**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide and document an effective discharge planning process that focused on the resident's discharge goals, the preparation of the residents to be active partners and effectively transition them to post discharge care, and the reduction of factors leading to preventable readmissions for 1 of 6 (Resident #1) of residents reviewed for safe discharge. On 4/26/2024 the facility discharged Resident #1 from the facility pending a hearing for an appeal. The facility transported Resident #1 and all of his belongings to RP1's home. There was no one at the home who was able to accept Resident #1, the facility left the resident sitting outside of the home that was located on a busy street. Resident #1 was considered blind, was moderately cognitively impaired, was at risk for elopement with a previous history of elopement. The facility failed to ensure a safe discharge for Resident #1 when the facility dropped Resident #1 off at his RP1's home on the front porch unsupervised. The facility failed to ensure and coordinate the discharge of Resident #1 with RP1. The facility failed to ensure the completion of the discharge appeal process prior to discharging Resident #1 An (IJ) Immediate Jeopardy was identified on 4/27/2024 at 3:40 p.m. The IJ Immediate Jeopardy template was provided to the Admin on 4/27/2024 at 3:40 p.m. While the (IJ) Immediate Jeopardy was removed on 4/30/2024 at 4:05 p.m., the facility remained out of compliance at a scope of isolated and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This failure could place residents at risk of an unsafe discharge from facility leading to hospitalization, injury, elopement, and death. Findings included: Record review of Resident #1's face sheet dated 4/27/2024 reflected, Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Unspecified Dementia (when symptoms and findings of cognitive dysfunction do not meet the criteria for a specific type of dementia), Unspecified Severity, without behavioral disturbance, psychotic disturbance (paranoid or delusional), mood disturbance (depression), and anxiety (worry), and blind. The face sheet listed RP 1 and RP 2 as the RP's for Resident #1. Record review of Resident #1's quarterly MDS dated [DATE] reflected in Section A identification information indicated Resident #1 preferred language was Spanish. Under section C cognitive patterns reflected a BIMS score of 8 indicating moderate impairment for daily decision making. Under section G functional status and ADL's reflected Resident #1 required supervision with transfers, eating, toileting. Record review of Resident #1's care plan dated 4/25/2024 reflected Resident #1 had impaired vision, at risk for falls due to vision, confusion and poor comprehension. The care plan reflected Resident #1 was an elopement risk and a previous elopement from the facility on 10/22/2023. Interventions indicated watch for wandering behaviors, request to leave, attempt to leave facility, home, or hospital. The care reflected an ADL performance deficit and required 1x staff assistance with bathing, mobility, toileting, and dressing. The care plan also reflected that a discharge from the facility is not feasible as evidenced by Resident #1's dementia, inability to care for himself, administer medications, and recognize a change in condition. In an interview via phone on 4/26/2024 at 12:30 p.m. with Resident #1 RP2, she stated the facility dropped Resident #1 off on Resident #1's RP1's front porch. She stated there was no one home and she was leaving as soon as possible to go to the home because Resident #1 was unattended. She stated she could see him on the camera all alone with his belongings. In a follow-up interview she stated she arrived to find Resident #1 confused on the doorstep of RP1's home. She reported it took her about 15 minutes to get to home, so Resident #1 was there for that period of time with no supervision. She stated Resident #1 did not know where he was and thought he was in a different state. She did not understand how the facility could leave him unattended when there is a busy street nearby. She stated he could have fallen or been hit by a car. She stated they did receive a discharge notice from the facility but filed an appeal with the assistance of an ombudsman. She stated she thought the facility could not discharge Resident #1 until the appeal was decided. She stated they cannot care for Resident #1 at home as his medical needs are high and that is why he required nursing facility care. In an interview on 4/27/2024 at 12:45 p.m. the Admin stated on 4/26/2024 she and other staff members dropped Resident # 1 off at RP1's home. The Admin stated on 4/23/2024 the facility issued the family an emergency discharge of Resident #1 due to ongoing behaviors at the facility. The Admin stated the family did file and appeal for this discharge she stated the facility moved forward with the discharge and did not wait on the appeal process because they had already spoken with the family and started the discharge process due to the residents behavior. The Admin stated they provided the family with three choices for Resident #1, she stated they tried to locate another placement for the resident, and none were found. She stated the facility tried to get Resident #1 sent to the behavioral psychiatric hospital, she stated he was not accepted because he was not having current behaviors. The Admin stated the last choice was Resident #1 was going to be discharged to the family. She stated the family was going to have a family meeting on 4/25/2024 and let the facility know what they decided. The Admin stated she never heard back from the family so the facility discharged Resident #1 to RP1's home on 4/26/2024. The Admin stated she was not aware of who the person was who answered the door, but stated it was not either of the RPs for Resident #1. The Admin stated when they dropped Resident #1 off at the home they did not speak with or see either of the RPs for Resident #1 but thought they may have been in the home. The Admin stated she left the aftercare service for Resident #1 on the porch along with his other personal items. In an interview on 4/27/2024 at 1:55 p.m. with Admissions Coordinator revealed she assisted with the discharge of the resident. Stated they wanted to ensure that the family was home. She stated someone did answer the door and stated the Admin. provided whoever answered the door the resident's medications. She stated when they got ready to leave whoever answered the door opened the door and threw the residents medications outside on the bench where the Resident #1 was sitting. She stated the resident tried to get up and walk away and stated their CNA A spoke with the resident in Spanish and advised him to continue to sit on the porch. She stated the Admin. called the police to complete a welfare check and stated she also called APS because someone, whoever was in the house did not allow Resident #1 to come into the home and closed the door. In an interview via phone on 4/27/2024 at 2:10 p.m. with BOM revealed they took the resident to RP1's house and stated they went to the door and a lady answered the door. Stated the Admin. spoke with the person who answered the door that this was the resident's medications, and this was the provider aftercare information. She stated the lady took the medication and closed the door, then she opened the door and started speaking in Spanish and threw the medications out on the bench. She stated before they were leaving the resident started walking down the driveway with his walker and stated they went back and talked with the resident about sitting in the chair and waiting for his daughter to come. She stated the other staff were speaking to him in Spanish because he does not speak English that good. She stated they unloaded his stuff and left it on the porch and stated they were not there that long. She stated she did not think that this person spoke English. Record review of facility discharge policy dated 11/28/2016 that reflected the following: The facility must discharge planning when you anticipate discharging a resident to a private home, another nursing facility or skilled nursing facility or any type, or another type of residential facility. The Admin was notified on 4/27/2024 at 3:40 p.m., An (IJ) Immediate Jeopardy was identified due to the above failures. The Admin was provided with the (IJ) Immediate Jeopardy template on 4/27/2024 at 3:40 p.m., and a Plan of Removal (POR) was requested. The POR was accepted on 4/30/2024 at 3:32 p.m. The POR included the following: Problem: F660 Discharge Planning On 04/27/2024 an abbreviated survey was initiated at facility. On 4/27/24 the surveyor provided an Immediate Jeopardy (IJ)Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate Jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: 660: The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable Readmissions. The facility failed to ensure a safe discharge for Resident #1 when the facility dropped Resident #1 off at his RP1's home on the front porch unsupervised. The facility failed to ensure and coordinate the discharge of Resident #1 to RP1. The facility failed to ensure the completion of the discharge appeal process prior to discharging Resident #1 Interventions: 1. Resident #1 currently does not reside in the facility as of 4/27/24. Facility contacted family on 04/30/2024 and offered to return to facility. Family is pending decision to return. 2. The Administrator, DON, Admissions Coordinator, Social Worker, and Business Office Coordinator were in-serviced 1:1 by the [NAME] President of Clinical Services on 4/27/24 on the follow topics. Completed 4/27/24. a. Abuse and Neglect Policy b. Discharge Process Policy: Administrator will ensure a safe discharge in a safe environment with the family representative. Accommodation will be made with the RP prior to discharge during a care plan meeting. The resident will remain in the facility until the family has agreed to the services and care arranged for the discharge. c. Provider Letter/Discharge Appeal Process: A resident will not be discharged pending a discharge appeal. The resident will remain in the facility unless the resident/family agrees to a transfer or safe discharge. 3. The medical Director was notified of the Immediate Jeopardy on 4/27/24 by the Administrator. 4. An ADHOC QAPI meeting was completed with interdisciplinary team on 4/27/24 which included the medical director, Administrator, Director of Nursing, Social Worker, and Business Office Coordinator to discuss the citations and plan of removal. In-services The Administrator and DON initiated the following in-services. Training began 4/27/24 and will be completed 4/28/24. 1. All staff were in-serviced on Abuse/Neglect and Discharge Process, including safe discharge and implementation of discharge plan. All staff not present will not work their next scheduled shift until in-serviced. All new hires will be in-serviced during facility orientation. All agency staff will in be serviced before working their assignment. Monitoring of POR on 4/29/2024 included the following: 2. Observation made on 4/29/2024 at 11:15 a.m. reflected a clean, homelike facility. Residents were up, out of their rooms, dressed and groomed appropriately for the weather. There were no foul odors present or soiled residents. Staff was observed assisting residents in the dining areas, answering call lights in a timely manner, and interacting with residents respectfully. The facility had a sufficient number of staff members to meet residents' needs. No environmental issues noted. 