**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 7 residents (Resident #1) reviewed for medication errors. On 07/24/25 LVN A administered 8 units of insulin outside of parameters (hold for BG less than 100). LVN B noted a change of condition for Resident #1 on 07/24/25. She was unable to rouse, clammy, and lethargic and only responded to painful stimuli. Resident #1 was admitted to hospital for hypoglycemia. The facility did not identify this significant medication error. An IJ was identified on 07/29/25. The IJ template was provided to the facility on [DATE] at 1:18 p.m. While the IJ was removed on 07/30/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems. These failures could place residents at risk of not receiving the intended therapeutic benefit of the medications, worsening or exacerbation of chronic medical conditions, hospitalization, and death.Findings included: Record review of Resident #1's face sheet dated 07/30/25 indicated she was a [AGE] year old female, admitted on [DATE], and her diagnoses included cerebral infarction (stroke) and Type II diabetes (the body becomes resistant to insulin or when the pancreas fails to produce insulin). Record review of Resident #1's quarterly MDS dated [DATE] indicated she was rarely able to make herself understood, sometimes understood others, and had severe impaired cognitive skills for daily decision making. Resident #1 received insulin injection for 6 of 7 days. Record review of Resident #1's care plan dated 02/17/25 (revised 07/29/25) indicated Resident #1 had diabetes. On 07/24/25 Resident #1 responded to painful stimuli only, blood sugar was 46 and she was sent to ER and admitted . Interventions dated 02/17/25 included check glucose before meals and call if above 350 and diabetes medications as ordered by physician. Monitor/document for side effects and effectiveness. Monitor/document/report PRN any ss/sx of hypoglycemia. Record review of Resident #1's physician orders dated 06/24/25 indicated Insulin Aspart Injection Solution (fast acting insulin) 100 unit/ml inject 8 units subcutaneously with meals for DM2. Hold for BG <100. Record review of Resident #1's MAR dated 07/24/25 at 5:00 p.m. indicated LVN A administered 8 units of Insulin Aspart Injection Solution. The MAR indicated hold for BG less than 100. LVN A noted Resident #1's BG was 99. Record review of Resident #1's progress nurse note dated 07/24/25 at 7:37 p.m., completed by LVN B indicated Resident #1 responded to painful stimuli only, blood sugar 46 and has worsened. Physician and RP notified. Record review of Change of Condition Form dated 07/25/25 at 12:00 a.m., completed by LVN B indicated LVN B noticed Resident #1 appeared sleeping during medication pass. Resident #1 was unable to maintain proper body posture. Blood sugar was 46. Administered Baqsimi (dry nasal spray used to treat severe hypoglycemia). in left nostril and called emergency services. Physician and RP notified. Resident #1 was transferred to hospital. Record review of Resident #1's progress nurse note dated 07/25/25 at 9:15 a.m., completed by LVN H, indicated Resident #1 was admitted to the hospital and her admitting diagnosis was hypoglycemia (low blood sugar-level). Record review of Resident #1's hospital records dated 07/25/25 indicated Resident #1 presented to the emergency department via EMS with complaints of hypoglycemia. Staff reported Resident #1 had a glucose of 99 and facility administered 8 units of insulin causing Resident #1 glucose to drop to 25. EMS administered 250 ml of D10 (dextrose/sugar), raised glucose to 169. Resident remained responsive to painful stimuli only. Record review of Resident #1's hospital records dated 07/26/25 Blood glucose earlier this a.m. was 58. Continue to monitor glucose and hold diabetic medications and insulin. Record review of Resident #1's hospital records dated 07/27/25 indicated hypoglycemia was resolved. Discharge plan for tomorrow. Record review of Resident #1's progress nurse noted dated 07/28/25 at 5:37 p.m., completed by LVN J indicated Resident #1 was readmitted to the facility in stable condition. During an interview on 07/29/25 at 10:50 a.m., the DON said she was not aware LVN A administrated Resident #1's insulin outside of parameters on 07/24/25. She said she was aware the physician was notified of Resident #1's change of condition and transport to hospital for evaluation and treatment. She said she reviewed Resident #1's clinical record for a change of condition but did not investigate the possible reasons for hypoglycemia. She said it was her expectation LVN A would have held Resident #1's insulin on 07/24/25 due to the BG being out of parameters. She said the risk for Resident #1 receiving insulin out of parameters were hypoglycemia leading to coma and possible death. During an interview on 07/29/25 at 11:18 p.m., LVN A said she must have made a mistake on 07/24/25 when she administered Resident #1's insulin outside of parameters. She said she did not recall if Resident #1 ate her supper meal. She could not recall if she gave Resident #1 a supplement. She said she did not recall if staff reported a change of condition. She said she left the facility at 6:00 p.m. on 07/24/25 after working a 4 hour shift. She said she was not aware Resident #1 had a change of condition, became unresponsive, or was sent to the hospital for evaluation and treatment for hypoglycemia. She said she was aware of the proper medication administration procedures. She said the risk for Resident #1 receiving insulin out of parameters were hypoglycemia leading to coma and possible death. During an interview on 07/29/25 at 1:27 p.m., the DON said she did not know why LVN A administered insulin outside of parameters on 07/24/25 was missed as a med error. She said she missed that LVN A documented Resident #1's BG at 99 and the parameters indicated to hold if BG was less than 100. She said it was an oversight. During an interview on 07/29/25 at 2:28 p.m., CNA C said Resident #1 was sleeping in her wheelchair after the supper meal. She said Resident #1 would not wake up so she could transfer her to bed. She said she called for LVN B to come and assist. She said LVN B could not wake Resident #1 and called for another nurse and ambulance. She said she was trained on recognizing the signs of diabetes and hypoglycemia and figured something was wrong with Resident #1 when she could not wake her up to get ready for bed. During an interview on 07/29/25 at 3:30 p.m., CNA D said Resident #1 was awake when she gave her supper tray on 07/24/25. She said Resident #1 did not eat her supper meal. She said she advised LVN A Resident #1 did not eat her meal. She said she believed LVN A gave Resident #1 a supplement. She said she moved Resident #1 closer to her room to get ready for bed. She said CNA C was getting Resident #1 ready for bed and couldn't wake her up. I thought she was deep sleeping because she was snoring loud. She said CNA C and LVN B could not wake Resident #1 so they called for the crash cart and EMS. She said Resident #1 was sent to the hospital because her BG had dropped. She said she was trained to call for the nurse immediately if a resident was unresponsive or the residents were not at their normal. During an observation on 07/29/25 at 3:37 p.m., Resident #1 was lying in bed. She pulled the blanket over her face and did not respond to questions from the surveyor. During an interview on 07/29/25 at 5:05 p.m., LVN B said she arrived for her shift on 07/24/25 at 6:00 p.m. She said LVN A did not report Resident #1 was not at her normal baseline. LVN A did not report Resident #1 did not eat her supper meal. She said CNA C reported she could not wake Resident #1 to get her ready for bed. She said Resident #1 did not respond to anything, not even painful stimuli. She said she called for another nurse and the crash cart just in case it was needed and EMS. She said she tested Resident #1's BG and it was 46. She said EMS arrived and tested Resident #1's BG and the result was 25. She said EMS transported Resident #1 to the hospital for evaluation and treatment. She said giving insulin when not following parameters was dangerous. She said administering insulin outside of parameters could lead to hypoglycemia, coma, and death. During an observation on 07/30/25 at 2:00 p.m., Resident #1 was sitting in her wheelchair in the common area watching TV. She did not respond to questions from the surveyor. She displayed no signs of anxiety or agitation. During an interview on 07/30/25 at 9:33 a.m. NP D said she was aware Resident #1 was transferred to hospital on [DATE] for change of condition. She said if Resident #1's BG was 99, LVN A should have held the insulin due to the BG being out of parameters. She said Resident #1's BG usually ran high. She said giving insulin when not following parameters was dangerous. She said administering insulin outside of parameters could lead to hypoglycemia, coma, and death. Review of the facility's Medication Administration policy dated 10/24/22, indicated Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: . 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. An Immediate Jeopardy/Immediate Threat was identified on 07/29/25 at 1:05 p.m. The Administrator and the DON were notified of the Immediate Jeopardy and provided the IJ template on 07/29/25 at 1:18 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's POR was approved on 07/30/25 at 11:15 a.m. and indicated: Actions for Resident Involved: On 7/24/25, Resident #1 was assessed by LVN B and transferred to the hospital as per physician's orders due to a change in condition and returned to the facility on 7/28/25. Resident #1 was treated for Hypoglycemia with EMS and received D10, blood sugar elevated to 169. Resident #1 was treated with IV fluids with dextrose during hospitalization. On 7/29/25, Resident #1 was assessed by ADON and there was no change in condition noted. On 7/29/25, Resident #1's medications were reviewed by the Director of nursing with the physician and Aspart was discontinued. Identify residents who could be affected: On 7/29/2025, the Director of Nursing and/or designee completed 100% audit of all residents with current insulin orders to ensure Insulin is given within ordered parameters in the last 30 days. Any insulin administered outside of ordered parameters will be addressed with physician, Responsible party notified, resident assessment and medication error report completed if error is identified. Any unclear or missing insulin parameters will be clarified with the Attending physician and order changes as needed. 3 residents were identified as insulin administered outside of parameters and 4 residents that had insulin parameters ordered. Identified residents were assessed with no adverse effects, medication error reports completed, and MD/RP notified. No new order for residents that were identified as insulin administered outside of parameters. Action Taken/ System Change: On 7/29/25, the Regional Clinical Specialist re-educated the Director of Nursing and Assistant Directors of Nursing on Medication review and reconciliations to ensure that resident is free of significant medication errors, insulin parameters are followed and review of medication record to identify any errors when resident exhibits change in condition with appropriate notifications to physician and RP. Education includes this process: New physicians order will be reviewed in clinical morning meeting M-F by DON/Designee and RN supervisor/designee on weekends. The Medication Administration Record will also be reviewed with resident changes of condition to include transfer to hospital during clinical morning meeting M-F by DON/Designee and RN supervisor/designee on weekends. On 7/29/25, All license nurses and Medication Aides were immediately re-educated by the Director of Nursing/Designee on Medication Administration, Medication Errors and Identification of parameters. All license nurses were re-educated by the Director of Nursing/Designee on Insulin administration to include parameters and blood glucose monitoring. Residents experiencing change in condition will have medication administration record reviewed to ensure orders were followed and notify physician if errors were identified. Licensed Nurses will review medication record after medication administration to ensure insulin parameters are followed as ordered. Licensed Nurses were educated on this process and to notify DON/Designee if medication error is identified. A post-test will be completed to ensure comprehension of knowledge of the education provided . If 100% is not achieved, re-education will be completed and re-tested prior to taking an assignment. Licensed Nurses and Medication Aides not in the facility on 7/29/25 and/ or on PTO/ FMLA/ Leave of Absence will have the re-education completed prior to the start of their next scheduled shift. Beginning 7/29/25 and ongoing, newly hired licensed nurses and Certified Medication Aides will receive this training during orientation prior to providing care to the residents. The training will include the above-stated educational components. Beginning 7/29/25 and ongoing Medication administration audit report and Medication error incidents will be reviewed during the morning clinical meeting to ensure identification of medication errors and that physician is notified if error is identified. Monitoring Beginning 7/29/25 and going forward, DON/Designee will monitor compliance with medication administration policy through review of medication administration record to ensure insulin parameters are followed as ordered and medication pass observations. Beginning 7/29/25 and going forward, the DON/Designee will monitor compliance with the weekday morning review of new medication orders, insulin medication administration record, medication error incidents and change in conditions to ensure medications are administered as ordered and identify medications errors if any and referred to physician timely. The Administrator will attend the morning clinical meeting to ensure the Director of Nursing and/or designee reviews the Incident reports and medication administration report during clinical meetings. On 7/29/25, An Ad Hoc QAPI meeting was held with the Medical Director, Facility Administrator, Director of Nursing, and Regional Clinical Specialist to review the plan of removal. The Surveyor monitored the POR on 07/30/25 by: During observation on 07/30/25 from 1:20 p.m. through 3:54 p.m., LVN F, LVN G, and LVN H checked Residents #2, #3, and #4 BG and administered insulin as required. During interviews on 07/30/25 from 1:20 p.m. through 4:30 p.m., DON, ADON, LVN B, LVN F, LVN G, LVN H, LVN J, CMA K, CMA L, CMA M. MDS LVN N, LVN O, and LVN P who represented all shifts, (6:00 a.m.-6:00 p.m., 6:00 p.m. -6:00 a.m., 6:00 a.m.