. A record review of Resident #3's MDS assessment dated [DATE] reflected a BIMS score of 3, which indicated severe cognitive impairment. During an observation on 12/08/2022 at 10:58 a.m., Resident #1 was observed in her wheelchair rolling down the 400-hall saying, I am so confused. During an observation and interview translated by and HHSC employee on 12/08/2022 beginning at 11:21 a.m., Resident #2 was observed sitting in a wheelchair in his room. When asked if he had touched Resident #1, Resident #2 stated I have not touched her anymore. Resident #2 stated one of the ladies at the front of the facility told him not to touch Resident #1. Resident #2 stated the ladies asked him to come over there but he would not do that anymore. Upon exiting Resident #2's room, Resident #2 pointed to HK A and stated, she knows. In an interview on 12/08/2022 at 11:37 a.m., DON stated HK A saw Resident #1 with a napkin on her chest and saw Resident #2 take the napkin off and put his hand back on her chest. In an interview translated by an HHSC employee on 12/08/2022 at 11:47 a.m., HK A stated she was working in the 400 hall when she observed Resident #1 in her room with Resident #2. HK A stated Resident #1 was wearing a clothing protector and Resident #2 took off Resident #1's clothing protector and started touching Resident #1 under over and under her shirt. HK A stated the incident between Resident #1 and Resident #2 had occurred the weekend prior just before 2:00 p.m. HK A stated she reported the incident to LVN B. HK A stated that Resident #2 had touched a different female resident, Resident #3, about one or two months ago in the dining room. HK A stated Resident #3 was not cognitively intact. HK A stated the previous company did not do anything to prevent incidents like that from happening but stated since the incident on 12/04/2022, staff had been keeping an eye on Resident #2. In a confidential resident interview, a cognitively intact female resident stated Resident #2 went for women that wanted a lot of attention. When asked if women he went for understood what he was going for, the resident stated no. The resident stated Resident #2 had been going for her roommate and she had seen Resident #2 touching her roommate's arm but never her breast area. The resident stated Resident #2 thought he was god's gift to women, preyed on weak and older women, and stated she did not trust him at all. In an interview on 12/09/2022 at 9:26 a.m., Resident #2's family stated the facility notified her of the incident between Resident #2 and Resident #1. Resident #2's family stated Resident #2 had never done anything indecent prior to being admitted but that was the second time someone at the facility had seen him sticking his hand in another lady's shirt. In an interview on 12/09/2022 at 10:03 a.m., DON stated Resident #2 came to the DON's office after Resident #2's psychologist appointment on 12/06/2022 and they discussed the plan for him to not go into ladies' rooms and touch them. The DON stated an incident like that had never happened before. The DON stated Resident #2 took Depakote for behaviors. In an interview on 12/09/2022 at 10:45 a.m., Resident #1's family stated DON had called her to explain what had happened. Resident #1's family stated DON stated to her that Resident #1 went back to her room with a napkin and Resident #2 pulled it off and put his hand down Resident #1's shirt. Resident #1's family stated DON told her Resident #2 had dementia, but not to Resident #1's extent. Resident #1's family stated DON told her the facility would do a full investigation. Resident #1's family stated DON did not tell her how they planned to keep Resident #1 and other residents safe. Resident #1's family stated she could not recall DON saying they planned to move either Resident #1 or Resident #2 to a different room in order to keep them separated. Resident #1's family member stated Resident #1 had a history of sexual assault as a child, stating Resident #1 told her that Resident #1's uncle used to touch Resident #1 all the time down there and do things when Resident #1 was five years old. After this, Resident #1's family stated Resident #1 did not speak for an entire year after the assault. Resident #1's family stated she learned about this when Resident #1's dementia came out, stating she was blown away and had no idea Resident #1 had PTSD. Resident #1's family stated it all made sense since Resident #1 was always a worrier, always stressed, and had so much anxiety about that. In an interview on 12/09/2022 at 11:05 a.m., when asked why she had revised Resident #2's care plan to reflect hypersexual behaviors, the MDS Resource stated honestly I don't remember. It would have been something communicated to me from nursing staff. The MDS Resource stated information in the care plan comes from the MDS assessment or from nursing, and if nurses were busy she would enter information for them. The MDS Resource stated she did not remember which nurse had communicated to her the hypersexual behaviors and she just typed up care plans using information from nursing. In interviews on 12/09/2022 from 10:56 a.m.