3. In an interview on 4/29/2024 at 11:20 a.m. the Admin stated she had completed 100 percent of in-service training with all staff including Aides and Dietary. The in-services included Abuse/Neglect, Discharge procedures and policy and Resident Property. The Administrator stated she was given one to one inservice by the [NAME] President of Clinical services. She stated knowledge of Abuse Neglect exploitation Policy. The Administrator stated the discharge of Resident #1 should have been accepted by a responsible family member. 4. In an interview on 4/29/2024 at 12:30 p.m. LVN A stated she received in-service education this morning on Abuse Neglect and Discharge Procedures. LVN A stated Abuse Neglect Policy included provisions for providing optimal care to improve a resident's health or living conditions. She stated a Resident must be discharged to a safe and responsible person after discharge planning. 5. In an interview on 4/29/2024 at 12:45 p.m. with Resident #10 stated he had no problems with staff at the facility. He stated they were always polite and kind to him. 6. In an interview on 4/29/2024 at 12:50 p.m. the ADON stated she had received in-service education on Abuse Neglect and Discharge Procedures. The ADON stated knowledge of the Abuse Neglect Policy, she stated staff were tested on knowledge, but she felt familiar with the policy. The ADON stated she received Discharge Planning and Discharge Procedures training, she stated the RP must accept discharged residents and state knowledge of their care needs and medication lists. 7. In an interview on 4/29/2024 at 12:55 p.m. with CNA G stated she had been in serviced on Abuse Neglect and Discharge Procedures. CNA G stated she was inserviced this morning as she had been off work. She stated failing to provide a safe secure environment for a resident would be an example of neglect. She stated the RP must receive a copy of the Discharge Plan and Medication list and understanding of the instructions for care should be checked. 8. In an interview on 4/29/2024 at 1:02 p.m. with Resident # 4, Resident # 7, Resident #8, and Resident #11 stated most staff were nice and that they had no complaints at this time. 9. In an interview on 4/29/2024 at 2:20 p.m. Med Aide A stated she worked the night shift. Med Aide A stated everyone had been in-serviced on Abuse Neglect, Dementia Care, Discharge Procedures, and Customer Service. Med Aide A stated she had worked with the Resident #1 and he took his medications without any problems. The Med Aide A stated knowledge of Abuse Neglect policy, she stated a resident must be provided a safe secure environment and care as needed to avoid neglect. Med Aide A stated discharge planning should include a list of medications, instructions for their administration and a daily schedule. 10. In an interview on 4/30/2024 at 3:38 p.m. the Admin stated she had spoken to the family of Resident #1 today (4/30/2024) and they were still considering their options. She stated the family was still appealing Resident #1's discharge and there was a hearing scheduled for 5/29/24, she stated she was notified of the hearing date today. 11. Record review of facility's abuse and neglect policy revealed the policy included the key components of screening, training, prevention, identification, investigation, protection and reporting alleged incidents of abuse, neglect, and exploitation/misappropriation. 12. Record review of facility's discharge policy revealed the policy included key components of the discharge process. On 4/30/2024 at 4:05 p.m., the Admin was informed the (IJ) Immediate Jeopardy was removed. While the (IJ) Immediate Jeopardy was removed on 4/30/2024 at 4:05 p.m., the facility remained out of compliance at a scope of isolated and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain timely laboratory services to meet the needs of 1 of 4 residents reviewed for laboratory services. (Resident #3) The facility failed to obtain laboratory values as ordered on [DATE]. Resident #3's laboratory blood draw specimen became useless after an extended time and was not redrawn. Resident #3 was hospitalized on [DATE] with diagnoses including sepsis. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 5:10 p.m. While the IJ was removed on [DATE] at 1:45 p.m., 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 for a delay in identifying or diagnosing medical issues. Findings Include: Review of Resident #3's undated face sheet reflected she was a [AGE] year-old female with diagnoses including Alzheimer's, dementia, congestive heart failure and type II diabetes. Resident #3 was discharged on [DATE] to a local hospital. Review of Resident #3's MDS dated [DATE] revealed a BIMS of 3, indicating moderately impaired cognitive functioning. Review of Resident #3's Care Plan updated [DATE] revealed the following focus: infection Pacemaker placement [DATE]. The goal of the focus was written as discomfort or adverse side effects of antibiotic therapy through the review date. The interventions included in the care plan are, Any antibiotic may cause diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions. Monitor q [every] shift for adverse reaction. Observe for possible side effects every shift. Review of Resident #3's Progress Notes revealed on [DATE], Resident #3 was readmitted to the facility after having a pacemaker implanted. Review of Resident #3's E Transfer Form, dated [DATE] revealed at 11 a.m. resident was sent to the hospital emergency room for pacemaker site bleeding. Review of Resident #3's [DATE] TAR revealed on [DATE] an order for standard labs including a CBC, CMP, HgBA1c, lipid evaluation and TSH was ordered by the NP. The 31st contains initials. Review of Resident #3's [DATE] TAR revealed the order was carried over, but all days were blocked off with an X. Review of the Laboratory Results Form for Resident #3 revealed that on [DATE] a blood draw was conducted; specimen was obtained for the laboratory tests ordered. On [DATE] at 3:27 p.m. the laboratory returned results that did not show values for any of the ordered laboratory test. The reason the tests were not performed noted to be Test cancelled due to the age of the specimen. Continued review revealed there were no initials on the form indicating it had been seen by a nurse or that the NP had been notified of the labs not having been completed. Review of the Nurses' Lab Logging Book kept at the nurse's station revealed the front cover of the notebook contains the following: LOG ALL LAB ORDERS YOU RECEIVE INTO THIS BOOK. **6P-6A NURSES: COMPLETE LOG WHEN LAB IS PICKED UP. CHECK DAILY FOR LAB RESULTS **6A-6P NURSES: FOLLOW UP WITH LAB RESULTS. COMPLETE LOG WHEN RESULTS ARE RECEIVED/NOTIFY MD. Review of the book revealed pages titled Lab Audit Forms which contain a section for the nurse to document the date, resident name, labs ordered, whether the order is stat, date collected/picked up, date results received, and MD notification. Resident #3's name was not listed as a resident that had labs or lab orders for the months of October or November. The lab results or initial order were not located in the book. Review of Resident #3's hospital admission records from the local hospital revealed Resident #3 was admitted on [DATE]. On [DATE] Resident #3 was transferred to a larger hospital where the pacemaker had been implanted, for removal, due to a MRSA infection at the pacemaker site and Sepsis. Review of the facility In-services revealed on [DATE] an in-service was provided by ADON/LVN D contains the following: Lab Procedures: When charge nurse receives new lab order, must notify DON/ADONs. A copy of the lab requisition form and the order should be placed in the lab book, located at the nurse's station. At the start of the shift, all nurses are to check the lab portal for results. The DON/ADON will audit the book regularly to ensure all nurses are following the new protocol. All abnormal results must be reported to the NP/MD. By signing you understand the new process and are aware of how to log into new lab portal and obtain results. Interview on [DATE] at 1:50 p.m., RN A revealed when a lab order comes in the nurse's document it in the lab book kept at the nurse's desk. Once they get results, which arrive by fax or you can also check the portal on computer, the Doctor or NP will be notified. RN A stated the nurse will write on the lab or the NP will initial indicating if new orders. RN A stated some labs do take longer than others but there is a lab trouble shooter that works for lab company that the nurse can call. RN A stated she did not know of a negative outcome because of lab values but if ever encountered that situation would send the resident to the emergency room. Interview on [DATE] at 1:56 p.m., LVN B revealed when a nurse gets an order for a lab draw, they put the order in the lab book and when the results come back, they notify the doctor or NP. LVN B stated they put the hard copy into medical records drawer after the nurse signs it and puts the date it was sent to the doctor or NP. If the NP sees the lab in person, she will initial the hard copy. Interview on [DATE] at 11:11 a.m., LVN C revealed the nurses get orders several different ways mostly from the NP and she will give them a written order on an order sheet. We put the order into the computer under the resident that it was ordered for, and it makes the order pop up on the resident's TAR. LVN C stated once on the TAR, it will let the licensed person knows that the order was made, and that lab is going to be drawn, it is a method of keeping track of whether it was done or not, the nurse initials the TAR when it was drawn and puts in the lab book. LVN C stated the orders also go into the lab website, so they will know to come and collect. LVN C stated she put the lab results hard copy into the medical records drawer where medical records will scan it into the residents EHR. LVN C stated that after we have written the items in the lab book, she believes the ADON or someone else audits the entries. LVN C stated that she has worked at the facility 5 or 6 months and has not received training on the use of the lab book, but the other nurses did explain to her how it is to be used. LVN C stated she has not seen a lab returned without being done due to the specimen being too old. Interview on [DATE] at 11:49 a.m. with LVN D, who is also an ADON, revealed they explained to the nurses when they receive an order, they are supposed to log in the lab book so the next nurses know to look for the lab results and can follow-up. LVN D stated the purpose of the lab book is so it can be tracked when drawn and when to watch for results. The nurses also must make sure to put the order into the EHR but when they notify the lab that triggers the order to appears on the EHR. When an order is made the nurse is acknowledging they have seen and have taken the order off to be completed. The ADON stated she does not know anything about Resident #3's lab results other than it was not documented in the book. LVN D stated that all nurses are to be checking the lab book each time they work, that she works the halls occasionally and always looks