-2:00 p.m., 2:00 p.m. - 10:00 p.m., 8:00 a.m. - 5:00 p.m.) indicated they were aware to complete medication review and reconciliations to ensure that residents were free of significant medication errors, that insulin parameters were followed and review of medication record to identify any errors when resident exhibits change in condition with appropriate notifications to physician and RP. They were aware new physician orders would be reviewed in clinical morning meeting M-F by DON/Designee and RN supervisor/designee on weekends. They were aware the Medication Administration Record would also be reviewed with resident changes of condition to include transfer to hospital during clinical morning meeting M-F by DON/Designee and RN supervisor/designee on weekends. They were aware insulin administration included parameters and blood glucose monitoring. The indicated residents who experienced change in condition would have medication administration record reviewed to ensure orders were followed and to notify physician if errors were identified. Nursing staff indicated they would review medication record after medication administration to ensure insulin parameters were followed as ordered and to notify DON/Designee if a medication error was identified. During an interview on 07/30/25 at 3:30 p.m., the Administrator said he would be attending the morning clinical meeting to ensure the Director of Nursing and/or designee reviewed the incident reports and medication administration report during clinical meetings and all errors were addressed as required. He said he expected the nursing staff to administer medications per the facility policy and protocols. Record review of Resident #1's clinical chart indicated On 7/24/25, Resident #1 was assessed by LVN B and transferred to the hospital as per physician's orders due to a change in condition and returned to the facility on 7/28/25. Resident #1 was treated for hypoglycemia with EMS and received D10, blood sugar elevated to 169. Resident #1 was treated with IV fluids with dextrose during hospitalization. On 7/29/25, Resident #1 was assessed by ADON and there was no change in condition noted. On 7/29/25, Resident #1's medications were reviewed by the DON with the physician and Aspart (fast acting insulin) was discontinued. Record review of the facility audit of residents with current insulin orders 3 residents were identified as insulin administered outside of parameters and 4 residents that had insulin parameters ordered. The residents were assessed with no adverse effects, medication error reports completed, and MD/RP notified. There were no new orders for the identified residents that were identified as insulin administered outside of parameters. Record review of in-services dated 07/29/25 indicated the Regional Clinical Specialist re-educated the Director of Nursing and Assistant Directors of Nursing on medication review and reconciliations to ensure that residents were free of significant medication errors, insulin parameters were followed and review of medication record to identify any errors when resident exhibits change in condition with appropriate notifications to physician and RP. Education included new physician orders would be reviewed in clinical morning meeting M-F by DON/Designee and RN supervisor/designee on weekends. The Medication Administration Record would also be reviewed with resident changes of condition to include transfer to hospital during clinical morning meeting M-F by DON/Designee and RN supervisor/designee on weekends. Record review of in-service dated 07/29/25 indicated licensed nurses and Medication Aides were re-educated by the Director of Nursing/Designee on Medication Administration, Medication Errors and Identification of Parameters. All license nurses were re-educated by the Director of Nursing/Designee on insulin administration to include parameters and blood glucose monitoring. Residents experiencing change in condition would have medication administration record reviewed to ensure orders were followed and to notify physician if errors were identified. Licensed Nurses would review medication record after medication administration to ensure insulin parameters were followed as ordered. Licensed Nurses were educated on this process and to notify DON/Designee if medication error was identified. Record review of an in-service post-tests dated 07/29/25 indicated all tested nursing staff and medication aides achieved 100%. The Administrator and DON were notified on 07/30/25 at 4:35 p.m., the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy 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 interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the abuse coordinator or HHSC and failed to ensure that all alleged violations involving abuse were reported no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or neglect resulting in serious bodily injury, to the State Survey Agency, 2 of 2 residents (Residents #1 and #2) reviewed for reporting allegations of abuse or neglect. 1. The SW did not report to Administrator D that Resident #1 made an allegation in approximately October 2024 that CNA A wanted to be intimate with her. The DON did not report to Administrator D that Resident #1 made an allegation in approximately October 2024 that CNA A wanted her to put on her new lipstick and and put it on him (Resident #1 looked toward her private area) 2. Administrator C and the DON did not report an allegation of abuse or neglect to HHSC after they were informed Resident #2 indicated CNA B injured his leg during care in November 2024 . An Immediate Jeopardy (IJ) was identified on 02/06/25. The IJ Template was provided to the facility on [DATE] at 11:48 a.m. While the IJ was removed on 02/07/25 at 3:15 p.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. The failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of Resident #1's face sheet dated 02/05/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE], and her diagnoses included cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body and is usually the result of brain damage) and hemiparesis (one-sided muscle weakness) affecting left non-dominant side, and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and understood others, had moderate impaired cognition (BIMS 11), and had verbal behaviors directed at others (behavior of this type occurred 4-6 days but less than daily). Record review of Resident #1's care plan dated 06/19/24 indicated Resident #1 made false allegations against staff stating, I will get y'all fired and makes false allegations to get things she needs. Interventions included administer medications as ordered, anticipate, and meet Resident #1's needs, provide opportunity for positive interactions, and monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential causes. Record review of TULIP on 02/04/25 indicated there was no facility report for Resident #1's allegation of sexual abuse. 2. Record review of Resident #2 face sheet dated 02/05/25 indicated he was a [AGE] year old male, admitted on [DATE] and his diagnoses included traumatic subarachnoid hemorrhage (bleeding in the space below one of the thin layers that covers and protects the brain) with loss of consciousness, bipolar disorder (mental illness that causes clear shifts in a person's mood, energy, activity levels, and concentration), and osteoporosis (condition in which bones become weak and brittle). Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated he was able to make himself understood and understood others, was cognitively intact (BIMS-13), and had no behaviors. Record review of Resident #2's x-ray dated 12/05/24 indicated chronic left femur fracture. Record review of Resident #2's progress note dated 11/27/24, at 12:26 p.m., completed by the DON indicated the DON and Administrator C spoke with Resident #2 on 11/26/24 (specific time not documented). Resident #2 indicated CNA B performed incontinent care and he heard a pop. He said it occurred about 1 week ago. CNA B said she was not assigned to Resident #2. Resident #2 was moved to his current room [ROOM NUMBER]/12/24 and CNA B was not assigned to that room. CNA B stated she and CNA J gave him a shower on Monday (date not documented) with no complaints and CNA B did not hear a pop. Resident #2 stated nothing had happened intentionally. Record review of TULIP on 02/04/25 indicated there was no facility report for Resident #2's allegation of harm. During an interview on 02/04/25 at 11:36 a.m., Resident #2 said CNA B was providing care and he heard a pop. He said CNA B broke his leg, but it was not on purpose. He said CNA B was not mean or rough during care. He said CNA B did not do it on purpose. He said he had pain before and after he heard the pop. He said he received pain medication for his pain. During an interview on 02/04/25 at 1:46 p.m., previous Administrator E said she was no longer employed at the facility by mid-August 2024. She said she was not made aware of any allegations of sexual abuse made by Resident #1 against CNA A. During confidential interview on 02/04/25 at 3:19 p.m., the surveyor was informed Resident #2 said CNA B broke his leg. The surveyor was also informed ADON A said the allegation of harm was investigated and it was not intentional but Resident #2 repeated she broke my leg but not on purpose. CNA B was not suspended, and Resident #2 did not want her providing his care. During an interview on 02/04/25 at 4:00 p.m., ADON A said Resident #2 alleged CNA B broke his leg. She said she told Administrator C about Resident #2's allegation that CNA B broke his leg. She said Resident #2 said he did not want CNA B providing his care. She said she thought the allegation was reported to HHS by Administrator C. She said she heard of the allegation of sexual abuse from Resident #1 against CNA A during a morning meeting. She could not recall the date of the meeting. She said Resident #1 was moved to a different hall and room. She said the allegation of sexual abuse was reportable to HHS . She said CNA A was suspended due to Resident #1's allegations. She said all residents were at risk of further abuse when allegations were not reported, and residents were not protected. During an interview on 02/04/25 at 4:25 p.m., the DON said an allegation of abuse was not reported to HHS regarding CNA B because Resident #2 said she was not mean or rough and did not mind if CNA B took care of him. She said Resident #1 said she did not like CNA A from a previous facility. She said Resident #1 said CNA A wanted her to put on lipstick and put it on his privates. She said she did not report the allegations because Resident #1 said it happened at another facility. She said CNA A continued to work at the facility until he was terminated on 11/14/24 for insubordination and threatening behavior towards other staff. She said all residents were at risk of further abuse when allegations were not reported, and residents were not protected. During an interview on 02/05/25 at 9:24 a.m., CNA B said she and CNA J had bathed Resident #2 in bed as he usually was bathed. She said it was a few days before the DON asked her if Resident #2 complained of pain and she told the DON Resident #2 did not complain of pain. She said she heard Resident #2 said he heard a pop but had told the DON she and CNA J had not done anything, that it had just happened. She said she would have reported immediately to the charge nurse if Resident #2 had complained of pain or if she had heard a pop during care. She said she was never suspended or informed there was an investigation related to Resident #2's injury. During an interview on 02/05/25 at 1:54 p.m., the SW said Resident #1 reported CNA A wanted her to give him oral sex. She said she did not recall what day or time Resident #1 made the allegation. She said she did not document Resident #1's allegation. She said she did not report the allegation to the administrator, DON, or HHS because Resident #1's behaviors included telling lies on staff to get them fired. She said she was trained on abuse, abuse prevention, and reporting allegations. She said she was aware all allegations were reportable to the administrator immediately and to HHS within two hours. She said all residents were at risk of further abuse when allegations were not reported, and residents were not protected. During an interview on 02/06/25 at 7:35 a.m., the DON said she could not recall who reported CNA B provided care to Resident #2 and hurt his leg. She said she could not recall the exact words the reporter used or what day the allegation was reported. She said Resident #2 was interviewed on 11/26/24 and he said there was no intentional abuse. She said Resident #2 said he heard a pop during care. She said Resident #2 was diagnosed with a chronic fracture to his femur on 12/05/24. During an interview on 02/06/25 at 10:20 a.m., Administrator C said he had been employed with the facility for a few days in November 2024, when a staff (he could not recall who the staff was) had reported CNA B had provided care to Resident #2 and caused Resident #2 harm. He said he was not familiar with the residents and asked the DON to accompany him to interview Resident #2. He said Resident #2 said CNA B provided care and he heard a pop. He said Resident #2 did not alleged abuse and denied CNA B had cause him harm intentionally. He said he was aware all allegations of abuse were reportable with two hours to HHS. He said he should have reported the allegation of harm as abuse, suspended CNA B and investigated. He said all residents were at risk of further abuse when allegations were not reported, and residents were not protected. During an interview on 02/06/25 at 10:55 a.m., LVN J said Resident #1 had reported a male staff had done something to her. She said she could not recall the exact date. She said it was at the end of September 2024 or beginning of October 2024. She said interim Administrator D was dealing with the allegation and it was the reason Resident #1's room was moved to a different hall. LVN J said she was making rounds (she could not recall the date or time) when Resident #2 reported his leg hurt because someone had dropped him. She said she reported the allegation to interim Administrator D. She said she believed the complaint was being addressed. During an interview on 02/06/25 at 12:45 p.m., interim Administrator D said he was not aware of Resident #1's allegation of sexual abuse against CNA A. He said if he were made aware, CNA A would have been immediately suspended and he would have reported to HHS within 2 hours as required. He said he could not recall an allegation Resident #2 reported of a staff breaking his leg during care or being dropped. During an interview on 02/06/25 at 4:18 p.m., CNA A said he was suspended for a day due to allegations of sexual abuse. He said he could not recall the day he was suspended. He said he could not recall which staff advised him of the suspension. He said Resident #1 was moved to a different hall and he was advised to not go in her room or provide her care. He denied the allegation he told Resident #1 to suck his dick. He said Resident #1 had a behavior of telling lies on staff to get them fired when she did not like the staff. During an interview on 02/07/25 at 9:15 a.m., Resident #1 said CNA A wanted her to suck his dick. She said CNA A kept asking her to be intimate. She said he should not have been asking her for sex. She said she told the facility manager about CNA A asking her to have oral sex, but she could not recall his name. She said she could not remember the date she reported the allegation. She said she also reported the allegation to the SW but could not remember her