-11:30 a.m., LVN B stated HK A had made a remark to her on 12/04/2022, stating she had seen Resident #2 touching Resident #1 inappropriately by putting his hand down Resident #1's shirt. LVN B stated at that point, she went down the 400 hall and saw both residents in their own room. LVN B stated she looked down Resident#1's blouse and did not see anything so she came back to the nurses station because she did not see any evidence that Resident #2 had been close to Resident #1. When asked if there was anyone she reported this incident to on that Sunday, LVN B stated, that day, I did not. LVN B stated it was reported to DON Monday. When asked if she had reported it to DON, LVN B stated no. When asked what the facility's policy was on reporting alleged abuse, LVN B stated, we have to report it immediately to someone in charge. When asked if in that instance, she reported it immediately, LVN B stated, I did not. In that instance I did not see anything I felt was abuse. When asked about Resident #2's hypersexual behaviors, LVN B stated LVN C had reported to her a prior incident in which Resident #2 had touched another female resident on the 300 hall. LVN B stated she did not remember when this was. In an interview on 12/09/2022 at 12:00 p.m., LVN C stated there was a previous incident reported to her by two CNAs on her hall who saw Resident #2 touching Resident #3 inappropriately. LVN C stated the incident was sometime before October of 2022 and that she had reported it to the prior administrator. LVN C stated the new company took over the facility on 10/01/2022. In an interview on 12/09/2022 at 12:40 p.m., DON stated the incident between Resident #1 and Resident #2 was reported to her Monday morning (12/05/2022) by the Housekeeping Supervisor. In an interview on 12/09/2022 at 12:06 p.m., Resident #1's other family member stated, I want to make sure that this person is not near my mother again. Resident #1's other family member stated she hoped Resident #1 and Resident #2 were not still on the same hallway. In an interview on 12/09/2022 at 12:41 p.m., the Housekeeping Supervisor stated HK A had told her she witnessed Resident #2 removing a napkin or clothing protector from Resident #1 and at first HK A thought Resident #2 was trying to help Resident #1 but then HK A saw Resident #2 put his hand inside Resident #1's shirt. The Housekeeping Supervisor stated that since the incident occurred on 12/04/2022, and DON did not become aware of it until 12/05/2022, she thought that meant LVN B had not reported it to the DON. The Housekeeping Supervisor stated that nurses were supposed to check with residents, ensure they were not in danger, and ensure they were not being abused. When asked what LVN B did as a result of HK A reporting the incident to her on 12/04/2022, the Housekeeping Supervisor stated she heard that LVN B did an incident report. In an interview on 12/09/2022 at 1:50 p.m., when asked how the facility would ensure continuity of care during changes in the facility's leadership, DON stated some staff were from the previous company including the MDS nurses, and when she started at the facility in October 2022 she received a report from the previous DON with residents' care plans and a summary of what was going on with residents. DON stated she was not aware of any other residents with hypersexual behaviors. DON stated the facility would protect Resident #1 by ensuring staff were aware of Resident #1 and Resident #2, were observant of them, and knew to redirect them when seen together. DON stated this was communicated to staff one on one and in the nurses shift change report. DON clarified that this was a verbal training in which staff were instructed to redirect Resident #1 and Resident #2. When asked if this training was documented, DON referred to an in-service, with no written text and only signatures from staff, dated 12/06/2022 and titled care of resident in room [ROOM NUMBER]A. When asked if these interventions were documented in PCC, DON stated interventions would be documented in residents' care plans. When asked if this was documented in either Resident #1's or Resident #2's care plans, DON stated, I believe so because we had a discussion as a team. DON stated it can be anyone's responsibility to document in care plans. When asked how staff knew who they needed to protect and who they needed to monitor, DON stated to me, I believe it is documented in the care plan and in Kardex. In his chart it is documented and we are observant. Resident #2's care plan was pulled up and DON observed it had not been revised since the incident on 12/04/2022. DON then stated upon reviewing his care plan earlier that week, she believed Resident #2's current interventions were appropriate and thus, his care plan did not need to be revised. DON stated Resident #1 and Resident #2's care plans were reviewed during morning meetings and during the facility's high risk meeting earlier that week on Monday or Tuesday but could not specify an exact date or who participated in the care plan review. Resident #1's care plan was pulled up and DON pointed out that her care plan had been updated on 12/06/2022 to include