at the book. Interview on [DATE] at 1:08 p.m. with LVN E revealed she did work Resident #3's hall the day the lab results came in but that does not mean she would have automatically been the one to pick the results up off the fax machine in the medication room. LVN E stated if it were not in the lab book she would not have known to be watching for the results. LVN E stated she did not see those results and if she had she would have notified the NP that the labs were not conducted and would have expected a new order for a new draw. LVN E stated if lab results come in and it was not documented they add it in the lab book to show it was completed. If there is a critical value or the labs show something that needs to be communicated to the NP, they will call her and make a note on the lab that they did so. If it is a lab that can wait till the NP's next visit, she comes several times a week, they will place it in a folder on her door so she will see it next time comes in. LVN E stated she was initially told how to do the lab book from other nurses but thinks that there may have been an in-service about the lab procedures making sure the nurses were doing it correctly. Interview on [DATE] at 12:55 p.m. and on [DATE] at 10:24 a.m. with the facility NP revealed the last order she made for Resident #3 to have labs on 10/31 were a prophylactic measure because she had just finished antibiotics after the pacemaker procedure and standard labs due to diagnoses. The NP stated that the nurses are to send the results to her or hand them to her when she is in the facility. She stated she did not specifically remember being told or seeing the insufficient sample results but if she had she would have just ordered that new lab be taken. The NP stated she is almost certain she would have been told of the labs because 95% of the time the nurses let her know. She stated if she had given verbal orders the nurse would place the orders in the EHR, but she does not see any orders for a redraw. The NP stated that she does rely heavily on the nurses to keep up with the labs, that she is just one person, and, in this case, it was a total flub up but usually it is not. She stated she does see how it looks like there is not a good system, but the lab was drawn, it was a mix up on the part of the lab that the specimen was too old. The NP stated there has been some issues with this lab company in the past. Interview on [DATE] at 1:23 p.m. with the facility DON revealed she stated that she was not happy with the current lab company they are using, she has looked into changing to another company and spoken to corporate about the amount of time some of the labs take to receive back. She stated the problem is finding a company that has a phlebotomist to make the blood draws. The DON stated she was not aware when this company started that they would be sending labs to Los Angeles for processing unless it is a stat order. She stated when they started with this company in April an in-service was given for the nurses explaining the new process. She and the ADONs monitor the lab book. The DON stated the nurses are notifying the lab when they get an order, but they are not always documenting in the lab book. She stated she was not notified of this lab specimen being too old for Resident #3 but knows that a nurse must have seen the results as the hard copy was put in the drawer for medical records and uploaded to Resident #3's EHR. The DON stated she will be getting with the medical records person to let them know not to upload a lab that does not include a nurse or NP signature. The DON stated there is not a policy and/or procedure on labs or the process. The DON confirmed that the current system for tracking lab values was broken or was not utilized correctly, and the laboratory was not efficient. Interview on [DATE] at 1:44 p.m. with the RCN revealed that she is at the facility to monitor the process of the lab system as of last week. Do have plans in action we are discussing the process that they have been employing. The RNC stated she think for this facility they are going to have to have someone that audits the process daily. In addition, she stated there is no procedure written up, so she is going to type up the procedures for the new floor nurses that start working for the facility. The RNC stated while she has been speaking to the current facility nurses, they were familiar with the process, but they do not always follow the process the same each time. The RCN stated they have had some issues with the lab company and are in the process of getting a different company that is in a nearby city. Interview on [DATE] at 10:57 a.m. with the facility Administrator revealed she was unable to locate a policy specific to the lab process for nurses. She stated her expectation is that nurses follow the physicians' orders, she assumes they are taught this in nursing school, and it is also located in the facility Physician Order policy. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 5:10 p.m. The facility Administrator, DON, and RCN were notified. The Administrator was provided with the IJ template on [DATE] at 5:10 p.m. The facility plan of removal was accepted on [DATE] at 1:45 p.m. was as follows. Plan of Removal Problem: F770 Laboratory Services Residents Affected: Residents requiring labs have the potential to be affected by deficient practice. Interventions: 1. Resident #3 remains in the hospital as of [DATE]. 2. Director of Nursing contacted the lab as of [DATE] to follow up on why communication was not made sooner for expired specimen and how can it be prevented. Lab rep stated it was an error on their part and the results will be in the next day. DON/designee will monitor labs daily to check portal for results for 4 weeks. 3. Adhock QAPI meeting held with staff and medical director on [DATE] to discuss and address lab findings. 4. DON/designee audited 100% of resident labs to ensure results were reported to NP/MD, completed on [DATE]. No additional abnormal findings were found. 5. DON/designee audited 100% of lab log notifications on [DATE]. No additional abnormal findings were found. 6. DON/designee pulled new order listing report from PCC daily starting [DATE] to ensure no new orders go unaddressed. This is be an ongoing process and will be regularly monitored by DON/designee. 7. DON/designee in-serviced all licensed staff on [DATE] on checking and printing all lab results from portal at start of shift and end of shift for abnormal results. All abnormal labs will be reported to MD immediately. All lab results will be placed in NP/MDs box for review and signature. DON ADON/weekend supervisor will check daily that labs are printed, reviewed, and reported to MD. DON will conduct random audits starting [DATE] and will continue for the next 4 weeks. 8. All licensed staff not inserviced on [DATE] will be inserviced prior to start of shift, completed [DATE]. All licensed new hires will be inserviced on day 1 of orientation by DON/designee. 9. Compliance Nurse inserviced Administrator, DON and ADON on [DATE] on auditing resident labs daily and on checking and printing all lab results from portal at start of the shift for abnormal results. All abnormal labs will be reported to MD. All lab results will be placed in NP/MDs box for review and signature. DON ADON/weekend supervisor will check daily that labs are printed, reviewed, and reported to MD. DON will conduct random audits [DATE] and will continue for the next 4 weeks. 10. Medical Director notified of immediate jeopardy on [DATE]. Monitoring: 1. The DON and/or ADON will monitor the following at least 5 times per week for at least 4 weeks then monthly thereafter: a. Resident orders to ensure that the timing was appropriate (routine pick up or stat) for all lab orders and to ensure the lab was completed timely according to the order. This will be performed by reviewing the 24-hour report in PCC, and then reviewing the documented condition of each resident who had a lab ordered. b. Review the 24-hour report and documentation to ensure any lab order was entered into PCC correctly and ensure that the lab was ordered via the lab service portal. c. Lab results were reported to the physician or nurse practitioner immediately. 2. The DON and/or ADON will ask at least 4 nurses per week for 4 weeks and then quarterly thereafter to ensure compliance. If staff are no able answer questions, DON/designee will re-inservice on the spot until staff fully understand. a. the timing parameters for the current lab service, i.e., non-stat vs stat b. what they would do if there is a delay in obtaining a lab specimen by the lab. c. What they would do if there is a resident change while awaiting the lab service to obtain a specimen. 3. All findings will be reported to QAPI for the next 3 months. The Surveyor monitored the POR on [DATE] as followed: During interviews on [DATE] from 10:16 a.m. - 3:40 p.m. with the Adm, the DON, two RNs and two LVNs revealed they all stated they were in-serviced on lab procedures. The DON reported they are continuing to audit the lab book. Review of an Ad Hoc QAPI Meeting Agenda Summary, dated [DATE], reflected the NP, RCN, ADM, DON, RNs and LVNs were in attendance. Review of an in-service titled Lab Procedures, dated [DATE] and conducted by the DON, reflected staff were educated on the protocol for labs including the nurse that confirms the order must be the nurse documenting on the lab book, each nurse at the beginning of shift checks the lab portal and faxes, results must be reported to MD/NP, nurse documents name, date and time and places in MD/NP box. The ADON and DON to check the lab book regularly. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by : Interview with Adm on [DATE] at 12:10 p.m. revealed they have finished monitoring all lab orders for all residents. They have audited the month of [DATE] and all labs were completed as ordered. The facility has a new process if labs are needed sooner and will use the hospital lab for stat labs. Review of lab book to show 100% completion of audit for labs ordered in November. Review of sampled resident's lab orders, results and notifications revealed no concerns noted. While the IJ was removed on [DATE] at 1:45 p.m., the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy at a scope of 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 observations, interviews, and record reviews the facility failed to protect residents' rights to be free from sexual abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed immediately intervene to ensure Resident #1 was free from sexual abuse. An allegation was reported that Resident #1 had sexual abuse as non-consensual contact of any type with a resident. Resident #1 did not have a capacity assessment to determine if she was able to provide consent and had a BIMs score of 01 indicating a severe cognitive impairment. The facility failed to protect Resident #1 from potential abuse as the AP was in the facility at the time of allegation was reported. An IJ (Immediate Jeopardy) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:14 p.m. to ADM, the facility remained out of compliance at no actual harm with a potential for more than minimal harm that is not immediate with a scope of isolated. This failure placed Residents at risk for abuse and not being provided a safe environment. Findings Included: Review of Resident #1's face sheet, dated [DATE], reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), and dementia (impaired ability to remember, think, or make decisions). Review of Resident #1's admission MDS, dated [DATE], reflected a BIMS of 01, indicating a severe cognitive impairment. Review of Resident #1's assessments tab, no date, reflected no assessment completed to determine Resident #1's capacity to consent. Review of Resident #2's face sheet, dated [DATE], reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hyperglycemia (too much sugar in blood), mild cognitive impairment, and altered mental status (abnormal state of alertness or awareness). Review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS of 15, indicating an intact cognitive response. Further review of Resident #2's MDS reflected a 0 for hearing indicating adequate-no difficulty in normal conversation, social interaction, listening to TV. Interview on [DATE] at 1:02 p.m., NA A stated at the start of her shift she was made aware that Resident #2 heard Resident #1 having sexual intercourse with the AP. NA A stated that she did not know who the AP was, she did not know his name. NA A stated that the AP would leave sometimes at ten o'clock in the evenings, sometimes in the early mornings. NA A stated that the AP would visit frequently with Resident #1, she stated that she would inquire the identity to nursing staff, although there was no confirmation on the person. NA stated that facility policy is to keep residents free from abuse and neglect and report all allegations to the administrator. Interview on [DATE] at 1:12 p.m., Resident #2 informed CNA D and stated she overheard Resident #1 and the AP having sexual intercourse on [DATE] in the early morning. Resident #2 stated that she is sure Resident #1 said no. Resident #2 stated the AP would come frequently during the afternoons and stay until late at night. Resident #2 stated she did not know the identity of the AP. Resident #2 stated that, I think he (AP) is a pervert. , as AP would come to the facility for Resident #1 in the afternoons and stay until the night hours. Interview on [DATE] at 1:19 p.m., Resident #1 revealed that she is not aware of who is the current, or the previous, President of the United States. Resident #1 stated that she does not know where she is at, the city she is in, but knows that she lives in the state of Texas. Resident #1 stated that she does not know of anyone visiting her recently. Resident #1 stated she is terrible at remembering things. Resident #1 stated that she does not get visited from her family members. Interview on [DATE] at 2:03 p.m., CNA A revealed that she has seen Resident #1's AP. CNA A stated that the AP comes often and has lunch with Resident #1. CNA stated she provides aide to Resident #1 and recalled that sometimes during aide, Resident #1 will cry or when she is turned Resident #1 will cry. CNA A stated that she is unsure if that is Resident #1's RP. CNA A stated that she is not aware of the AP's name. Interview [DATE] at 2:11 p.m., CNA B revealed that she has observed Resident #1's AP at the facility frequently. CNA B stated that she sometimes she chooses to work a double shift and she would see AP stay late at night. CNA B stated she does not know the AP's name. Interview on [DATE] at 2:11 p.m., CNA C stated that she would see the AP occasionally stay until six o'clock in the morning the following day after coming in the afternoon the day before. CNA C stated that she does not know the AP's name or exactly who he is. Interview on 3/30.2023 at 2:17 p.m., LVN A stated that the male person has been visiting Resident #1 since she admitted to the facility. LVN A revealed that she does not know the AP's name, she stated that it may start with a B. LVN A stated the AP comes around daily. LVN A stated she has not seen him today, but the AP will stay for a long time. LVN A stated that the allegation was brought to her attention to her by LVN B at the morning meeting at approximately 6:00am, in that CNA D was doing her rounds in the overnight shift and Resident #2 woke up from noises and alleged that she overheard Resident #1 having sexual intercourse and that Resident #1 gave consent. LVN A stated that she called the ADM and DON after the morning meeting, and reported the allegation approximately at 6:30 p.m. Interview on [DATE] at 2:30 p.m., the DON stated that the details of the allegation in that Resident #2 reported she heard the AP ask Resident #1 to have sex, and that Resident #1 gave consent, and that Resident #2 heard noises that sounded like pain. The DON further added that Resident #2 recalled the AP asked Resident #1 are you ok?. The DON stated that Resident #1 and the AP have been friends for a long time since Resident #1 has been admitted , they are always sitting together. The DON stated that she cannot think of AP's name, she is unable to recall it. The DON confirmed that it is not Resident #1's family. The DON states that they found out about the allegation today, this morning. The DON stated that if that is a relationship of her (Resident #1) prior to being here, we must respect her wishes. The DON stated that they considered Resident #2's statement as consensual. The DON further stated that they have no other contact information of AP. Interview on [DATE] at 2:35 p.m., the ADM stated that the allegation was reported to her this morning at seven o'clock. The ADM revealed that there is a relationship between Resident #1 and AP, and is unsure of the history, she cannot confirm if Resident #1 and the AP are dating. The ADM stated she informed the RP of the AP this morning by phone call, and she left a voice message, and that AP has been visiting for a long time. The ADM stated that when she spoke to Resident #2 about the allegation this morning, no approximate time, Resident #1 gave consent, and when Resident #1 asked to stop the AP would stop. The ADM asked Resident #2 if she observed anything disrespectful to Resident #1, or if the AP did anything to not follow Resident #1's wishes and if the AP bothers her, Resident #2 responded no. The ADM was not able to recall the AP's name. During the interview the ADM stated that she is going to pull files from the electronic check in station to retrieve the AP's name. The ADM stated she referred to the allegation as consensual. Interview on [DATE] at 3:42 p.m., the ADM stated that this allegation has never been reported before. The ADM stated that visitation policy revealed that visitors can stay after hours, if residents want the visitor to stay after hours and it is not bothering his or her roommates, the visitors they can stay. The ADM revealed that she was able to retrieve the AP's name from its system. The ADM stated, I updated Resident #1's face sheet so his name is listed there. Record review of Resident #1's face sheet revealed update on [DATE] at 3:40 p.m. Interview on [DATE] at 3:46 p.m., RP revealed that Resident #1 is his family member. The RP stated that he was not aware of the AP's frequent visits. The RP stated that no one at the facility informed him of the AP visiting. The RP stated that he is has heard the name of the AP before, although he does not know who the AP is. The RP states he thinks the Resident #1 met the AP when they worked together at a store. The RP revealed that when Resident #1 was in the hospital, the hospital is the only entity that called him and inquired who the AP was, and the hospital wanted confirmation. The RP stated he never trusted the AP, and he did not give consent for the frequent visits. The RP further stated, if I had the authority, I would not consent to any visits from him. The RP reiterated that he does not trust this person and further stated, he (AP) seems a little weird, I (RP) felt like this person wants to get something if Resident #1 died. The RP further stated that he is not aware if Resident #1 and the AP are in an intimate relationship or dating, and further stated that he hopes they are not. The RP stated that assessments were not completed at the time of admit indicating if she can give consent, and that he does not know if Resident #1 can consent to an intimate relationship. Observation and interview on [DATE] at 5:14 p.m., revealed the AP in Resident #1's room, sitting on the chair next to Resident #1's bed. Resident #1 was asleep. The AP stated that his name, and that Resident #1 is his good friend. The AP stated they met at the store, and that they are not coworkers and met randomly. The AP reiterated that they are good friends. The AP stated that he does not provide medical care to Resident #1, and that he comes here often and a lot. The AP stated that he is sometimes alone with her, and sometimes he pushes Resident #1 when she is on her wheelchair around the facility, has lunch, and sits with Resident #1 in the room. The AP stated that he used to go to Resident #1's home and visit her. Interview on [DATE] at 6:42 p.m., the NP stated that it is hard to say if Resident #1 can give consent to sexual intercourse, Resident #1 can have fluctuation in mentation. The NP further stated that places she worked for in the past would have formal assessments to determine this. The NP further stated she would not be able to say if Resident #1 can give consent to having sexual intercourse as she did not perform an assessment on the resident, there was no indication other than today, assessments are not routinely done unless a situation arises. Interview on [DATE] at 6:42 p.m., LVN B revealed she works the 6 a.m. to 6 p.m., and she is on a rotating schedule. LVN B stated she has seen the AP leaving the facility approximately at 2 a.m. or 3 a.m., LVN B further stated she wanted to ask him to leave because Resident #1 cannot rest although she was informed, she had permission to stay. LVN B revealed observations of Resident #1 in that when the AP comes early in the day and Resident #1 will be happy, although at the late hours Resident #1 will become restless, for example Resident #1 will try climbing out of her bed and complain about pain. LVN B revealed observation of Resident #1 being partially undressed, and the AP would be in the room with Resident #1. LVN B revealed she first started noticing these items approximately in February 2023. LVN B stated that she has never seen the AP have intimate encounters with Resident #1 other than rubbing Resident #1's hand, face, or hair in a consoling manner. LVN B stated the events to her knowledge in that, Resident #2 told the allegation to CNA D approximately at 3:40 a.m., it was not documented, in that Resident #2 heard noises behind the curtains and it sounded like it was sexual in nature, Resident #1 was making noises in pain, and that Resident #1 said stop and then later said ok. LVN B stated she reported it to ADON on [DATE] at 7:42 a.m., then later updated her report to 7:20 a.m., LVN B stated that LVN A was also made aware of her suspicions. Interview on [DATE] at 8:07 p.m., CNA D stated that Resident #2 informed her of the allegation approximately on [DATE] at 3:30 a.m. while she was performing her rounds. CNA D recalled the allegation in that Resident #1 consented to sexual intercourse, and that Resident #1 screamed, and the AP left the room. CNA D recalled she informed LVN B. CNA D revealed that she has not observed any sexual intercourse between Resident #1 and the AP. CNA D that the night shift had concerns about the