name or when she reported the allegation to the SW. She said she was moved to another room on a different hall. She said she later moved to a different facility and was happy and safe at the new facility. Record review of the facility's Abuse, Neglect, and Exploitation policy dated 08/15/22 indicated: .1. Reporting of all alleged violation to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) withing specified timeframes: a. Immediately, but not later than2 hours after the allegation is made, if the events that cause the allegation involves abuse or result in serious bodily injury, .B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. This was determined to be an Immediate Jeopardy (IJ) on 02/06/25. The facility's Administrator, the VPO, and the RCS were notified. The Administrator was provided with the IJ template on 02/06/25 at 11:48 a.m. The following POR was accepted on 02/06/25 at 7:43 p.m.: The Administrator C and DON on 11/26/24 spoke to Resident #2 regarding a negative comment about C.N.A. B causing an injury during care of possible abuse or neglect. Resident #2 later assessed to have a femur fracture. Done for those affected: Resident #1 was discharged from the facility on 10/24/2024. An Allegation of Abuse was reported to HHSC for Resident #1 on 2/05/2025. On 2/5/2025, the LBSW Social Worker was suspended pending investigation outcome related to the allegation of sexual abuse for Resident #1. On 2/6/2025, the Director of Nursing was suspended pending investigation outcome related to the allegation of sexual abuse for Resident #1. On 2/5/2025, Resident #2 was interviewed regarding abuse and neglect with no reports and/ or allegations of being abused and/ or neglected. On 2/6/2025, Resident #2 was reassessed head to toe by the License Nurse related to abuse and neglect with no concerns noted. An allegation of abuse was reported to HHSC for Resident #2 on 2/6/2025. On 2/6/2025, the Director of Nursing was suspended pending investigation outcome related to the allegation of abuse for Resident #2. On 2/6/2025, the Administrator was suspended pending investigation outcome related to the allegation of abuse for Resident #2. On 2/6/2025, the C.N.A. Resident #2 reported provided care at the time of the incident was suspended pending investigation outcome related to the allegation of abuse for Resident #2. Identify residents who could be affected: Beginning 2/05/2025, the Administrator and/ or designee completed 100% of interviews of interviewable residents to assess for potential abuse, neglect, mistreatment, and misappropriation. Findings: No additional concerns were identified. Date of completion is 2/06/2025. Beginning 2/05/2025, head-to-toe assessments were completed by the Licensed Nurse on residents with a BIMS below 12 to identify any signs of injuries of unknown source and/ or evidence of abuse, neglect and mistreatment with no concerns identified. Date of completion was 2/06/2025. Beginning 2/05/2025, the Administrator and/ or designee completed staff interviews with all staff to identify concerns related to abuse, neglect, mistreatment, and misappropriation with no concerns noted. Date of completion was 2/06/2025. On 2/06/2025, the DON/designee reviewed the resident progress notes for the last 30 days to ensure concerns related to abuse, neglect, mistreatment and/ or misappropriation were identified, reported to HHSC and an investigation initiated with appropriate staff suspension. Findings: No additional concerns were identified. Date of completion is 2/06/2025. On 2/06/2025, the DON/ Designee reviewed incident/accidents in the last 30 days to ensure that investigations, timely reporting to HHSC as indicated with appropriate staff suspension, and resident assessments to include head to toe assessments were completed. Findings: No additional concerns were identified. Date of completion is 2/06/2025. On 2/06/2025, the Administrator and/or Designee reviewed resident grievances in the last 30 days to ensure that grievances were investigated and reported timely to HHSC as indicated with appropriate staff suspension(s). Findings: No additional concerns were identified. Date of Completion: 02/06/2025. Systemic Process: On 02/06/2025, the Regional [NAME] President of Operations and Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as timely initiation of the investigation into the allegation. Reeducation included immediate identification and suspension of all personnel suspected to be involved in the allegation. Date of Completion: 02/06/2025. Beginning 02/05/2025, the Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: On Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as resident protection with examples provided. Employees were reeducated on the facility investigation process which includes immediate identification and suspension of all personnel suspected to be involved in the allegation. Facility staff were reeducated the Abuse Coordinator and the Abuse Coordinator's role, as well as the Abuse Coordinator's contact information and where this information is located. Staff were reeducated on notifying the Director of Nursing, their immediate supervisor and/ or regional staff if they are unable to reach the abuse coordinator. Date of Completion: 02/06/2025. Effective 2/05/2025, any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator and/or designee prior to the start of their next scheduled shift. The facility maintains an onsite Weekend Manager and Nursing Supervisor that conduct rounds and may initiate and address resident incidents and will escalate to the appropriate administrative staff when required. The Administrator who is the Abuse Prevention Coordinator will be immediately notified for any concerns with Abuse, Neglect and Misappropriation. To monitor, the Administrator and/or designee and Director of Nursing/designee will review the 24-hour report, resident incidents, and grievances in facility Stand-up Morning Meeting, attended Monday-Friday. 24 Hour Report and resident incidents will be reviewed for potential abuse situations and need for reporting as per HHSC guidelines. Review will also include ensuring investigation, resident assessments to include a head-to-toe assessments were completed and provided. The Administrator will monitor to ensure new resident incidents are reviewed daily Monday-Friday to ensure concerns are addressed timely and if necessary, reported per HHSC guidelines, investigation was completed, resident assessments were completed and provided. Administrator/designee will conduct quarterly and as needed on Abuse, Neglect, & Exploitation education to ensure facility staff remains knowledgeable on the identification and reporting of abuse/neglect/exploitation. The facility has the [facility] Ambassador Rounds Program in place where administrative staff is assigned to residents. Staff will round and visit to ensure resident wellness and safety. Findings/ concerns will be reported to the Administrator/ Abuse Coordinator immediately. Monitoring: An AdHoc QAPI was conducted on 2/06/2025, attended by the Administrator, DON, Medical Director, and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F 609 - Immediate reporting of allegations of abuse, neglect, and exploitation and misappropriation of resident property and develop the above Action Plan. The surveyors monitored the POR on 02/07/25 as followed: During an interview on 02/07/25 at 11:30 a.m., Resident #2 indicated he was not abused and felt safe in the facility. He said he would report all abuse to the charge nurse and the Administrator. During interviews on 02/07/25 from 8:30 a.m. - 2:30 p.m. Administrator C, 2 ADONs (ADON F and ADON G), 11 CNAs (CNA B, CNA H, CNA J, CNA U, CNA V, CNA W, CNA Y, CNA AA, CNA DD, CNA EE), 5 LVNs ( LVN K, LVN M, LVN N, LVN P, LVN BB), 1 ( LVN/treatment nurse Q), 3 MA (MA L, MA R, MA MM), 1 dietary staff (DM X), 1 housekeeping staff (HSK GG ), 2 activities staff (Activity Director HH and Activity aide JJ , 2 nurse aides (NA S, NA T) and 1 Physical Therapists (PT NN), who represented all shifts (6:00 a.m. -6:00 p.m., 6:00 p.m. - 6:00 a.m., 6:00 a.m. -2:00 p.m., 2:00 p.m. - 10:00 p.m., 10:00 p.m. - 6:00 a.m.) said they were in-serviced and then given questionnaires to complete to verify their knowledge. All were able to state that their abuse coordinator was the Administrator, and if he was not available, they were to notify the DON. They were all able to give examples of physical, verbal, emotional abuse, and sexual abuse. They were aware of the importance of reporting alleged abuse immediately. They knew where the corporate compliance hotline number was posted and when to contact, as necessary. Interviews conducted on 02/07/25 from 8:00 a.m. - 2:30 p.m. with 9 residents who were alert and oriented (Residents #2, #5, #6, #7, #8, #9, #10, #11, #12) indicated they had no concerns about their safety, about the staff who provided their daily care, or the management at the facility. They would report abuse or neglect to the administrator or the DON. During an interview on 02/07/25 at 7:35 a.m., the DON said she was given one-on-one in-service with the VPO and the RCS regarding reporting alleged abuse allegations to the abuse coordinator immediately (if abuse coordinator was not available or was unreachable, then staff would report to her), the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and she was to begin investigating alleged allegations immediately if delegated by the abuse coordinator do so. She said if abuse were reported to her in the absence of the abuse coordinator that she would report the alleged allegation to HHSC within 2 hours of the alleged incident. She said the alleged perpetrator would be suspended immediately and would not be able to return to work until approval was granted. During an interview on 02/07/25 at 2:30 p.m., Administrator C said said he was in-serviced one-on-one with the VPO and the RCS regarding the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and that he was to begin investigating alleged allegations immediately and if he was not available, he was to delegate investigation responsibilities to the DON and/or management staff. He said the alleged perpetrator would be suspended immediately and would not be able to return to work until approval was granted. The Administrator said 75% of the active employees had been in-serviced and the remaining employees would be in-serviced before the start of their next shift. The Administrator said all new hires would receive training on abuse, neglect, and timely reporting prior to providing any resident care. Record review of Resident #1's closed clinical chart indicated she was discharged from the facility on 10/24/24. Record review of CNA A's personnel file on 02/07/25 indicated he was terminated on 11/14/24 for insubordination and threatening behavior. Record review of TULIP on 02/07/25 indicated an allegation of abuse was reported to HHSC for Resident #1 on 2/05/25. Record review of the the SW's personnel record on 02/07/25 indicated she was suspended as of 02/05/25, pending investigation outcome related to the allegation of sexual abuse for Resident #1. She was terminated on 02/07/25 for failure to report an allegation of sexual abuse. Record review of the DON's personnel file on 02/07/25 indicated she was suspended on 02/06/25 pending investigation outcome related to the allegation of sexual abuse for Resident #1. The DON resigned from the facility effective 02/07/25. Record review of TULIP 02/07/25 indicated an allegation of Resident Neglect was reported to HHSC for Resident #2 on 02/06/25. Record review of the DON's personnel file on 02/07/25 indicated she was suspended on 02/06/25 pending the investigation outcome related to the allegation of abuse for Resident #2. Record review of Administrator C's personnel file on 02/07/25 indicated he was suspended on 02/06/25, pending investigation outcome related to the allegation of abuse for Resident #2. On 2/6/2025, CNA B was suspended pending investigation outcome related to the allegation of neglect for Resident #2. Record review of head-to-toe assessments completed by the facility on residents with a BIMS below 12 to identify any signs of injuries of unknown source and/or evidence of abuse, neglect and mistreatment indicated no concerns were identified. Record review of resident progress notes for the last 30 days to ensure concerns related to abuse, neglect, mistreatment and/or misappropriation were identified, reported to HHSC and an investigation initiated with appropriate staff suspension indicated no concerns were identified. Record review of incident/accidents from 01/06/25 -02/06/25 indicated appropriate facility responses and investigations were completed as necessary and no additional concerns were identified related to abuse or neglect. Record review of grievances from 01/06/25-02/06/25, indicated appropriate facility responses and investigations were completed as necessary and no additional concerns were identified related to abuse or neglect. Record review dated 02/06/25, indicated the Regional [NAME] President of Operations and Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as timely initiation of the investigation into the allegation. Reeducation included immediate identification and suspension of all personnel suspected to be involved in the allegation. Record review dated 02/05/25, 02/06/25 and 02/07/25 indicated 75% of facility staff were re-educated by the Administrator, the DON and/or designee on the following: On Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as resident protection with examples provided. Employees were reeducated on the facility investigation process which includes immediate identification and suspension of all personnel suspected to be involved in the allegation. Facility staff were reeducated the Abuse Coordinator and the Abuse Coordinator's role, as well as the Abuse Coordinator's contact information and where this information is located. Staff were reeducated on notifying the Director of Nursing, their immediate supervisor and/ or regional staff if they are unable to reach the abuse coordinator. Record review of morning meeting minutes, the 24-hour report, and resident incidents dated 02/07/25 indicated there were no additional concerns identified related to abuse or neglect. Record review dated 02/07/25 indicated there were no concerns reported by [facility] Ambassadors. Administrator C, the VPO, and the RCS were informed the Immediate Jeopardy was removed on 02/07/25 at 3:15 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate and have evidence that all alleged violations were thoroughly investigated and/or prevent further potential abuse for 2 of 2 residents (Residents #1 and #2) reviewed for allegations of abuse or neglect. The facility failed to conduct a thorough investigation when Resident #1 alleged CNA A wanted to be intimate approximately in October 2024. The facility failed to conduct a thorough investigation when an unknown staff alleged CNA B caused Resident #2 injury during care November 26, 2024. An Immediate Jeopardy (IJ) was identified on 02/06/25. The IJ Template was provided to the facility on [DATE] at 11:48 a.m. While the IJ was removed on 02/07/25 at 3:15 p.m., the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. The failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of Resident #1's face sheet dated 02/05/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE], and her diagnoses included cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body and is usually the result of brain damage) and hemiparesis (one-sided muscle weakness) affecting left non-dominant side, and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated she was able to make herself understood and understood others, had moderate impaired cognition (BIMS 11), had verbal behaviors directed at others (behavior of this type occurred 4-6 days but less than daily). Record review of Resident #1's care plan dated 06/19/24 indicated Resident #1 made false allegations against staff stating, I will get y'all fired and makes false allegations to get things she needs. Interventions included administer medications as ordered, anticipate, and meet Resident #1's needs, provide opportunity for positive interactions, and monitor behavior episodes and attempt to determine underlying cause. Document behavior and potential causes. Record review of TULIP on 02/04/25 indicated there was no facility investigation report for Resident #1's allegation of sexual abuse. 