potential for a psychosocial well-being problem related to recent resident to resident interaction. When asked how the facility would ensure residents were protected int eh future with changes in management, DON stated, we have care plans and Kardex where it is documented and this is used by staff and CNAs. In an interview on 12/09/2022 at 4:19 p.m., DON stated she reviewed the facility's incidents/accidents for the past six months and did not see any reportable event involving Resident #2 and Resident #3. DON stated they had no record of any previous incident involving Resident #2. In an interview on 12/09/2022 at 2:45 p.m., CNA G stated she had received an in-service training that week about Resident #2 but did not recall that it addressed Resident #1. In an interview on 12/09/2022 at 2:46 p.m., LVN E stated she received training that week on abuse, inappropriate behavior, and redirecting residents who looked confused and were about to go in other residents' rooms. LVN E did not recall whether the in-service pertained to Resident #2 or not. In an interview on 12/09/2022 at 4:46 p.m., DON stated the facility had no record of any previous incidents of inappropriate behavior involving Resident #2. DON stated that after reviewing their incidents and accident log for the past six months, she did not see any reportable event involving Resident #2 and Resident #3. DON stated the facility's incident reports were QA protected and could not be shared. In an interview on 12/09/2022 at 5:06 p.m., DON stated the facility prevented abuse by educating staff and completing background checks on staff. DON stated this process was monitored via rounding with residents and completing safe surveys after an incident had occurred. When asked if and how the facility prevented abuse proactively rather than reactively, DON stated through rounding with residents and talking to staff. DON stated Resident #1 was protected by ensuring staff redirected patients and made sure Resident #2 was not going into Resident #1's room. DON stated she discussed with Resident #2 about his behavior being unacceptable. When asked if there was any potential for a negative resident outcome if residents were not protected from abuse, the DON stated, I don't understand what you're asking because I think residents were protected. In an interview on 12/09/2022 at 5:24 p.m., the Administrator stated the facility's policy on protecting residents from abuse included monitoring patients, in-servicing staff, doing rounds, interdisciplinary meetings, and high risk meetings. The Administrator stated herself, DON, and charge nurses monitored this as a team but it was mostly herself and DON who monitored this policy. The Administrator stated incidents were put onto Kardex to ensure staff monitored and all staff had been in-serviced on Kardex. When asked if staff had been trained on preventing abuse, the Administrator stated, if we see it starting to happen, we intervene to prevent it from happening and redirect. The Administrator stated staff had been in-serviced on that process. The Administrator stated there was monitoring after the event between Resident #1 and Resident #2 so there was not harm and she did not see that Resident #1 was at risk. In an interview on 12/10/2022 at 1:42 p.m., LVN D stated the facility's Kardex system told staff about ADLs and other particular things about residents. Observed LVN D pull up Resident #2's Kardex on his computer. When asked if he could find where Resident #2's Kardex had been updated on 12/05/2022, as the facility's PIR for the incident reflected it had been, LVN D could not find any update on that day. In an interview and record review on 12/10/2022 at 2:00 p.m., the Administrator stated the facility had a paper Kardex system which was just an Excel spreadsheet that got updated daily as needed. The Administrator stated the updates in Kardex were not dated. The Administrator provided a paper copy of an undated document titled C.N.A 400 Hall Kardex which reflected Resident #2 had special care needs that included redirecting him if found in another room. In an interview on 12/10/2022 at 4:18 p.m., RN I stated she had checked the previous company's QAPI binder and did not find anything regarding a prior incident of inappropriate touching with Resident #2. In an interview on 12/11/2022 at 12:24 p.m., Resident #2's Psychologist stated she had met with Resident #2 that day and made it clear to him that he was not to go into other residents' rooms. The Psychologist's meeting with Resident #2 was translated by RN H, the facility's DON in training. The Psychologist stated Resident #2 seemed more stressed during this meeting as compared to last week's meeting and was concerned that they were going to meet again. The Psychologist stated Resident #2 had denied any inappropriate behavior and stated cultural norms about touching and personal space were different for him. The Psychologist stated she acknowledged his cultural outlook but reiterated to Resident #2 that he was not to touch other residents. During an observation and interview on 12/11/2022 beginning at 1:07 p.m., Resident #3 was observed