AP staying in the late hours., CNA D stated she wrote a letter to the ADM about the night shifts concerns. CNA D stated that, in the past, she did not know who the AP was and one instance she had to ask him who he was, how are you and Resident #1 related. The AP informed CNA D that they met at the store. The CNA D stated that occasionally she would do rounds, and Resident #1 would have feces all over her, and would pull her covers back and Resident #1's diaper would be off. Interview on [DATE] at 7:39 a.m., the ADM and DON revealed that Resident #1 returned from the hospital and that according to the SANE nurse there were no significant findings. Resident #1 was sent to the hospital on [DATE]. Interview on [DATE] at 8:30 a.m., the ADON stated she was text messaged by LVN B on [DATE] at 7:34 a.m. about the allegation, although she had already been made aware by LVN A at 6:00 a.m., The ADON further stated that she advised LVN A to contact the ADM immediately about the allegation. Interview on [DATE] at 9:16 a.m., ADM revealed on [DATE] as he was being escorted out of the facility, the AP wanted to inform the details of the allegation in that all he was doing was attempting to get Resident #1's gown in place to get comfortable. The ADM further stated that she does not have the letter from the night shift about expressing their concerns. Interview on [DATE] at 11:09 a.m., Resident #1 stated she is doing fine today, although she revealed that she does not recall meeting the Investigator yesterday. Interview on [DATE] at 2:47 p.m., the ADM stated that before Resident #1 was sent to the hospital, she was assessed for pain, the pubic fracture was identified at the hospital. X-rays were completed at the hospital after the SANE. The ADM added that per the SANE nurse there was no evidence of significant injuries, and the report would be sent off for further testing. The ADM further stated that the NP and other clinical staff discussed the pubic ramus fracture (fracture to the bones to the lower pelvis), and determine it was a new injury. The ADM stated she found out about the injury on [DATE] at 8:15 a.m. and reported it as a facility reported incident as an injury of unknown origin to health and human services. Interview on [DATE] at 9:15 a.m., the DON revealed at the entrance conference that Resident #1 and Resident #2 are having a telehealth with NPPS. The DON revealed copies of the progress notes will be supplied. The DON further stated Resident #1 had pain and pain medication was administered this morning. Interview on [DATE] at 9:52 a.m., NP stated that x-rays were reviewed for Resident #1's visit from the hospital and based on the location of pubic fracture she cannot fathom how the injury would be sustained during sexual intercourse. The NP further stated that the pubic bone that was fractured was the sit bones that you would see injured in a fall to the ground in which a resident landed on her buttocks. The NP stated Resident #1 did recently have a fall in which she landed on her buttocks after slipping out of the bed. The NP stated the recent fall would be more likely to cause that type of fracture as opposed to sexual intercourse because the fracture is located on the interior rim of pubic bone. The NP stated Resident #1 had very brittle bones and the osteoporosis (condition when bone strength weakens and is susceptible to fracture) was easily visible in x-rays of Resident #1's ribs. The NP did not think Resident #1 would be limber enough to be in a sexual position that would cause the broken pubic bone. Interview on [DATE] at 10:20 a.m., Resident #2 stated that Resident #1 did cry out in pain when the AP was having sexual intercourse with her. Resident #2 stated the AP would ask permission for sexual intercourse and Resident #1 would say yes, but Resident #1 would cry out in pain and AP would stop. Resident #2 further stated that a little later the AP would ask again and attempt to have sex with Resident #1, but she would cry out in pain and then stop. Resident #2 added that after 5 to 6 times of trying to have sexual intercourse with Resident #1, the AP would stop. Resident #2 stated this was the first time AP attempted to have sex with Resident #1. Interview on [DATE] at 10:45 a.m., the ADM revealed she spoke to the RP and further stated that when the investigations are closed out and if there are no concerns for Resident #1's safety with the AP, the RP would allow continued visits with Resident #1. The ADM explained about a resident's ability to make decisions, stating that Resident #1 can consent to sexual intercourse or Resident #1 can decline to go to the hospital after at will. ADM revealed RP has no medical power of attorney for Resident #1. Interview on [DATE] at 9:04 a.m., NPPS described Resident #1 of having significant dementia, Resident #1 could not recall date of birth , and family's names. NPPS stated she is not able to determine if Resident #1 can consent to sexual intercourse from one psychiatric evaluation alone. Interview on [DATE] at 2:09 p.m., LCSW described Resident #1's memory is as impaired, and is oriented to person but not to time, place, or situation. Resident #1 has impaired judgement related to memory impairment. LCSW was not able to answer if Resident #1 has the capacity to give consent to sexual intercourse as it is beyond her scope of practice, and she does not assess for capacity. Interview on [DATE] at 4:16 p.m., NP stated that she is not able to answer if Resident #1 is able to understand the risks and benefits of sexual behavior., NP stated that Resident #1 needs formal assistance, and explained that the BIMS is not as detailed as a formal assessment. Interview on [DATE] at 4:17 p.m., NPPS stated she does not know if Resident #1 is able to understand the risks and benefits of sexual behavior, Resident #1 has dementia (impaired ability to remember, think, or make decisions), The NPPS further reiterated her previous statement that she is not able to determine if Resident #1 can consent to sexual intercourse from one psychiatric evaluation alone. Interview on [DATE] at 9:39 a.m., the SANE nurse confirmed that she reported the incident to HHSC generating intake #416188. The SANE nurse confirmed she performed the SANE on Resident #1. The SANE nurse stated there were findings on the left back of Resident #1 revealing scratch marks, and an abrasion inside of Resident #1's right labia majora (outer folds of the vulva), she added Resident #1 complained of hip pain and orders were made for additional x-rays. The SANE nurse revealed she was not aware of the additional findings of Resident #1's fractured Pubic ramus, she furthered added there are multiple possibilities of sustaining an abrasion in the labia majora, such as scratching or a fingernail causing it, she could not confirm what action could have caused it but confirmed the abrasion had to be from some type of penetration to that area. The SANE nurse stated that Resident #1 was baseline alert and oriented x1, and Resident #1 had memory issues during the exam as Resident #1 could not recall the previous steps of the assessments after it being explained to her. Interview on [DATE] at 10:38 a.m., CNA E revealed proper technique when performing perineal care, proper infection control practices of wearing gloves and PPE. CNA E revealed that nails are to be trimmed at an appropriate length to perform properly quality of care. CNA E stated that she provided care to Resident #1 occasionally and she is aware to gently provide care to Resident #1 and all residents. CNA E recalls performing care to Resident #1 in that there is always a barrier of her gloved hand and designated wipes, and to always be mindful of not scratching Resident #1 or any residents. Interview on [DATE] at 11:10 a.m., CNA A revealed proper technique when performing perineal care, proper infection control practices of wearing gloves and PPE. CNA A revealed that nails are to be trimmed at an appropriate length to perform properly quality of care. CNA A she provides care to Resident #1 and is familiar on the proper steps to be gentle with the Resident #1 when in perineal care and when applying barrier cream. CNA A stated that she has not seen Resident #1 scratch herself in her perineal areas. CNA A states that Resident #1's movements are usually slow. Observation on [DATE] at 11:22 a.m., Resident #1's nails on both hands appear short and not sharp. Record review of Resident #1's advance directive acknowledgement, dated [DATE], revealed RP signed document. Review of incident reports, no date, revealed Resident #1 fall on [DATE] in that she slid off the side of her bed and fell to the floor. No injuries were noted at that time and pain level was 0. Review of Resident #1's hospital records, dated [DATE], revealed x-ray impressions indicating an age-indeterminate left inferior pubic fracture ramus fracture, new from previous CT. Review of Resident #1's physician orders, dated [DATE], revealed Monitor resident for pain every 4 hours. Assess for verbal and non-verbal cues. If resident is having signs or symptoms of pain, medicate with PRN Norco per order. Hold for signs or symptoms of over sedation and notify medical doctor (examples: increased drowsiness, respiratory changes). Review of Resident #1's MAR, no date, revealed Resident #1 received PRN Norco on [DATE] at 8:16 p.m. with a pain level at 7 and [DATE] at 2:48 p.m. with pain level at 6. Resident #1 received 2 doses on [DATE] at 10:00 a.m. and 3:38 p.m. with a pain level of 4 and 5 respectively. On [DATE] Resident#1 received 1 dose at 10:00 a.m. for a pain level of 6. Review of Resident #1's medical forensic assessment report, dated [DATE], revealed Resident #1 alert and oriented x1, unknown for penetration and ejaculation, top hip left buttocks approximately 5 liner abrasions-similar to scratch like appearance new per ADON, bottom left buttock small red circular abrasions with yellow to red bruising surrounding tender to touch new per ADON, and small abrasion to labia majora at about the 10 o'clock position no bleeding noted at the time of exam, and in follow up care DFPS mandatory if abuse suspected-yes. Review of Resident #1's psychiatric evaluation, dated [DATE], revealed a presumptive diagnosis of dementia, disorganized thinking, general appearance, and behavior as confused, orientation x1, intelligence unable to determine, anxious affect, and disorganized thought content. Review of Resident #1's psychosocial evaluation, dated [DATE], revealed impaired memory, cognitive/executive function not intact, and impaired judgement. Review of the facility's abuse and neglect policy, revised [DATE], revealed, Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Definitions 4. Sexual Abuse: non-consensual sexual contact of any type with a resident. C. Prevention 3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or anise preventionist within 24-hours of complaint. Appropriate notification to state and home office will be the responsibility of the administrator per policy. 4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising of resident, occurrences, patterns, and trends that may constitute abuse. All occurrences of potential abuse or criminal behavior will be investigated by the Abuse Preventionist and/or designee. E. Reporting 1. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect, or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated persons. 2. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside normal business hours, the Abuse Preventionist or designee will be called. 3. Facility employees must report all allegation of: abuse. Neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated [DATE]. a. if the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. b. if the allegation does not involve abuse or serious bodily injury, the report must be made within 2 hours of the allegation. G. Protection The facility will take necessary measures to protect residents and employees from harm during and following an abuse, neglect, exploitation, mistreatment of residents of property investigation. Review of QAPI meeting, no date, completed for the facility's plan of removal-actions taken to remove the immediate jeopardy. An IJ (Immediate Jeopardy) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:14 p.m. to ADM and a Plan of Removal was requested. A Plan of Removal was first submitted by the ADM on [DATE] at 2:24 p.m.pm. The Plan of removal was accepted on [DATE] at 9:00 a.m. Plan of Removal Immediate Plan of Removal The facility submits this Plan of Removal to address the Immediate Jeopardy identified on [DATE]. Identification of Others Affected by Alleged Deficient Practice: All residents have the potential to be affected by this alleged deficient practice. Summary: Per the immediate jeopardy template, the facility failed to ensure the resident was free from abuse. Immediate Action Taken: 1. ADM/DON had alleged perpetrator removed from the facility on [DATE]. 2. The resident who was potentially assaulted was interviewed by ADM/DON for any emotion distress on [DATE]. 3. A head-to-toe assessment was performed on [DATE] by ADON 1 and ADON 2 for the resident who was potentially assaulted. No negative findings noted. 4. On [DATE], resident #1 had recent hospital visit to address the allegation of sexual abuse. 5. Resident 1 had psych service telehealth visit on [DATE] at 9:30 am. Resident 2 had psych service telehealth visit on [DATE] at 10:15 am. Resident 1 and 2 care plan updated as appropriate. 6. The ADM/DON/Social Worker interviewed other interviewable residents regarding any inappropriate behavior from residents or visitors on [DATE]. There were no negative findings found from interviews. To ensure non-interviewable residents are accounted for, skin assessments were performed on [DATE] by DON/ADON/MDS/Treatment Nurse/Charge nurses. There were no negative findings found from the skin assessments. 7. ADM/DON identified 65 residents with cognitive loss after reviewing the MDS' on [DATE]. 8. The ADM/DON/ADON interviewed all staff who have worked in the last 30 days regarding any observations of inappropriate/sexual behavior among resident, employees, visitors. No additional staff had observed or had concerns of inappropriate/sexual behavior. The 1 staff member who was the initial staff member made aware by resident #2, provided statement to ADM after allegation and investigation began on [DATE]. 9. The visitor entry door code has been changed by Maintenance Director on [DATE] so all staff can monitor who enters the facility. Visitors will only be allowed in by ringing doorbell and staff must open to allow entry. Visitors must sign in to include their name and who they are visiting. All facility staff are responsible for screening visitors, to include visitor name and resident visiting, prior to entry. ADM/DON/ADON inserviced all staff on [DATE] regarding new door policy. 10. ADM/DON/ADON inserviced all facility staff on [DATE] regarding visitor policy. 11. The ADM/DON/ADON began in-servicing on [DATE] for all staff. New hires will be inserviced at orientation. Facility does not utilize agency. Volunteers will be required to screen with any facility staff prior to entry. ADM inserviced Volunteers on [DATE] regarding Abuse/Neglect, Visitor Policy, and New Door Policy. On leave staff were in-service over phone by ADM on [DATE]. If staff are not present, they will be in-serviced prior to assuming their duties on their next scheduled shift regarding: o Abuse/Neglect Policy which includes sexual abuse/inappropriateness. Sexual abuse can occur from a resident, staff, or visitor. o If observed or reported: Separate the residents, staff, or visitors immediately. The alleged perpetrator will be asked to leave the facility. The ADM/DON inserviced all staff that the alleged perpetrator was removed from the facility due to a sexual abuse allegation. The in-service included the alleged perpetrator's name with directions to report to the ADM/DON immediately if seen in the facility. Inserviced performed on [DATE] Report any sexual abuse/inappropriateness to the administrator and DON immediately either in person or by speaking with them on the phone, including weekends. Law enforcement will be notified by ADM/DON immediately upon being made aware of sexual abuse allegation. If a resident is identified to request a sexual relationship, a care plan meeting will be initiated by the Social Service Director to determine the ability to consent. Care plan meetings will occur[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to implement written policies and procedures that prohibited and prevented abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed immediately intervene to ensure Resident #1 was free from abuse. An allegation was reported that Resident #1 had sexual abuse as non-consensual contact of any type with a resident and the facility failed to identify if Resident #1 had the capacity to consent to sexual intercourse, to assess if Resident #1's had the capacity to consent to sexual intercourse, to get consent acknowledged by the RP, limit and enforce the visitation hours, to report the allegation, and the facility failed to protect Resident #1 from potential abuse as the AP was in the facility at the time of allegation was reported. An IJ (Immediate Jeopardy) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:14 p.m. to ADM, the facility remained out of compliance at no actual harm with a potential for more than minimal harm that is not immediate with a scope of isolated, because all staff had not been trained on Abuse/Neglect, denying AP entrance into the facility, tracking visitors entering the facility, and the facility's need to evaluate the effectiveness of the corrective systems. This failure placed Residents at risk for abuse and not being provided a safe environment. Findings Included: Review of Resident #1's face sheet, dated [DATE], reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), and dementia (impaired ability to remember, think, or make decisions). Review of Resident #1's admission MDS, dated [DATE], reflected a BIMS of 01, indicating a severe cognitive impairment. Review of Resident #1's assessments tab, no date, reflected no assessment completed to determine Resident #1's capacity to consent. Review of Resident #2's face sheet, dated [DATE], reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hyperglycemia (too much sugar in blood), mild cognitive impairment, and altered mental status (abnormal state of alertness or awareness). Review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS of 15, indicating an intact cognitive response. Further review of Resident #2's MDS reflected a 0 for hearing indicating adequate-no difficulty in normal conversation, social interaction, listening to TV. Interview on [DATE] at 1:02 p.m., NA A stated at the start of her shift she was made aware that Resident #2 heard Resident #1 having sexual intercourse with the AP. NA A stated that she did not know who the AP was, she did not know his name. NA A stated that the AP would leave sometimes at ten o'clock in the evenings, sometimes in the early mornings. NA A stated that the AP would visit frequently with Resident #1, she stated that she would inquire the identity to nursing staff, although there was no confirmation on the person. NA stated that facility policy is to keep residents free from abuse and neglect and report all allegations to the administrator. Interview on [DATE] at 1:12 p.m., Resident #2 informed CNA D and stated she overheard Resident #1 and the AP having sexual intercourse on [DATE] in the early morning. Resident #2 stated that she is sure Resident #1 said no. Resident #2 stated the AP would come frequently during the afternoons and stay until late at night. Resident #2 stated she did not know the identity of the AP. Resident #2 stated that, I think he (AP) is a pervert. , as AP would come to the facility for Resident #1 in the afternoons and stay until the night hours. Interview on [DATE] at 1:19 p.m., Resident #1 revealed that she is not aware of who is the current, or the previous, President of the United States. Resident #1 stated that she does not know where she is at, the city she is in, but knows that she lives in the state of Texas. Resident #1 stated that she does not know of anyone visiting her recently. Resident #1 stated she is terrible at remembering things. Resident #1 stated that she does not get visited from her family members. Interview on [DATE] at 2:03 p.m., CNA A revealed that she has seen Resident #1's AP. CNA A stated that the AP comes often and has lunch with Resident #1. CNA stated she provides aide to Resident #1 and recalled that sometimes during aide, Resident #1 will cry or when she is turned Resident #1 will cry. CNA A stated that she is unsure if that is Resident #1's RP. CNA A stated that she is not aware of the AP's name. Interview [DATE] at 2:11 p.m., CNA B revealed that she has observed Resident #1's AP at the facility frequently. CNA B stated that she sometimes she chooses to work a double shift and she would see AP stay late at night. CNA B stated she does not know the AP's name. Interview on [DATE] at 2:11 p.m., CNA C stated that she would see the AP occasionally stay until six o'clock in the morning the following day after coming in the afternoon the day before. CNA C stated that she does not know the AP's name or exactly who he is. Interview on 3/30.2023 at 2:17 p.m., LVN A stated that the male person has been visiting Resident #1 since she admitted to the facility. LVN A revealed that she does not know the AP's name, she stated that it may start with a B. LVN A stated the AP comes around daily. LVN A stated she has not seen him today, but the AP will stay for a long time. LVN A stated that the allegation was brought to her attention to her by LVN B at the morning meeting at approximately 6:00am, in that CNA D was doing her rounds in the overnight shift and Resident #2 woke up from noises and alleged that she overheard Resident #1 having sexual intercourse and that Resident #1 gave consent. LVN A stated that she called the ADM and DON after the morning meeting, and reported the allegation approximately at 6:30 p.m. Interview on [DATE] at 2:30 p.m., the DON stated that the details of the allegation in that Resident #2 reported she heard the AP ask Resident #1 to have sex, and that Resident #1 gave consent, and that Resident #2 heard noises that sounded like pain. The DON further added that Resident #2 recalled the AP asked Resident #1 are you ok?. The DON stated that Resident #1 and the AP have been friends for a long time since Resident #1 has been admitted , they are always sitting together. The DON stated that she cannot think of AP's name, she is unable to recall it. The DON confirmed that it is not