2. Record review of Resident #2's face sheet dated 02/05/25 indicated he was a [AGE] year old male, admitted on [DATE] and his diagnoses included traumatic subarachnoid hemorrhage (bleeding in the space below one of the thin layers that covers and protects the brain) with loss of consciousness, bipolar disorder (mental illness that causes clear shifts in a person's mood, energy, activity levels, and concentration), and osteoporosis (condition in which bones become weak and brittle). Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated he was able to make himself understood and understood others, was cognitively intact (BIMS-13), and had no behaviors. Record review of Resident #2's x-ray dated 12/05/24 indicated chronic left femur fracture. Record review of Resident #2's progress note dated 11/27/24, at 12:26 p.m., completed by the DON indicated the DON and Administrator C spoke with Resident #2 on 11/26/24 (specific time not documented). Resident #2 indicated CNA B performed incontinent care and he heard a pop. He said it occurred about 1 week ago. CNA B said she was not assigned to Resident #2. Resident #2 was moved to his current room [ROOM NUMBER]/12/24 and CNA B was not assigned to that room. CNA B stated she and CNA J gave him a shower on Monday (date not documented) with no complaints and CNA B did not hear a pop. Resident #1 stated nothing had happened intentionally. Record review of TULIP on 02/04/25 indicated there was no facility investigation report for Resident #2's allegation of harm. During an interview on 02/04/25 at 11:36 a.m., Resident #2 said CNA B was providing care and he heard a pop. He said CNA B broke his leg, but it was not on purpose. He said CNA B was not mean or rough during care. He said CNA B did not do it on purpose. He said he had pain before and after he heard the pop. He said he received pain medication for his pain. During confidential interview on 02/04/25 at 3:19 p.m., the surveyor was informed Resident #2 said CNA B broke his leg. The surveyor was also informed ADON A said the allegation of harm was investigated and it was not intentional but Resident #2 repeated she broke my leg but not on purpose. CNA B was not suspended, and Resident #2 did not want her providing his care. During an interview on 02/04/25 at 4:00 p.m., ADON A said Resident #2 alleged CNA B broke his leg. She said she told Administrator C about Resident #2's allegation that CNA B broke his leg. She said Resident #2 said he did not want CNA B providing his care. She said she thought the allegation was reported to HHS by Administrator C. She said she heard of the allegation of sexual abuse from Resident #1 against CNA A during a morning meeting. She could not recall the date of the meeting. She said Resident #1 was moved to a different hall and room. She said the allegation of sexual abuse was reportable to HHS. She said CNA A was suspended due to Resident #1's allegations. She said all residents were at risk of further abuse when allegations were not reported, and residents were not protected. During an interview on 02/04/25 at 4:25 p.m., the DON said an allegation of abuse was not reported to HHS regarding CNA B because Resident #2 said she was not mean or rough and did not mind if CNA B took care of him. She said Resident #1 said she did not like CNA A from a previous facility. She said Resident #1 said CNA A wanted her to put on lipstick and put it on his privates. She said she did not report the allegations because Resident #1 said it happened at another facility. She said CNA A continued to work at the facility until he was terminated on 11/14/24 for insubordination and threatening behavior towards other staff. She said all residents were at risk of further abuse when allegations were not reported, and residents were not protected. During an interview on 02/05/25 at 9:24 a.m., CNA B said she and CNA J had bathed Resident #2 in bed as he usually was bathed. She said it was a few days before the DON asked her if Resident #2 complained of pain and she told the DON Resident #2 did not complain of pain. She said she heard Resident #2 said he heard a pop but had told the DON she and CNA J had not done anything, that it had just happened. She said she would have reported immediately to the charge nurse if Resident #2 had complained of pain or if she had heard a pop during care. She said she was never suspended or informed there was an investigation related to Resident #2's injury. During an interview on 02/05/25 at 1:54 p.m., the SW said Resident #1 reported CNA wanted her to give him oral sex. She said she did not recall what day or time Resident #1 made the allegation. She said she did not document Resident #1's allegation. She said she did not report the allegation to the administrator, DON, or HHS because Resident #1's behaviors included telling lies on staff to get them fired. She said she was trained on abuse, abuse prevention, and reporting allegations. She said she was aware all allegations were reportable to the administrator immediately and to HHS within two hours. She said all residents were at risk of further abuse when allegations were not reported, and residents were not protected. During an interview on 02/06/25 at 7:35 a.m., the DON said she could not recall who reported CNA B provided care to Resdient #2 and hurt his leg. She said she could not recall the exact words the reporter used or what day the allegation was reported. She said Resident #2 was interviewed on 11/26/24 and he said there was no intentional abuse. She said Resident #2 said he heard a pop during care. She said Resident #2 was diagnosed with a chronic fracture to his femur on 12/05/24. During an interview on 02/06/25 at 10:20 a.m., Administrator C said he had been employed with the facility for a few days in November 2024, when a staff (he could not recall who the staff was) had reported CNA B had provided care to Resident #2 and caused Resident #2 harm. He said he was not familiar with the residents and asked the DON to accompany him to interview Resident #2. He said Resident #2 said CNA B provided care and he heard a pop. He said Resident #2 did not alleged abuse and denied CNA B had cause him harm intentionally. He said he was aware all allegations of abuse were reportable with two hours to HHS. He said he should have reported the allegation of harm as abuse, suspended CNA B and investigated. During an interview on 02/06/25 at 10:55 a.m., LVN J said Resident #1 had reported a male staff had done something to her. She said she could not recall the exact date. She said it was at the end of September 2024 or beginning of October 2024. She said interim Administrator D was dealing with the allegation and it was the reason Resident #1's room was moved to a different hall. LVN J said she was making rounds (she could not recall the date or time) when Resident #2 reported his leg hurt because someone had dropped him. She said she reported the allegation to interim Administrator D. She said she believed the complaint was being addressed. During an interview on 02/06/25 at 12:45 p.m., interim Administrator D said he was not aware of Resident #1's allegation of sexual abuse against CNA A. He said if he were made aware, CNA A would have been immediately suspended and he would have reported to HHS within 2 hours as required. He said he could not recall an allegation Resident #2 reported of a staff breaking his leg during care. During an interview on 02/06/25 at 4:18 p.m., CNA A said he was suspended for a day due to allegations of sexual abuse. He said he could not recall the day he was suspended. He said he could not recall which staff advised him of the suspension. He said Resident #1 was moved to a different hall and he was advised to not go in her room or provide her care. He denied the allegation he told Resident #1 to suck his dick. He said Resident #1 had a behavior of telling lies on staff to get them fired when she did not like the staff. During interview on 02/07/25 at 9:15 a.m., Resident #1 said CNA A told her he wanted her to suck his dick. She said she told interim Administrator D, the DON, and the SW. She said she moved to another room on another hall. She said it was not right for CNA A to tell her he wanted her to suck his dick. She said she moved from the facility and was happier in the new facility. During an interview on 02/07/25 at 9:15 a.m., Resident #1 said CNA A wanted her to suck his dick. She said CNA A kept asking her to be intimate. She said he should not have been asking her for sex. She said she told the facility manager about CNA A asking her to have oral sex, but she could not recall his name. She said she could not remember the date she reported the allegation. She said she also reported the allegation to the SW but could not remember her name or when she reported the allegation to the SW. She said she was moved to another room on a different hall. She said she later moved to a different facility and was happy and safe at the new facility. Record review of CNA A's employee file indicated there was no suspension August through October 2024 related to the allegations of sexual abuse. Record review of the facility's Abuse, Neglect, and Exploitation policy dated 08/15/22 indicated: .1. Reporting of all alleged violation to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) withing specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse or result in serious bodily injury, .B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.5. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur 6. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation This was determined to be an Immediate Jeopardy (IJ) on 02/06/25. The facility's Administrator, the VPO, and the RCS were notified. The Administrator was provided with the IJ template on 02/06/25 at 11:48 a.m. The following POR was accepted on 02/06/25 at 7:43 p.m.: Done for those affected: Resident #1 was discharged from the facility on 10/24/2024. An Allegation of Abuse was reported to HHSC for Resident #1 on 2/05/2025. On 2/5/2025, the Social Worker was suspended pending investigation outcome related to the allegation of sexual abuse for Resident #1. On 2/6/2025, the Director of Nursing was suspended pending investigation outcome related to the allegation of sexual abuse for Resident #1. On 2/5/2025, Resident #2 was interviewed regarding abuse and neglect with no reports and/ or allegations of being abused and/ or neglected. On 2/6/2025, Resident #2 was reassessed head to toe by the License Nurse related to abuse and neglect with no concerns noted. An allegation of abuse was reported to HHSC for Resident #2 on 2/6/2025. On 2/6/2025, the Director of Nursing was suspended pending investigation outcome related to the allegation of abuse for Resident #2. On 2/6/2025, the Administrator was suspended pending investigation outcome related to the allegation of abuse for Resident #2. On 2/6/2025, the C.N.A. Resident #2 reported provided care at the time of the incident was suspended pending investigation outcome related to the allegation of abuse for Resident #2. Identify residents who could be affected: Beginning 2/05/2025, the Administrator and/ or designee completed 100% of interviews of interviewable residents to assess for potential abuse, neglect, mistreatment, and misappropriation. Findings: No additional concerns were identified. Date of completion was 2/06/2025. Beginning 2/05/2025, head to toe assessments were completed by the Licensed Nurse on residents with a BIMS below 12 to identify any signs of injuries of unknown source and/ or evidence of abuse, neglect and mistreatment with no concerns identified. Date of completion was 2/06/2025. Beginning 2/05/2025, the Administrator and/ or designee completed staff interviews with all staff to identify concerns related to abuse, neglect, mistreatment, and misappropriation with no concerns noted. Date of completion was 2/06/2025. On 2/06/2025, the DON/designee reviewed the resident progress notes for the last 30 days to ensure concerns related to abuse, neglect, mistreatment and/ or misappropriation were identified, reported to HHSC and an investigation initiated with appropriate staff suspension. Findings: No additional concerns were identified. Date of completion was 2/06/2025. On 2/06/2025, the DON/ Designee reviewed incident/accidents in the last 30 days to ensure that investigations, timely reporting to HHSC as indicated with appropriate staff suspension, and resident assessments to include head to toe assessments were completed. Findings: No additional concerns were identified. Date of completion was 2/06/2025. On 2/06/2025, the Administrator and/or Designee reviewed resident grievances in the last 30 days to ensure that grievances were investigated and reported timely to HHSC as indicated with appropriate staff suspension(s). Findings: No additional concerns were identified. Date of completion was 2/06/2025. Systemic Process: On 02/06/2025, the Regional [NAME] President of Operations and Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as timely initiation of the investigation into the allegation. Reeducation included immediate identification and suspension of all personnel suspected to be involved in the allegation. Date of Completion: 02/06/2025. Beginning 02/05/2025, the Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: On Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as resident protection with examples provided. Employees were reeducated on the facility investigation process which includes immediate identification and suspension of all personnel suspected to be involved in the allegation. Date of Completion: 02/06/2025. Effective 2/05/2025, any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator and/or designee prior to the start of their next scheduled shift. The facility maintains an onsite Weekend Manager and Nursing Supervisor that conduct rounds and may initiate and address resident incidents and will escalate to the appropriate administrative staff when required. The Administrator who is the Abuse Prevention Coordinator will be immediately notified for any concerns with Abuse, Neglect and Misappropriation. To monitor, the Administrator and/ or designee and Director of Nursing/ designee will review the 24-hour report, resident incidents, and grievances in facility Stand-up Morning Meeting, attended Monday - Friday. 