walking to her room. Resident #3 appeared very confused, stated she was going home, and was not able to answer whether or not she had been inappropriately touched in the past. An interview with Resident #3's family was attempted on 12/12/2022 at 12:12 p.m. but Resident #3's family did not answer the phone so a voicemail message was left. In an interview on 12/12/2022 at 11:44 a.m., Resident #1's family stated she had mentioned to the facility many times the fact that Resident #1 had a history of sexual assault. Resident #1's family stated they had brought it up at the beginning, when Resident #1 was admitted , because of Resident #1's anxiety. Resident #1's family stated they made the facility aware of this through care plan meetings, discussions with the psych NP, and through one-on-one meetings with facility staff. Resident #1's family stated her other family member and herself had made it really known during care plan meetings that that was why Resident #1 had anxiety. Resident #1's family could not recall exactly when she notified the psych NP of this history or the names of staff members she notified. Resident #1's family stated, if there is no documentation about that, that is absolutely crazy to me, stating Resident #1 had terrible anxiety and that was their biggest concern. In an interview on 12/12/2022 at 11:49 a.m., Resident #1's other family member stated they had communicated Resident #1's history of sexual assault several times, and it was discussed during care plan meetings. Resident #1's other family member could not recall the names of staff she spoke to about this. In an interview on 12/12/2022 at 12:15 p.m., DON stated Resident #1's history of sexual assault was never mentioned to her and she was not aware. When asked what would be put in place to protect residents with a history of sexual assault, DON stated, in general, we would have a care plan for the patient and we would make sure staff were aware of whether the resident needed female only caregivers or whatever their needs were. If they were not cognitive we would contact family. The DON stated it depend on what the circumstance weas but the care plan would reflect any history of sexual assault. DON stated interventions would include monitoring, educating staff, and redirecting. In an interview on 12/12/2022 at 12:26 p.m., DON stated she did not see any record in Resident #1's chart that reflected a history of assault. DON stated yes, if the facility knew there was a history, then it should be in Resident #1's chart. In an interview on 12/12/2022 at 12:36 p.m., LVN F stated she had worked in the facility for ten years and was not aware of Resident #1's history of sexual assault. LVN F stated the reason why psych services were initiated for Resident #2 was because someone had observed him in the dining room touching Resident #3. LVN F stated that was in September of 2022. LVN F stated she was not part of the investigation, did not know how the facility investigated the incident, and that she was just asked to do a psych referral and update Resident #2's care plan. LVN F stated she would think the facility would have an interdisciplinary meeting to discuss Resident #1 and decide whether her history of sexual assault needed to be care planned or not. LVN F stated things that were active issues were included in the care plan, stating you would potentially not care plan this because it was not an active issue for which interventions and monitoring would need to be in place. LVN F stated sexual assault was part of the big picture but she did not think it was an active issue since Resident #1's memory was impaired. LVN F stated she had never heard Resident #1 voice distress about past issues and never heard she had behaviors related to that. LVN F stated to her knowledge, Resident #1's family had not communicated to the facility that Resident #1 had behaviors related to trauma. LVN F stated whoever was present during discussions with family regarding history of sexual assault or trauma should have notated it in the care plan. LVN F stated if it were a CNA who received that message, it should be reported to their charge nurse, ADON, or DON. When asked how effective she thought Resident #2's interventions were for hypersexual behaviors, LVN F stated she thought they were effective with Resident #3. When asked if she felt Resident #2's interventions for hypersexual behaviors were effective in preventing future incidents, LVN F stated, we did not know whether it happens so I feel like the interventions were still good even though now we have more in place. LVN F stated she had not participated in Resident #1's care plan meetings but stated if staff were aware of any history of trauma or sexual assault, that she expected it to be care planned. LVN F stated the facility did not have a Social Worker at that time but if they did, the Social Worker would document any communications from family. LVN F stated the Social Worker took notes during all care plan meetings but she quit three weeks ago. LVN F stated she did not have access to old care plan meeting minutes but the facility should have those notes. In an interview