Resident #1's family. The DON states that they found out about the allegation today, this morning. The DON stated that if that is a relationship of her (Resident #1) prior to being here, we must respect her wishes. The DON stated that they considered Resident #2's statement as consensual. The DON further stated that they have no other contact information of AP. Interview on [DATE] at 2:35 p.m., the ADM stated that the allegation was reported to her this morning at seven o'clock. The ADM revealed that there is a relationship between Resident #1 and AP, and is unsure of the history, she cannot confirm if Resident #1 and the AP are dating. The ADM stated she informed the RP of the AP this morning by phone call, and she left a voice message, and that AP has been visiting for a long time. The ADM stated that when she spoke to Resident #2 about the allegation this morning, no approximate time, Resident #1 gave consent, and when Resident #1 asked to stop the AP would stop. The ADM asked Resident #2 if she observed anything disrespectful to Resident #1, or if the AP did anything to not follow Resident #1's wishes and if the AP bothers her, Resident #2 responded no. The ADM was not able to recall the AP's name. During the interview the ADM stated that she is going to pull files from the electronic check in station to retrieve the AP's name. The ADM stated she referred to the allegation as consensual. Interview on [DATE] at 3:42 p.m., the ADM stated that this allegation has never been reported before. The ADM stated that visitation policy revealed that visitors can stay after hours, if residents want the visitor to stay after hours and it is not bothering his or her roommates, the visitors they can stay. The ADM revealed that she was able to retrieve the AP's name from its system. The ADM stated, I updated Resident #1's face sheet so his name is listed there. Record review of Resident #1's face sheet revealed update on [DATE] at 3:40 p.m. Interview on [DATE] at 3:46 p.m., RP revealed that Resident #1 is his family member. The RP stated that he was not aware of the AP's frequent visits. The RP stated that no one at the facility informed him of the AP visiting. The RP stated that he is has heard the name of the AP before, although he does not know who the AP is. The RP states he thinks the Resident #1 met the AP when they worked together at a store. The RP revealed that when Resident #1 was in the hospital, the hospital is the only entity that called him and inquired who the AP was, and the hospital wanted confirmation. The RP stated he never trusted the AP, and he did not give consent for the frequent visits. The RP further stated, if I had the authority, I would not consent to any visits from him. The RP reiterated that he does not trust this person and further stated, he (AP) seems a little weird, I (RP) felt like this person wants to get something if Resident #1 died. The RP further stated that he is not aware if Resident #1 and the AP are in an intimate relationship or dating, and further stated that he hopes they are not. The RP stated that assessments were not completed at the time of admit indicating if she can give consent, and that he does not know if Resident #1 can consent to an intimate relationship. Observation and interview on [DATE] at 5:14 p.m., revealed the AP in Resident #1's room, sitting on the chair next to Resident #1's bed. Resident #1 was asleep. The AP stated that his name, and that Resident #1 is his good friend. The AP stated they met at the store, and that they are not coworkers and met randomly. The AP reiterated that they are good friends. The AP stated that he does not provide medical care to Resident #1, and that he comes here often and a lot. The AP stated that he is sometimes alone with her, and sometimes he pushes Resident #1 when she is on her wheelchair around the facility, has lunch, and sits with Resident #1 in the room. The AP stated that he used to go to Resident #1's home and visit her. Interview on [DATE] at 6:42 p.m., the NP stated that it is hard to say if Resident #1 can give consent to sexual intercourse, Resident #1 can have fluctuation in mentation. The NP further stated that places she worked for in the past would have formal assessments to determine this. The NP further stated she would not be able to say if Resident #1 can give consent to having sexual intercourse as she did not perform an assessment on the resident, there was no indication other than today, assessments are not routinely done unless a situation arises. Interview on [DATE] at 6:42 p.m., LVN B revealed she works the 6 a.m. to 6 p.m., and she is on a rotating schedule. LVN B stated she has seen the AP leaving the facility approximately at 2 a.m. or 3 a.m., LVN B further stated she wanted to ask him to leave because Resident #1 cannot rest although she was informed, she had permission to stay. LVN B revealed observations of Resident #1 in that when the AP comes early in the day and Resident #1 will be happy, although at the late hours Resident #1 will become restless, for example Resident #1 will try climbing out of her bed and complain about pain. LVN B revealed observation of Resident #1 being partially undressed, and the AP would be in the room with Resident #1. LVN B revealed she first started noticing these items approximately in February 2023. LVN B stated that she has never seen the AP have intimate encounters with Resident #1 other than rubbing Resident #1's hand, face, or hair in a consoling manner. LVN B stated the events to her knowledge in that, Resident #2 told the allegation to CNA D approximately at 3:40 a.m., it was not documented, in that Resident #2 heard noises behind the curtains and it sounded like it was sexual in nature, Resident #1 was making noises in pain, and that Resident #1 said stop and then later said ok. LVN B stated she reported it to ADON on [DATE] at 7:42 a.m., then later updated her report to 7:20 a.m., LVN B stated that LVN A was also made aware of her suspicions. Interview on [DATE] at 8:07 p.m., CNA D stated that Resident #2 informed her of the allegation approximately on [DATE] at 3:30 a.m. while she was performing her rounds. CNA D recalled the allegation in that Resident #1 consented to sexual intercourse, and that Resident #1 screamed, and the AP left the room. CNA D recalled she informed LVN B. CNA D revealed that she has not observed any sexual intercourse between Resident #1 and the AP. CNA D that the night shift had concerns about the AP staying in the late hours., CNA D stated she wrote a letter to the ADM about the night shifts concerns. CNA D stated that, in the past, she did not know who the AP was and one instance she had to ask him who he was, how are you and Resident #1 related. The AP informed CNA D that they met at the store. The CNA D stated that occasionally she would do rounds, and Resident #1 would have feces all over her, and would pull her covers back and Resident #1's diaper would be off. Interview on [DATE] at 7:39 a.m., the ADM and DON revealed that Resident #1 returned from the hospital and that according to the SANE nurse there were no significant findings. Resident #1 was sent to the hospital on [DATE]. Interview on [DATE] at 8:30 a.m., the ADON stated she was text messaged by LVN B on [DATE] at 7:34 a.m. about the allegation, although she had already been made aware by LVN A at 6:00 a.m., The ADON further stated that she advised LVN A to contact the ADM immediately about the allegation. Interview on [DATE] at 9:16 a.m., ADM revealed on [DATE] as he was being escorted out of the facility, the AP wanted to inform the details of the allegation in that all he was doing was attempting to get Resident #1's gown in place to get comfortable. The ADM further stated that she does not have the letter from the night shift about expressing their concerns. Interview on [DATE] at 11:09 a.m., Resident #1 stated she is doing fine today, although she revealed that she does not recall meeting the Investigator yesterday. Interview on [DATE] at 2:47 p.m., the ADM stated that before Resident #1 was sent to the hospital, she was assessed for pain, the pubic fracture was identified at the hospital. X-rays were completed at the hospital after the SANE. The ADM added that per the SANE nurse there was no evidence of significant injuries, and the report would be sent off for further testing. The ADM further stated that the NP and other clinical staff discussed the pubic ramus fracture (fracture to the bones to the lower pelvis), and determine it was a new injury. The ADM stated she found out about the injury on [DATE] at 8:15 a.m. and reported it as a facility reported incident as an injury of unknown origin to health and human services. Interview on [DATE] at 9:15 a.m., the DON revealed at the entrance conference that Resident #1 and Resident #2 are having a telehealth with NPPS. The DON revealed copies of the progress notes will be supplied. The DON further stated Resident #1 had pain and pain medication was administered this morning. Interview on [DATE] at 9:52 a.m., NP stated that x-rays were reviewed for Resident #1's visit from the hospital and based on the location of pubic fracture she cannot fathom how the injury would be sustained during sexual intercourse. The NP further stated that the pubic bone that was fractured was the sit bones that you would see injured in a fall to the ground in which a resident landed on her buttocks. The NP stated Resident #1 did recently have a fall in which she landed on her buttocks after slipping out of the bed. The NP stated the recent fall would be more likely to cause that type of fracture as opposed to sexual intercourse because the fracture is located on the interior rim of pubic bone. The NP stated Resident #1 had very brittle bones and the osteoporosis (condition when bone strength weakens and is susceptible to fracture) was easily visible in x-rays of Resident #1's ribs. The NP did not think Resident #1 would be limber enough to be in a sexual position that would cause the broken pubic bone. Interview on [DATE] at 10:20 a.m., Resident #2 stated that Resident #1 did cry out in pain when the AP was having sexual intercourse with her. Resident #2 stated the AP would ask permission for sexual intercourse and Resident #1 would say yes, but Resident #1 would cry out in pain and AP would stop. Resident #2 further stated that a little later the AP would ask again and attempt to have sex with Resident #1, but she would cry out in pain and then stop. Resident #2 added that after 5 to 6 times of trying to have sexual intercourse with Resident #1, the AP would stop. Resident #2 stated this was the first time AP attempted to have sex with Resident #1. Interview on [DATE] at 10:45 a.m., the ADM revealed she spoke to the RP and further stated that when the investigations are closed out and if there are no concerns for Resident #1's safety with the AP, the RP would allow continued visits with Resident #1. The ADM explained about a resident's ability to make decisions, stating that Resident #1 can consent to sexual intercourse or Resident #1 can decline to go to the hospital after at will. ADM revealed RP has no medical power of attorney for Resident #1. Interview on [DATE] at 9:04 a.m., NPPS described Resident #1 of having significant dementia, Resident #1 could not recall date of birth , and family's names. NPPS stated she is not able to determine if Resident #1 can consent to sexual intercourse from one psychiatric evaluation alone. Interview on [DATE] at 2:09 p.m., LCSW described Resident #1's memory is as impaired, and is oriented to person but not to time, place, or situation. Resident #1 has impaired judgement related to memory impairment. LCSW was not able to answer if Resident #1 has the capacity to give consent to sexual intercourse as it is beyond her scope of practice, and she does not assess for capacity. Interview on [DATE] at 4:16 p.m., NP stated that she is not able to answer if Resident #1 is able to understand the risks and benefits of sexual behavior., NP stated that Resident #1 needs formal assistance, and explained that the BIMS is not as detailed as a formal assessment. Interview on [DATE] at 4:17 p.m., NPPS stated she does not know if Resident #1 is able to understand the risks and benefits of sexual behavior, Resident #1 has dementia (impaired ability to remember, think, or make decisions), The NPPS further reiterated her previous statement that she is not able to determine if Resident #1 can consent to sexual intercourse from one psychiatric evaluation alone. Interview on [DATE] at 9:39 a.m., the SANE nurse confirmed that she reported the incident to HHSC generating intake #416188. The SANE nurse confirmed she performed the SANE on Resident #1. The SANE nurse stated there were findings on the left back of Resident #1 revealing scratch marks, and an abrasion inside of Resident #1's right labia majora (outer folds of the vulva), she added Resident #1 complained of hip pain and orders were made for additional x-rays. The SANE nurse revealed she was not aware of the additional findings of Resident #1's fractured Pubic ramus, she furthered added there are multiple possibilities of sustaining an abrasion in the labia majora, such as scratching or a fingernail causing it, she could not confirm what action could have caused it but confirmed the abrasion had to be from some type of penetration to that area. The SANE nurse stated that Resident #1 was baseline alert and oriented x1, and Resident #1 had memory issues during the exam as Resident #1 could not recall the previous steps of the assessments after it being explained to her. Interview on [DATE] at 10:38 a.m., CNA E revealed proper technique when performing perineal care, proper infection control practices of wearing gloves and PPE. CNA E revealed that nails are to be trimmed at an appropriate length to perform properly quality of care. CNA E stated that she provided care to Resident #1 occasionally and she is aware to gently provide care to Resident #1 and all residents. CNA E recalls performing care to Resident #1 in that there is always a barrier of her gloved hand and designated wipes, and to always be mindful of not scratching Resident #1 or any residents. Interview on [DATE] at 11:10 a.m., CNA A revealed proper technique when performing perineal care, proper infection control practices of wearing gloves and PPE. CNA A revealed that nails are to be trimmed at an appropriate length to perform properly quality of care. CNA A she provides care to Resident #1 and is familiar on the proper steps to be gentle with the Resident #1 when in perineal care and when applying barrier cream. CNA A stated that she has not seen Resident #1 scratch herself in her perineal areas. CNA A states that Resident #1's movements are usually slow. Observation on [DATE] at 11:22 a.m., Resident #1's nails on both hands appear short and not sharp. Record review of Resident #1's advance directive acknowledgement, dated [DATE], revealed RP signed document. Review of incident reports, no date, revealed Resident #1 fall on [DATE] in that she slid off the side of her bed and fell to the floor. No injuries were noted at that time and pain level was 0. Review of Resident #1's hospital records, dated [DATE], revealed x-ray impressions indicating an age-indeterminate left inferior pubic fracture ramus fracture, new from previous CT. Review of Resident #1's physician orders, dated [DATE], revealed Monitor resident for pain every 4 hours. Assess for verbal and non-verbal cues. If resident is having signs or symptoms of pain, medicate with PRN Norco per order. Hold for signs or symptoms of over sedation and notify medical doctor (examples: increased drowsiness, respiratory changes). Review of Resident #1's MAR, no date, revealed Resident #1 received PRN Norco on [DATE] at 8:16 p.m. with a pain level at 7 and [DATE] at 2:48 p.m. with pain level at 6. Resident #1 received 2 doses on [DATE] at 10:00 a.m. and 3:38 p.m. with a pain level of 4 and 5 respectively. On [DATE] Resident#1 received 1 dose at 10:00 a.m. for a pain level of 6. Review of Resident #1's medical forensic assessment report, dated [DATE], revealed Resident #1 alert and oriented x1, unknown for penetration and ejaculation, top hip left buttocks approximately 5 liner abrasions-similar to scratch like appearance new per ADON, bottom left buttock small red circular abrasions with yellow to red bruising surrounding tender to touch new per ADON, and small abrasion to labia majora at about the 10 o'clock position no bleeding noted at the time of exam, and in follow up care DFPS mandatory if abuse suspected-yes. Review of Resident #1's psychiatric evaluation, dated [DATE], revealed a presumptive diagnosis of dementia, disorganized thinking, general appearance, and behavior as confused, orientation x1, intelligence unable to determine, anxious affect, and disorganized thought content. Review of Resident #1's psychosocial evaluation, dated [DATE], revealed impaired memory, cognitive/executive function not intact, and impaired judgement. Review of the facility's abuse and neglect policy, revised [DATE], revealed, Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Definitions 4. Sexual Abuse: non-consensual sexual contact of any type with a resident. C. Prevention 3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or anise preventionist within 24-hours of complaint. Appropriate notification to state and home office will be the responsibility of the administrator per policy. 4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising of resident, occurrences, patterns, and trends that may constitute abuse. All occurrences of potential abuse or criminal behavior will be investigated by the Abuse Preventionist and/or designee. E. Reporting 1. Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect, or exploitation must report this to the DON, administrator, state and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated persons. 2. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside normal business hours, the Abuse Preventionist or designee will be called. 3. Facility employees must report all allegation of: abuse. Neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated [DATE]. a. if the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. b. if the allegation does not involve abuse or serious bodily injury, the report must be made within 2 hours of the allegation. G. Protection The facility will take necessary measures to protect residents and employees from harm during and following an abuse, neglect, exploitation, mistreatment of residents of property investigation. Review of QAPI meeting, no date, completed for the facility's plan of removal-actions taken to remove the immediate jeopardy. An IJ (Immediate Jeopardy) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:14 p.m. to ADM and a Plan of Removal was requested. A Plan of Removal was first submitted by the ADM on [DATE] at 2:24 p.m.pm. The Plan of removal was accepted on [DATE] at 9:00 a.m. Plan of Removal Immediate Plan of Removal The facility submits this Plan of Removal to address the Immediate Jeopardy identified on [DATE]. Identification of Others Affected by Alleged Deficient Practice: All residents have the potential to be affected by this alleged deficient practice. Summary: Per the immediate jeopardy template, the facility failed to ensure the resident was free from abuse. Immediate Action Taken: 12. ADM/DON had alleged perpetrator removed from the facility on [DATE]. 13. The resident who was potentially assaulted was interviewed by ADM/DON for any emotion distress on [DATE]. 14. A head-to-toe assessment was performed on [DATE] by ADON 1 and ADON 2 for the resident who was potentially assaulted. No negative findings noted. 15. On [DATE], resident #1 had recent hospital visit to address the allegation of sexual abuse. 16. Resident 1 had psych service telehealth visit on [DATE] at 9:30 am. Resident 2 had psych service telehealth visit on [DATE] at 10:15 am. Resident 1 and 2 care plan updated as appropriate. 17. The ADM/DON/Social Worker interviewed other interviewable residents regarding any inappropriate behavior from residents or visitors on [DATE]. There were no negative findings found from interviews. To ensure non-interviewable residents are accounted for, skin assessments were performed on [DATE] by DON/ADON/MDS/Treatment Nurse/Charge nurses. There were no negative findings found from the skin assessments. 18. ADM/DON identified 65 residents with cognitive loss after reviewing the MDS' on [DATE]. 19. The ADM/DON/ADON interviewed all staff who have worked in the last 30 days regarding any observations of inappropriate/sexual behavior among resident, employees, visitors. No additional staff had observed or had concerns of inappropriate/sexual behavior. The 1 staff member who was the initial staff member made aware by resident #2, provided statement to ADM after allegation and investigation began on [DATE]. 20. The visitor entry door code has been changed by Maintenance Director on [DATE] so all staff can monitor who enters the facility. Visitors will only be allowed in by ringing doorbell and staff must open to allow entry. Visitors must sign in to include their name and who they are visiting. All facility staff are responsible for screening visitors, to include visitor name and resident visiting, prior to entry. ADM/DON/ADON inserviced all staff on [DATE] regarding new door policy. 21. ADM/DON/ADON inserviced all facility staff on [DATE] regarding visitor policy. 22. The ADM/DON/ADON began in-servicing on [DATE] for all staff. New hires will be inserviced at orientation. Facility does not utilize agency. Volunteers will be required to screen with any facility staff prior to entry. ADM inserviced Volunteers on [DATE] regarding Abuse/Neglect, Visitor Policy, and New Door Policy. On leave staff were in-service over phone by ADM on [DATE]. If staff are not present, they will be in-serviced prior to assuming their duties on their next scheduled shift regarding: o Abuse/Neglect Policy which includes sexual abuse/inappropriateness. Sexual abuse can occur from a resident, staff, or visitor. o If observed or reported: Separate the residents, staff, or visitors immediately. The alleged perpetrator will be asked to leave the facility. The ADM/DON inserviced all staff that the alleged perpetrator was removed from the facility due to a sexual abuse allegation. The in-service included the alleged perpetrator's name with directions to report to the ADM/DON immediately if seen in the facility. Inserviced performed on [DATE] Report any sexual abuse/inappropriateness to the administrator and DON immediately either in person or by speaking with them on the phone, including weekends. Law enforcement will be notified by ADM/DON im[TRUNCATED]