24 Hour Report and resident incidents will be reviewed for potential abuse situations and need for reporting as per HHSC guidelines. Review will also include ensuring investigation, resident assessments to include a head to toe assessments were completed and provided. The Administrator will monitor to ensure new resident incidents are reviewed daily Monday-Friday to ensure concerns are addressed timely and if necessary, reported per HHSC guidelines, investigation was completed, resident assessments were completed and provided. Administrator/designee will conduct quarterly and as needed on Abuse, Neglect, & Exploitation education to ensure facility staff remains knowledgeable on the identification and reporting of abuse/neglect/exploitation. The facility has the [facility] Ambassador Rounds Program in place where administrative staff is assigned to residents. Staff will round and visit to ensure resident wellness and safety. Findings/ concerns will be reported to the Administrator/ Abuse Coordinator immediately. Monitoring: An AdHoc QAPI was conducted on 2/06/2025, attended by the Administrator, DON, Medical Director, and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F 610 - thoroughly investigate allegations of sexual and physical abuse and implement interventions to prevent the potential for further abuse from occurring while the investigation was in progress and develop the above Action Plan. The surveyors monitored the POR on 02/07/25 as followed: During an interview on 02/07/25 at 11:30 a.m., Resident #2 indicated he was not abused and felt safe in the facility. He said he would report all abuse to the charge nurse and the Administrator. During interviews on 02/07/25 from 8:30 a.m. - 2:30 p.m. Administrator C, 2 ADONs (ADON F and ADON G), 11 CNAs (CNA B, CNA H, CNA J, CNA U, CNA V, CNA W, CNA Y, CNA AA, CNA DD, CNA EE), 5 LVNs ( LVN K, LVN M, LVN N, LVN P, LVN BB), 1 ( LVN/treatment nurse Q), 3 MA (MA L, MA R, MA MM), 1 dietary staff (DM X), 1 housekeeping staff (HSK GG ), 2 activities staff (Activity Director HH and Activity aide JJ , 2 nurse aides (NA S, NA T) and 1 Physical Therapists (PT NN), who represented all shifts (6:00 a.m. -6:00 p.m., 6:00 p.m. - 6:00 a.m., 6:00 a.m. -2:00 p.m., 2:00 p.m. - 10:00 p.m., 10:00 p.m. - 6:00 a.m.) said they were in-serviced and then given questionnaires to complete to verify their knowledge. All were able to state that their abuse coordinator was the Administrator, and if he was not available, they were to notify the DON. They were all able to give examples of physical, verbal, emotional abuse, and sexual abuse. They were aware of the importance of reporting alleged abuse immediately. They knew where the corporate compliance hotline number was posted and when to contact, as necessary. During interviews on 02/07/25 from 8:00 a.m. - 2:30 p.m. with alert and oriented (Residents #2, #5, #6, #7, #8, #9, #10, #11, #12) indicated they had no concerns about their safety, about the staff who provided their daily care, or the management at the facility. They would report abuse or neglect to the administrator or the DON. During an interview on 02/07/25 at 7:35 a.m., the DON said she was given one-on-one in-service with the VPO and the RCS regarding reporting alleged abuse allegations to the abuse coordinator immediately (if abuse coordinator was not available or was unreachable, then staff would report to her), the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and she was to begin investigating alleged allegations immediately if delegated by the abuse coordinator do so. She said if abuse were reported to her in the absence of the abuse coordinator that she would report the alleged allegation to HHSC within 2 hours of the alleged incident. She said the alleged perpetrator would be suspended immediately and would not be able to return to work until approval was granted. During an interview on 02/07/25 at 2:30 p.m., Administrator C said said he was in-serviced one-on-one with the VPO and the RCS regarding the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and that he was to begin investigating alleged allegations immediately and if he was not available, he was to delegate investigation responsibilities to the DON and/or management staff. He said the alleged perpetrator would be suspended immediately and would not be able to return to work until approval was granted. The Administrator said 75% of the active employees had been in-serviced and the remaining employees would be in-serviced before the start of their next shift. The Administrator said all new hires would receive training on abuse, neglect, and timely reporting prior to providing any resident care. Record review of Resident #1's closed clinical chart indicated she was discharged from the facility on 10/24/2024. Record review of CNA A's personnel file indicated he was terminated on 11/14/24 for insubordination and threatening behavior. Record review of TULIP on 02/07/25 indicated an allegation of abuse was reported to HHSC for Resident #1 on 2/05/25. Record review of the the SW's personnel record indicated she was suspended as of 02/05/25, pending investigation outcome related to the allegation of sexual abuse for Resident #1. Record review of the DON's personnel file indicated she was suspended on 02/06/25 pending investigation outcome related to the allegation of sexual abuse for Resident #1. The DON resigned from the facility effective 02/07/25. Record review of TULIP 02/07/25 indicated an allegation of Resident Neglect was reported to HHSC for Resident #2 on 02/06/25. Record review of the DON's personnel file on 02/07/25 indicated she was suspended on 02/06/25 pending the investigation outcome related to the allegation of abuse for Resident #2. Record review of Administrator C's personnel file on 02/07/25 indicated he was suspended on 02/06/25, pending investigation outcome related to the allegation of abuse for Resident #2. On 2/6/2025, CNA B was suspended pending investigation outcome related to the allegation of neglect for Resident #2. Record review of head to toe assessments completed by the facility on residents with a BIMS below 12 to identify any signs of injuries of unknown source and/or evidence of abuse, neglect and mistreatment indicated no concerns were identified. Record review of resident progress notes for the last 30 days to ensure concerns related to abuse, neglect, mistreatment and/or misappropriation were identified, reported to HHSC and an investigation initiated with appropriate staff suspension indicated no concerns were identified. Record review of incident/accidents from 01/06/25 -02/06/25 indicated appropriate facility responses and investigations were completed as necessary and no additional concerns were identified related to abuse or neglect. Record review of grievances from 01/06/25-02/06/25, indicated appropriate facility responses and investigations were completed as necessary and no additional concerns were identified related to abuse or neglect. Record review dated 02/06/25, indicated the Regional [NAME] President of Operations and Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as timely initiation of the investigation into the allegation. Reeducation included immediate identification and suspension of all personnel suspected to be involved in the allegation. Record review dated 02/05/25, 02/06/25 and 02/07/25 indicated 75% of facility staff were re-educated by the Administrator, the DON and/or designee on the following: On Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as resident protection with examples provided. Employees were reeducated on the facility investigation process which includes immediate identification and suspension of all personnel suspected to be involved in the allegation. Facility staff were reeducated the Abuse Coordinator and the Abuse Coordinator's role, as well as the Abuse Coordinator's contact information and where this information is located. Staff were reeducated on notifying the Director of Nursing, their immediate supervisor and/ or regional staff if they are unable to reach the abuse coordinator. Record review of morning meeting minutes, the 24-hour report, and resident incidents dated 02/07/25 indicated there were no additional concerns identified related to abuse or neglect. Record review of monitoring sheets dated 02/07/25 indicated there were no concerns reported by [facility] Ambassadors . Administrator C, the VPO, and the RCS were informed the Immediate Jeopardy was removed on 02/07/25 at 3:15 p.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents the right to be free from abuse for 1 of 18 residents (Resident #1) reviewed for abuse. 1. The facility failed to ensure LVN A intervened and investigated when she heard two episodes of what sounded like slapping sounds while CNA B provided care to Resident #1 on 06/29/23. 2. LVN A did not remove CNA B from providing care to other residents leaving them at risk for abuse. An Immediate Jeopardy (IJ) situation was identified on 07/14/23 at 2:30 p.m. While the IJ was removed on 07/15/23, the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of Resident #1's face sheet dated 07/13/23 indicated Resident #1 was a [AGE] year-old female, admitted on [DATE], and her diagnoses included cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), dysphagia (difficulty swallowing), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), aphasia (loss of ability to understand or express speech, caused by brain damage), need for assistance with personal care, cerebral infarction (result of disrupted blood flow to the brain due to problems with the blood vessels), developmental disorder (impairments in a physical, cognitive, language, or behavioral development), microcephaly (head is smaller than normal), and delusional disorders(psychotic disorders). Record review of Resident #1's MDS assessment dated [DATE] indicated Resident #1 had unclear speech, was rarely or never understood, sometimes understood others, was able to recall the location of her room and staff names and faces, had severely impaired cognitive skills for daily decision making, was totally dependent of two+ persons for transfers (to or from bed, chair, wheelchair), and totally dependent of 1 person for toilet use. Record review of Resident #1's care plan initiated on 12/07/23 indicated Resident #1 had a behavior problem. Interventions included provide opportunity for positive interaction, if reasonable discuss the resident's behavior (Explain/reinforce why behavior is inappropriate or unacceptable.) and intervene as necessary to protect the rights and safety of others. The care plan was revised on 01/08/23 and indicated Resident #1 became agitated when a CNA asked to put her to bed. She followed the staff down the hall grabbing and spitting at the CNA. There were no revisions to the interventions. Record review Resident #1's progress note dated 06/30/23 at 9:30 a.m., completed by the DON, indicated there was an allegation of abuse involving Resident #1. CNA B was separated from resident via suspension pending outcome of investigation. All proper authorities were contacted. City Police department took Resident #1's statement. RP was notified of the incident. Record review of the facility investigation dated 07/07/23 indicated on 06/09/23 at approximately 9:00 p.m. LVN A was passing evening medications between rooms [ROOM NUMBERS]. CNA B was seen taking Resident #1 to her room and then she closed the door. Approximately two or three minutes later, LVN A indicated she heard five sounds like hand against skin, like spanking, then silence, no sounds followed, no one called out or other indications of concern. LVN A then finished administering medications. Approximately one minute later as she returned to her cart, she heard the same sound again like hand against skin. She then saw CNA B exit Resident #1's room. When CNA B exited Resident #1's room, she told LVN A Resident #1 was acting out. LVN A asked CNA B what she meant, and she said, Oh she's flopping around and won't let me change her, when I was trying to put her to bed. She then stated, I had to get with her. LVN A went to Resident #1's room to check on Resident #1. Resident #1 was lying in bed and LVN A leaned over and asked Are you about to go to sleep? Resident #1 was pouting. When asked what happened, Resident #1 responded pop. LVN A asked, Are you saying pop? Resident #1 nodded her head yes. LVN A asked Resident #1 who popped her. Resident #1 began looking at the door. LVN A closed the door and assured Resident #1 she was not in trouble and asked again Who popped you? Resident #1 responded girl. LVN A assessed Resident #1 and found no injuries. CNA B did not provide further care and left the facility. LVN A attempted to notify the DON. The DON received the information on the morning of 06/30/23. Record review of CNA B's personnel file indicated she was suspended on 06/30/23 pending the outcome of the facility investigation. CNA B was terminated on 07/05/23. During observation and interview on 07/13/23 at 12:45 p.m., Resident #1 was seated in her wheelchair. She smiled at the surveyor and nodded yes when asked if she would like to talk. She looked at the door and when asked if she would like the door shut, she nodded her head yes. She nodded yes when asked if staff were taking good care of her. When asked if she liked the food the facility served for meals she nodded yes. When asked if was happy she nodded yes. When asked if any staff wherever mean to her, she nodded yes. Resident #1 nodded her head yes when asked if staff ever said bad words to her or swore at her. When asked if it was all the staff, she shook her head no. She nodded her head yes when asked if staff hurt her and used her right hand to hit the top of her head. When asked if the staff hit her head, she nodded her head yes. When asked if it was all the staff who hit her, she said no. When asked if it was one staff she nodded yes. During an interview on 07/13/23 at 3:05 p.m., LVN A said on 06/09/23, she was passing medications between rooms [ROOM NUMBERS]. She said the CNA B came out of another resident's room and asked her if she was going in Resident #1's room. She told her she was not going in the Resident #1's room and CNA B pushed Resident #1 into her room. LVN A said after a few seconds she heard what sounded like 5 slaps. She said she asked herself if that was really CNA B popping Resident #1, knowing that she could hear. She said she paused what she was doing and waited to hear a cry. She said she gave a resident medication and another resident a shake before returning to her medication cart. She said she then heard 5 more slapping sounds coming from Resident #1's room. She said CNA B exited Resident #1's room and looked at her (LVN A) like she was surprised to see her. CNA B said Resident #1 was upset and acting out. She said she was getting Resident #1 ready for bed, trying to clean her and change her and Resident #1 was tossing and turning and did not want to act right. LVN A said CNA B told her she had to get with her. LVN A said in her mind, it confirmed CNA B was hitting Resident #1, but she did not ask CNA B what she meant. She said she went in Resident #1's room and Resident #1 was under the covers facing the door. She said she got to Resident #1's eye level and asked her if she was o.k. and ready for bed. LVN A said Resident #1 nodded yes. She said she told Resident #1 she heard noises and Resident #1 said pop. She said she asked Resident #1 if she was saying pop and Resident #1 nodded her head yes. She asked who popped her and Resident #1 looked at the door. LVN A asked Resident #1 if she wanted the door closed and she nodded her head yes. She asked Resident #1 who popped her, and Resident #1 said girl. She said she asked where the girl hit her, and Resident #1 hit herself on her right thigh. LVN A pulled the covers back and looked her over and asked if she was o.k. She said Resident #1 had no observable injuries. She said she covered the resident and left the room. She said she had been trained on abuse, neglect, and reporting. She said she should have reported immediately to the DON and the Administrator. She said she sent the DON a text after she clocked out on 06/30/23 at 12:53 a.m. LVN A said she did not call the Administrator, who was the abuse coordinator. She said she did not call the DON when the DON did not respond to her text message. She said she should have stopped everything she was doing, intervened, and investigated the slapping sounds she heard. She said she should have sent CNA B home immediately. She said she did not know if CNA B provided any care to any other residents after she left Resident #1's room. She said she did not see CNA B again. She said other residents were at risk of abuse and not protected from abuse when allegations were not reported immediately. During an interview on 07/14/23 at 9:09 a.m., CNA B said she did the normal things to get Resident #1 ready for bed. She said she changed her brief and dressed her. She said Resident #1 turned over and watched TV. CNA B denied saying I had to get with her (Resident #1) to LVN A. She said she then took care of Resident #1's roommate, put the used briefs in a bag, and left the room. She said LVN A was at her cart and asked what was wrong. She said she replied she had to do it all by herself. She said she did it all by herself because everyone else was busy. She said she asked everyone one else for help. She said everyone else said they were busy. She said Resident #1 and her roommate were the last residents she provided care for, and she left the facility at approximately 10:00 p.m. on 06/29/23. CNA B said she had been working in the facility since March 2023 and was trained on abuse, neglect, and reporting. She said if LVN A heard sounds like slaps coming from Resident #1's room then she should have checked what was going on. She said she never slapped Resident #1. During an interview on 07/13/23 at 11:15 a.m., the DON said the Administrator was the abuse coordinator. She said she did not receive the text message from LVN A until 06/30/23 after 6:00 a.m. because her phone had shut off. She said she immediately called the administrator and informed her of the allegation of abuse. She said LVN A did not follow the facility's policy and procedures by not sending the CNA home or for reporting abuse immediately to the Administrator and the DON. She said other residents were at risk of abuse due to CNA B remaining in the facility for approximately one hour after the alleged incident. During an interview on 07/14/23 at 10:30 a.m., the Administrator said LVN A should have reported the allegations immediately to her and the DON. She said she (LVN A) should have called and not texted the DON. She said LVN A should not have waited until after her shift. She said CNA B should have been escorted out of the facility. She said CNA B was suspended on 06/30/23 pending the facility's investigation. She said the police were notified and were conducting their own investigation. The Administrator said CNA B was terminated on 07/05/23. She said facility staff were retrained on abuse, neglect, and reporting. She said she held an ad-hoc QAPI meeting on 06/30/23. She said the medical director was made aware of the incident and the QAPI meeting by phone. She said the facility had not completed all staff re-training on abuse, neglect, and reporting. She said she had not implemented a formal monitoring system to monitor the effectiveness of the retraining for abuse, neglect, and reporting. She said residents were at risk of further abuse due to LVN A allowing CNA B to remain in the facility and not reporting the allegations immediately. During an interview on 07/17/23 at 4:45 p.m., the SW said she interviewed Resident #1 regarding the allegation of abuse from staff. She said Resident #1 was not upset or angry except when CNA B's name was mentioned. She said Resident #1 was able to distinguish between named staff and only got upset when she mentioned CNA B. During an interview on 07/17/23 at 3:17 p.m., DP D said LVN A told him she heard two separate incidents of slapping sounds coming from Resident #1's room. He said she (LVN A) said she did not intervene or investigate the slapping sounds. He said his report had gone to the DA for consideration of possible charges of elder abuse. Record review of the facility's Abuse, Neglect, and Exploitation policy dated 08/15/22 indicated: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, reasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish which can include staff to resident abuse .Physical abuse included, but is not limited to hitting slapping, punching, biting and kicking. The facility will make efforts to ensure all residents are protected from physical abuse and psychosocial harm, as well as additional abuse, .A. Responding immediately to protect the alleged victim and integrity of the investigation. Reporting of all alleged violations to the Administrator, state agency, adult protective service and to all other required agencies (e.g., law enforcement when applicable) within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not involve serious bodily injury. The Administrator and the DON were notified of the Immediate Jeopardy on 07/14/23 at 2:30 p.m. and the Administrator was provided the Immediate Jeopardy template. The Administrator was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 07/15/23 at 9:23 a.m. and reflected the following: Done for those affected: Head to toe assessment was completed on 6/29/23 for Resident #1 by the Licensed Nurse with no negative outcome. The Medical Director and the attending physician were notified on 6/30/23. Social Services completed a psychosocial assessment on Resident #1 on 6/30/23 with no ill effects. Head to toe reassessment was completed by Licensed Nurse on Resident #1 on 7/14/23 with no negative outcome. Social Service completed a psychosocial reassessment on Resident #1 on 7/14/23 with no ill effects. Identify residents who could be affected: Administrator and/ or designee reviewed the last 30 days of incident reports to evaluate if anyone else could have been affected. No other residents were identified. Facility residents with a BIMS Score of 12 out of 15 and above we interviewed regarding abuse, neglect and mistreatment with no concerns identified. All other residents were assessed head to toe by a licensed nurse related to abuse, neglect and mistreatment with no concerns identified. Action Taken: Effective immediately on 7/14/2023, the Administrator/ DON and/ or designee began reeducation to all staff on the facility abuse and neglect policy, as well as the policy for abuse and neglect reporting requirements. The reeducation will also include the different types of Abuse, timely reporting, reporting to the Abuse Prevention Coordinator and immediate actions to take when an allegation is made and/ or identified; such as immediately removing the alleged perpetrators from providing care to residents. Staff were educated on facility posting related to reporting abuse. This education will include locations of postings, examples of methods of communication such as utilizing phone calls and/ or text messages to communicate with the abuse coordinator, and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. Staff will be provided with a posttest to validate understanding of the education. The facility Administrator and/or Director of Nursing will be responsible for monitoring the process. This will be completed through rounding, as well as resident and staff interviews and observations related to abuse, neglect and mistreatment, and abuse and neglect reporting three times weekly for four weeks effective 7/14/2023. 24 Hour Report and Incident Reports will be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegation or instances of abuse and/ or neglect. The RN Supervisor and/ or the Manager on duty will act as designees for the Administrator and Director of Nursing on the weekend. This is effective 7/14/2023 and on-going. Those that are not scheduled to work on 7/14/2023 will have the reeducation completed prior to the start of their next scheduled shift. On 6/30/2023 and 7/14/2023, the Administrator provided one to one reeducation to LVN A on examples of abuse and neglect, abuse and neglect reporting, who abuse and neglect should be reported to, time frames for reporting, immediate actions to take when an allegation of abuse is received; including immediate removal of the alleged perpetrator from providing care and alternate means of reporting abuse and neglect if the abuse coordinator cannot be reached. On 6/30/2023 CNA B was suspended pending outcome of investigation. On 7/5/2023 CNA B was terminated. On 07/15/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on 07/15/23 from 11:45 a.m. through 2:15 p.m. and included 5 alert residents, nurses including 1 RN, 4 LVNs, 8 CNAs, 1 MA, (who work all shifts), activity director, housekeeping supervisor, 2 housekeeping staff, 3 dietary staff, 1 floor tech, 1 laundry staff, the SW, the ADON, and the DON. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/ or identified; such as immediately removing the alleged perpetrators from providing care to residents. Staff were educated on facility posting related to reporting abuse and were able to locate numbers for reporting and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. The facility implemented a monitoring system effective 07/14/23. The facility Administrator and/or Director of Nursing indicated they were responsible for the monitoring and would conduct observation rounds and conduct interviews related to abuse, neglect and mistreatment, and abuse and neglect reporting three times weekly for four weeks effective 7/14/2023. The Administrator and DON indicated the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegation or instances of abuse and/ or neglect. The Administrator and DON indicated the RN Supervisor and/or the Manager on duty will act as designees for the Administrator and Director of Nursing on the weekend. This is effective 7/14/2023 and on-going. LVN A indicated she received one on one re-education from the Administrator 6/30/2023 and 7/14/2023. She was able to give examples of abuse and neglect, abuse and neglect reporting, who abuse and neglect should be reported to, time frames for reporting, immediate actions to take when an allegation of abuse is received; including immediate removal of the alleged perpetrator from providing care and alternate means of reporting abuse and neglect if the abuse coordinator cannot be reached. During observations of staff and resident interactions on 07/15/23 from 11:45 a.m. through 2:15 p.m. indicated no evidence of abuse and residents did not appear afraid of staff. Record review of Resident #1's assessments dated 06/30/23 and 07/14/23 were reviewed and there were no injuries. Record reviews of social services assessments dated 06/30/23 and 07/14//23 were reviewed and no psychosocial concerns were identified. Record review of incident reports were reviewed from 04/10/23 through 07/15/23. There were no additional residents identified at risk for abuse. Record of staff post tests were reviewed for accuracy and knowledge. No concerns noted. On 07/15/23 at 2:20 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated 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 implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 18 Residents (Resident #1) reviewed for abuse. The facility failed to ensure LVN A reported immediately to the Administrator or DON or immediately sent CNA B home after hearing what sounded like slapping noises while CNA B provided care for Resident #1. An Immediate Jeopardy (IJ) situation was identified on 07/14/23 at 2:30 p.m. While the IJ was removed on 07/15/23, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet dated 07/13/23 indicated Resident #1 was a [AGE] year-old female, admitted on [DATE], and her diagnoses included cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), dysphagia (difficulty swallowing), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), aphasia (loss of ability to understand or express speech, caused by brain damage), need for assistance with personal care, cerebral infarction (result of disrupted blood flow to the brain due to problems with the blood vessels), developmental disorder (impairments in a physical, cognitive, language, or behavioral development), microcephaly (head is smaller than normal), and delusional disorders(psychotic disorders). Record review of an MDS dated [DATE] indicated Resident #1 had unclear speech, was rarely or never understood, sometimes understands others, was able to recall the location of her room and staff names and faces, had severely impaired cognitive skills for daily decision making, was totally dependent of two+ persons for transfers (to or from bed, char, wheelchair), and totally dependent of 1 person for toilet use. Record review of care plan initiated on 12/07/23 indicated Resident #1 had a behavior problem. Interventions included provide opportunity for positive interaction, if reasonable discuss the resident's behavior (Explain/reinforce why behavior is inappropriate or unacceptable.) and intervene as necessary to protect the rights and safety of others. The care plan was revised on 01/08/23 and indicated Resident #1 became agitated when a CNA asked to put her to bed. She followed the staff down the hall grabbing and spitting at the CNA. There were no revisions to the interventions. Record review of progress note dated 06/30/23 at 9:30 a.m., completed by the DON, indicated there was an allegation of abuse involving Resident #1. CNA B was separated from Resident via suspension pending outcome of investigation. All proper authorities were contacted. City Police department took Resident #1's statement. RP was notified of the incident. Record review of the facility investigation dated 07/07/23 indicated on 06/09/23 at approximately 9:00 p.m. LVN A was passing evening medications between rooms [ROOM NUMBERS]. CNA B was seen taking Resident #1 to her room and then she closed the door. Approximately two or three minutes later, LVN A indicated she heard five sounds like hand against skin, like spanking, then silence, no sounds followed, no one called out or other indications of concern. LVN A then finished administering medications. Approximately one minute later as she returned to her cart, she heard the same sound again like hand against skin. She then saw CNA B exit Resident #1's room. When CNA B exited Resident #1's room, she told LVN A Resident #1 was acting out. LVN A asked CNA B what she meant, and she said, Oh she's flopping around and won't let me change her, when I was trying to put her to bed. She then stated, I had to get with her. LVN A went to Resident #1's room to check on Resident #1. Resident #1 was lying in bed and LVN A leaned over and asked Are you about to go to sleep? Resident #1 was pouting. When asked what happened, Resident #1 responded pop. LVN A asked, Are you saying pop? Resident #1 nodded her head yes. LVN A asked Resident #1 who popped her. Resident #1 began looking at the door. LVN A closed the door and assured Resident #1 she was not in trouble and asked again Who popped you? Resident #1 responded girl. LVN A assessed Resident #1 and found no injuries. CNA B did not provide further care and left the facility. LVN A attempted to notify the DON. The DON received the information on the morning of 06/30/23. Record review of CNA B's personnel file indicated she was suspended on 06/30/23 pending the outcome of the facility investigation. CNA B was terminated on 07/05/23. During observation and interview on 07/13/23 at 12:45 p.m., Resident #1 was seated in her wheelchair. She smiled at the surveyor and nodded yes when asked if she would like to talk. She looked at the door and when asked if she would like the door shut, she nodded her head yes. She nodded yes when asked if staff were taking good care of her. When asked if she liked the food the facility served for meals she nodded yes. When asked if was happy she nodded yes. When asked if any staff wherever mean to her, she nodded yes. Resident #1 nodded her head yes when asked if staff ever said bad words to her or swore at her. When asked if it was all the staff, she shook her head no. She nodded her head yes when asked if staff hurt her and used her right hand to hit the top of her head. When asked if the staff hit her head, she nodded her head yes. When asked if it was all the staff who hit her, she said no. When asked if it was one staff she nodded yes. During an interview on 07/13/23 at 3:05 p.m., LVN A said on 06/09/23, she was passing medications between rooms [ROOM NUMBERS]. She said the CNA B came out of another resident's room and asked her if she was going in Resident #1's room. She told her she was not going in the Resident #1's room and CNA B pushed Resident #1 into her room. LVN A said after a few seconds she heard what sounded like 5 slaps. She said she asked herself if that was really CNA B popping Resident #1, knowing that she could hear. She said she paused what she was doing and waited to hear a cry. She said she gave a resident medication and another resident a shake before returning to her medication cart. She said she then heard 5 more slapping sounds coming from Resident #1's room. She said CNA B exited Resident #1's room and looked at her (LVN A) like she was surprised to see her. CNA B said Resident #1 was upset and acting out. She said she was getting Resident #1 ready for bed, trying to clean her and change her and Resident #1 was tossing and turning and did not want to act right. LVN A said CNA B told her she had to get with her. LVN A said in her mind, it confirmed CNA B was hitting Resident #1, but she did not ask CNA B what she meant. She said she went in Resident #1's room and Resident #1 was under the covers facing the door. She said she got to Resident #1's eye level and asked her if she was o.k. and ready for bed. LVN A said Resident #1 nodded yes. She said she told Resident #1 she heard noises and Resident #1 said pop. She said she asked Resident #1 if she was saying pop and Resident #1 nodded her head yes. She asked who popped her and Resident #1 looked at the door. LVN A asked Resident #1 if she wanted the door closed and she nodded her head yes. She asked Resident #1 who popped her, and Resident #1 said girl. She said she asked where the girl hit her, and Resident #1 hit herself on her right thigh. LVN A pulled the covers back and looked her over and asked if she was o.k. She said Resident #1 had no observable injuries. She said she covered the Resident and left the room. She said she had been trained on abuse, neglect, and reporting. She said she should have reported immediately to the DON and the Administrator. She said she sent the DON a text after she clocked out on 06/30/23 at 12:53 a.m. LVN A said she did not call the administrator, who was the abuse coordinator. She said she did not call the DON when the DON did not respond to her text message. She said she should have stopped everything she was doing, intervened and investigated the slapping sounds she heard. She said she should have sent CNA B home immediately. She said she did not know if CNA B provided any care to any other residents after she left Resident #1's room. She said she did not see CNA B again. She said other residents were at risk of abuse and not protected from abuse when allegations were not reported immediately. During an interview on 07/14/23 at 9:09 a.m., CNA B said she did the normal things to get Resident #1 ready for bed. She said she changed her brief and dressed her. She said Resident #1 turned over and watched TV. CNA B denied saying I had to get with her (Resident #1) to LVN A. She said she then took care of Resident #1's roommate, put the used briefs in a bag, and left the room. She said LVN A was at her cart and asked what was wrong. She said she replied she had to do it all by herself. She said she did it all by herself because everyone else was busy. She said she asked everyone one else for help. She said everyone else said they were busy. She said Resident #1 and her roommate were the last residents she provided care for, and she left the facility at approximately 10:00 p.m. on 06/29/23. CNA B said she had been working in the facility since March 2023 and was trained on abuse, neglect, and reporting. She said if LVN A heard sounds like slaps coming from Resident #1's room then she should have checked what was going on. She said she never slapped Resident #1. During an interview on 07/13/23 at 11:15 a.m., the DON said the administrator was the abuse coordinator. She said she did not receive the text message from LVN A until 06/30/23 after 6:00 a.m. because her phone had shut off. She said she immediately called the administrator and informed her of the allegation of abuse. She said LVN A did not follow the facility's policy and procedures by not sending the CNA home or for reporting abuse immediately to the Administrator and the DON. She said other residents were at risk of abuse due to CNA B remaining in the facility for approximately one hour after the alleged incident. During an interview on 07/14/23 at 10:30 a.m., the Administrator said LVN A should have reported the allegations immediately to her and the DON. She said she (LVN A) should have called and not texted the DON. She said LVN A should not have waited until after her shift. She said CNA B should have been escorted out of the facility. She said CNA B was suspended on 06/30/23 pending the facility investigation. She said the police were notified and were conducting their own investigation. The Administrator said CNA B was terminated on 07/05/23. She said facility staff were retrained on abuse, neglect, and reporting. She said she held an ad-hoc QAPI meeting on 06/30/23. She said the medical director was made aware of the incident and the QAPI meeting by phone. She said the facility had not completed all staff re-training on abuse, neglect, and reporting. She said she had not implemented a formal monitoring system to monitor the effectiveness of the retraining for abuse, neglect, and reporting. She said residents were at risk of further abuse due to LVN A allowing CNA B to remain in the facility and not reporting the allegations immediately. During an interview on 07/17/23 at 4:45 p.m., the SW said she interviewed Resident #1 regarding the allegation of abuse from staff. She said Resident #1 was not upset or angry except when CNA B's name was mentioned. She said Resident #1 was able to distinguish between named staff and only got upset when she mentioned CNA B. During an interview on 07/17/23 at 3:17 p.m., DP D said LVN A told him she heard two separate incidents of slapping sounds coming from Resident #1's room. He said she (LVN A) said she did not intervene or investigate the slapping sounds. He said his report had gone to the DA for consideration of possible charges of elder abuse. Record review of the facility's Abuse, Neglect, and Exploitation policy dated 08/15/22 indicated: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, reasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish which can include staff to resident abuse .Physical abuse included, but is not limited to hitting slapping, punching, biting and kicking. The facility will make efforts to ensure all residents are protected from physical abuse and psychosocial harm, as well as additional abuse, .A. Responding immediately to protect the alleged victim and integrity of the investigation. Reporting of all alleged violations to the Administrator, state agency, adult protective service and to all other required agencies (e.g., law enforcement when applicable) within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not involve serious bodily injury. The Administrator and the DON were notified of the Immediate Jeopardy on 07/14/23 at 2:30 p.m. and the Administrator was provided the Immediate Jeopardy template. The Administrator was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 07/15/23 at 9:23 a.m. and reflected the following: Done for those affected: Head to toe assessment was completed on 6/29/23 for Resident #1 by the Licensed Nurse with no negative outcome. The Medical Director and the attending physician were notified on 6/30/23. Social Services completed a psychosocial assessment on Resident #1 on 6/30/23 with no ill effects. Head to toe reassessment was completed by Licensed Nurse on Resident #1 on 7/14/23 with no negative outcome. Social Service completed a psychosocial reassessment on Resident #1 on 7/14/23 with no ill effects. Identify residents who could be affected: Administrator and/ or designee reviewed the last 30 days of incident reports to evaluate if anyone else could have been affected. No other residents were identified. Facility residents with a BIMS Score of 12 out of 15 and above we interviewed regarding abuse, neglect and mistreatment with no concerns identified. All other residents were assessed head to toe by a licensed nurse related to abuse, neglect and mistreatment with no concerns identified. Action Taken: Effective immediately on 7/14/2023, the Administrator/ DON and/or designee began reeducation to all staff on the facility abuse and neglect policy, as well as the policy for abuse and neglect reporting requirements. The reeducation will also include the different types of Abuse, timely reporting, reporting to the Abuse Prevention Coordinator and immediate actions to take when an allegation is made and/ or identified; such as immediately removing the alleged perpetrators from providing care to residents. Staff were educated on facility posting related to reporting abuse. This education will include locations of postings, examples of methods of communication such as utilizing phone calls and/ or text messages to communicate with the abuse coordinator, and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. Staff will be provided with a posttest to validate understanding of the education. The facility Administrator and/or Director of Nursing will be responsible for monitoring the process. This will be completed through rounding, as well as resident and staff interviews and observations related to abuse, neglect and mistreatment, and abuse and neglect reporting three times weekly for four weeks effective 7/14/2023. 24 Hour Report and Incident Reports will be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegation or instances of abuse and/ or neglect. The RN Supervisor and/ or the Manager on duty will act as designees for the Administrator and Director of Nursing on the weekend. This is effective 7/14/2023 and on-going. Those that are not scheduled to work on 7/14/2023 will have the reeducation completed prior to the start of their next scheduled shift. On 6/30/2023 and 7/14/2023, the Administrator provided one to one reeducation to LVN A on examples of abuse and neglect, abuse and neglect reporting, who abuse and neglect should be reported to, time frames for reporting, immediate actions to take when an allegation of abuse is received; including immediate removal of the alleged perpetrator from providing care and alternate means of reporting abuse and neglect if the abuse coordinator cannot be reached. On 6/30/2023 CNA B was suspended pending outcome of investigation. On 7/5/2023 CNA B was terminated. On 07/15/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on 07/15/23 from 11:45 a.m. through 2:15 p.m. and included 5 alert residents, nurses including 1 RN, 4 LVNs, 8 CNAs, 1 MA, (who work all shifts), activity director, housekeeping supervisor, 2 housekeeping staff, 3 dietary staff, 1 floor tech, 1 laundry staff, the SW, the ADON, and the DON. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/ or identified; such as immediately removing the alleged perpetrators from providing care to residents. Staff were educated on facility posting related to reporting abuse and were able to locate numbers for reporting and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. The facility implemented a monitoring system effective 07/14/23. The facility Administrator and/or Director of Nursing indicated they were responsible for the monitoring and would conduct observation rounds and conduct interviews related to abuse, neglect and mistreatment, and abuse and neglect reporting three times weekly for four weeks effective 7/14/2023. The Administrator and DON indicated the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegation or instances of abuse and/ or neglect. The Administrator and DON indicated the RN Supervisor and/or the Manager on duty will act as designees for the Administrator and Director of Nursing on the weekend. This is effective 7/14/2023 and on-going. LVN A indicated she received one on one re-education from the Administrator 6/30/2023 and 7/14/2023. She was able to give examples of abuse and neglect, abuse and neglect reporting, who abuse and neglect should be reported to, time frames for reporting, immediate actions to take when an allegation of abuse is received; including immediate removal of the alleged perpetrator from providing care and alternate means of reporting abuse and neglect if the abuse coordinator cannot be reached. During observations of staff and resident interactions on 07/15/23 from 11:45 a.m. through 2:15 p.m. indicated no evidence of abuse and residents did not appear afraid of staff. Record review of Resident #1's assessments dated 06/30/23 and 07/14/23 were reviewed and there were no injuries. Record reviews of social services assessments dated 06/30/23 and 07/14//23 were reviewed and no psychosocial concerns were identified. Record review of incident reports were reviewed from 04/10/23 through 07/15/23. There were no additional residents identified at risk for abuse. Record of staff post tests were reviewed for accuracy and knowledge. No concerns noted. On 07/15/23 at 2:20 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated 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 all alleged violations involving abuse or mistreatment were reported to the to the administrator of the facility and other State Survey Agency immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury for 1 of 18 (Resident #1) residents reviewed for abuse and neglect. LVN A heard two episodes of what sounded like slapping sounds from Resident #1's room while CNA B was providing care on 06/29/23 at approximately 9:00 p.m. and did not immediately report the alleged abuse to the administrator. An Immediate Jeopardy (IJ) situation was identified on 07/14/23 at 2:30 p.m. While the IJ was removed on 07/15/23, the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet dated 07/13/23 indicated Resident #1 was a [AGE] year-old female, admitted on [DATE], and her diagnoses included cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), dysphagia (difficulty swallowing), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), aphasia (loss of ability to understand or express speech, caused by brain damage), need for assistance with personal care, cerebral infarction (result of disrupted blood flow to the brain due to problems with the blood vessels), developmental disorder (impairments in a physical, cognitive, language, or behavioral development), microcephaly (head is smaller than normal), and delusional disorders(psychotic disorders). Record review of an MDS dated [DATE] indicated Resident #1 had unclear speech, was rarely or never understood, sometimes understands others, was able to recall the location of her room and staff names and faces, had severely impaired cognitive skills for daily decision making, was totally dependent of two+ persons for transfers (to or from bed, char, wheelchair), and totally dependent of 1 person for toilet use. Record review of care plan initiated on 12/07/23 indicated Resident #1 had a behavior problem. Interventions included provide opportunity for positive interaction, if reasonable discuss the resident's behavior (Explain/reinforce why behavior is inappropriate or unacceptable.) and intervene as necessary to protect the rights and safety of others. The care plan was revised on 01/08/23 and indicated Resident #1 became agitated when a CNA asked to put her to bed. She followed the staff down the hall grabbing and spitting at the CNA. There were no revisions to the interventions. During observation and interview on 07/13/23 at 12:45 p.m., Resident #1 was seated in her wheelchair. She smiled at the surveyor and nodded yes when asked if she would like to talk. She looked at the door and when asked if she would like the door shut, she nodded her head yes. She nodded yes when asked if staff were taking good care of her. When asked if she liked the food the facility served for meals she nodded yes. When asked if was happy she nodded yes. When asked if any staff wherever mean to her, she nodded yes. Resident #1 nodded her head yes when asked if staff ever said bad words to her or swore at her. When asked if it was all the staff, she shook her head no. She nodded her head yes when asked if staff hurt her and used her right hand to hit the top of her head. When asked if the staff hit her head, she nodded her head yes. When asked if it was all the staff who hit her, she said no. When asked if it was one staff she nodded yes. During an interview on 07/13/23 at 3:05 p.m., LVN A said on 06/09/23, she was passing medications between rooms [ROOM NUMBERS]. She said the CNA B came out of another resident's room and asked her if she was going in Resident #1's room. She told her she was not going in the Resident #1's room and CNA B pushed Resident #1 into her room. LVN A said after a few seconds she heard what sounded like 5 slaps. She said she asked herself if that was really CNA B popping Resident #1, knowing that she could hear. She said she paused what she was doing and waited to hear a cry. She said she gave a resident medication and another resident a shake before returning to her medication cart. She said she then heard 5 more slapping sounds coming from Resident #1's room. She said CNA B exited Resident #1's room and looked at her (LVN A) like she was surprised to see her. CNA B said Resident #1 was upset and acting out. She said she was getting Resident #1 ready for bed, trying to clean her and change her and Resident #1 was tossing and turning and did not want to act right. LVN A said CNA B told her she had to get with her. LVN A said in her mind, it confirmed CNA B was hitting Resident #1, but she did not ask CNA B what she meant. She said she went in Resident #1's room and Resident #1 was under the covers facing the door. She said she got to Resident #1's eye level and asked her if she was o.k. and ready for bed. LVN A said Resident #1 nodded yes. She said she told Resident #1 she heard noises and Resident #1 said pop. She said she asked Resident #1 if she was saying pop and Resident #1 nodded her head yes. She asked who popped her and Resident #1 looked at the door. LVN A asked Resident #1 if she wanted the door closed and she nodded her head yes. She asked Resident #1 who popped her, and Resident #1 said girl. She said she asked where the girl hit her, and Resident #1 hit herself on her right thigh. LVN A pulled the covers back and looked her over and asked if she was o.k. She said Resident #1 had no observable injuries. She said she covered the Resident and left the room. She said she had been trained on abuse, neglect, and reporting. She said she should have reported immediately to the DON and the Administrator. She said she sent the DON a text after she clocked out on 06/30/23 at 12:53 a.m. LVN A said she did not call the administrator, who was the abuse coordinator. She said she did not call the DON when the DON did not respond to her text message. She said she should have stopped everything she was doing, intervened and investigated the slapping sounds she heard. She said she should have sent CNA B home immediately. She said she did not know if CNA B provided any care to any other residents after she left Resident #1's room. She said she did not see CNA B again. She said other residents were at risk of abuse and not protected from abuse when allegations were not reported immediately. During an interview on 07/13/23 at 11:15 a.m., the DON said the Administrator was the abuse coordinator. She said she did not receive the text message from LVN A until 06/30/23 after 6:00 a.m. because her phone had shut off. She said she immediately called the administrator and informed her of the allegation of abuse. She said LVN A did not follow the facility's policy and procedures by not sending the CNA home or for reporting abuse immediately to the Administrator and the DON. She said other residents were at risk of abuse due to CNA B remaining in the facility for approximately one hour after the alleged incident. During an interview on 07/14/23 at 10:30 a.m., the Administrator said LVN A should have reported the allegations immediately to her and the DON. She said she (LVN A) should have called and not texted the DON. She said LVN A should not have waited until after her shift. She said CNA B should have been escorted out of the facility. She said residents were at risk of further abuse due to LVN A allowing CNA B to remain in the facility and not reporting the allegations immediately. Record review of CNA B's personnel file indicated she was suspended on 06/30/23 pending the outcome of the facility investigation. CNA B was terminated on 07/05/23. Record review of the facility's Abuse, Neglect, and Exploitation policy dated 08/15/22 indicated: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, reasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish which can include staff to resident abuse .Physical abuse included, but is not limited to hitting slapping, punching, biting and kicking. The facility will make efforts to ensure all residents are protected from physical abuse and psychosocial harm, as well as additional abuse, .A. Responding immediately to protect the alleged victim and integrity of the investigation. Reporting of all alleged violations to the Administrator, state agency, adult protective service and to all other required agencies (e.g., law enforcement when applicable) within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not involve serious bodily injury. The Administrator and the DON were notified of the Immediate Jeopardy on 07/14/23 at 2:30 p.m. and the Administrator was provided the Immediate Jeopardy template. The Administrator was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 07/15/23 at 9:23 a.m. and reflected the following: Done for those affected: Head to toe assessment was completed on 6/29/23 for Resident #1 by the Licensed Nurse with no negative outcome. The Medical Director and the attending physician were notified on 6/30/23. Social Services completed a psychosocial assessment on Resident #1 on 6/30/23 with no ill effects. Head to toe reassessment was completed by Licensed Nurse on Resident #1 on 7/14/23 with no negative outcome. Social Service completed a psychosocial reassessment on Resident #1 on 7/14/23 with no ill effects. Identify residents who could be affected: Administrator and/ or designee reviewed the last 30 days of incident reports to evaluate if anyone else could have been affected. No other residents were identified. Facility residents with a BIMS Score of 12 out of 15 and above we interviewed regarding abuse, neglect and mistreatment with no concerns identified. All other residents were assessed head to toe by a licensed nurse related to abuse, neglect and mistreatment with no concerns identified. Action Taken: Effective immediately on 7/14/2023, the Administrator/ DON and/ or designee began reeducation to all staff on the facility abuse and neglect policy, as well as the policy for abuse and neglect reporting requirements. The reeducation will also include the different types of Abuse, timely reporting, reporting to the Abuse Prevention Coordinator and immediate actions to take when an allegation is made and/ or identified; such as immediately removing the alleged perpetrators from providing care to residents. Staff were educated on facility posting related to reporting abuse. This education will include locations of postings, examples of methods of communication such as utilizing phone calls and/ or text messages to communicate with the abuse coordinator, and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. Staff will be provided with a posttest to validate understanding of the education. The facility Administrator and/or Director of Nursing will be responsible for monitoring the process. This will be completed through rounding, as well as resident and staff interviews and observations related to abuse, neglect and mistreatment, and abuse and neglect reporting three times weekly for four weeks effective 7/14/2023. 24 Hour Report and Incident Reports will be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegation or instances of abuse and/ or neglect. The RN Supervisor and/ or the Manager on duty will act as designees for the Administrator and Director of Nursing on the weekend. This is effective 7/14/2023 and on-going. Those that are not scheduled to work on 7/14/2023 will have the reeducation completed prior to the start of their next scheduled shift. On 6/30/2023 and 7/14/2023, the Administrator provided one to one reeducation to LVN A on examples of abuse and neglect, abuse and neglect reporting, who abuse and neglect should be reported to, time frames for reporting, immediate actions to take when an allegation of abuse is received; including immediate removal of the alleged perpetrator from providing care and alternate means of reporting abuse and neglect if the abuse coordinator cannot be reached. On 6/30/2023 CNA B was suspended pending outcome of investigation. On 7/5/2023 CNA B was terminated. On 07/15/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on 07/15/23 from 11:45 a.m. through 2:15 p.m. and included 5 alert residents, nurses including 1 RN, 4 LVNs, 8 CNAs, 1 MA, (who work all shifts), activity director, housekeeping supervisor, 2 housekeeping staff, 3 dietary staff, 1 floor tech, 1 laundry staff, the SW, the ADON, and the DON. Staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. They were able to state immediate actions to take when an allegation was made and/ or identified; such as immediately removing the alleged perpetrators from providing care to residents. Staff were educated on facility posting related to reporting abuse and were able to locate numbers for reporting and alternate methods of reporting abuse such as department supervisors and/ or charge nurses. The facility implemented a monitoring system effective 07/14/23. The facility Administrator and/or Director of Nursing indicated they were responsible for the monitoring and would conduct observation rounds and conduct interviews related to abuse, neglect and mistreatment, and abuse and neglect reporting three times weekly for four weeks effective 7/14/2023. The Administrator and DON indicated the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegation or instances of abuse and/ or neglect. The Administrator and DON indicated the RN Supervisor and/or the Manager on duty will act as designees for the Administrator and Director of Nursing on the weekend. This was effective 7/14/2023 and on-going. LVN A indicated she received one on one re-education from the Administrator 6/30/2023 and 7/14/2023. She was able to give examples of abuse and neglect, abuse and neglect reporting, who abuse and neglect should be reported to, time frames for reporting, immediate actions to take when an allegation of abuse is received; including immediate removal of the alleged perpetrator from providing care and alternate means of reporting abuse and neglect if the abuse coordinator cannot be reached. During observations of staff and resident interactions on 07/15/23 from 11:45 a.m. through 2:15 p.m. indicated no evidence of abuse and residents did not appear afraid of staff. Record review of Resident #1's assessments dated 06/30/23 and 07/14/23 were reviewed and there were no injuries. Record reviews of social services assessments dated 06/30/23 and 07/14//23 were reviewed and no psychosocial concerns were identified. Record review of incident reports were reviewed from 04/10/23 through 07/15/23. There were no additional residents identified at risk for abuse. Record of staff post tests were reviewed for accuracy and knowledge. No concerns noted. On 07/15/23 at 2:20 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.