**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 2 (Residents #1 and Resident #2) of 6 residents reviewed for resident abuse. 1. The facility failed to ensure Resident #1 was free from verbal and physical abuse by the Assistant Dietary Manager. 2. The facility failed to ensure the Assistant Dietary Manager did not work in the facility even though Resident #1 was afraid of him. 3. The facility failed to protect Resident #2, who was unable to give consent for sexual activity, from sexual abuse after Resident #3 was discovered in her bed with Resident #2 on top of her by facility staff. 4. The facility failed to protect Resident #2 who was a prior victim of abuse and unable to give consent for sexual activity. 5. The facility failed to follow physician's orders for Resident #3 and ensure that Resident #3 had un-monitored access to Resident #2 from 07/06/2024 to 07/11/2024 to prevent possible repeated abuse. An Immediate Jeopardy (IJ) was identified on 08/08/24 at 5:00 PM and 08/09/24 at 5:00PM. The IJ template was provided to the facility on [DATE] at 5:44PM and 08/09/24 at 5:24PM and signed by the Administrator. While the IJ was removed on 08/12/2024 at 7:05PM, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. These failures placed residents at risk for serious injuries, abuse, and serious harm. Findings included: 1. Record Review of Resident #1's admission MDS Assessment, dated 05/19/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. He was cognitively intact. He did not have any behaviors. His diagnoses included stroke, heart failure, and hemiplegia (paralysis of one side of the body.) Review of Resident #1's Care Plans , not dated, reflected: Resident had a history of making false allegations/inaccurate statements as evidenced by previously accusing/stating: Makes up stories of falling, explained the same fall with different version to other nurses Interventions: If statements were determined to be inaccurate, staff will reorient and redirect as needed with reassurance and reality orientation. Listen openly to allegations/inaccurate statements and offer clarification as needed. Resident had potential to demonstrate verbally abusive behaviors related to ineffective coping skills, and poor impulse control. Interventions: Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess resident's coping skills and support system. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Evaluate for side effects of medications. Provide positive feedback for good behavior. Emphasize the positive aspects of compliance. Psychiatric/Psychogeriatric consult as indicated. Record review of Resident #1's Progress Notes, dated 06/15/24 at 7:20 pm reflected: Resident came to the nursing station to complain that he requested a double portion, but he was served with one portion of meal at dinner. He was offered another tray of dinner, but he refused and said that he was going downstairs. 7:26 PM Nurse was notified by the weekend supervisor that the resident wanted to go into the kitchen, but he was prevented from going in and he started altercation with the kitchen personnel. It was reported that the resident called the police. The resident came upstairs and said get my meds ready because I'm going out. Nurse had his medication prepared but the resident never came back to take his scheduled night medication. 8:15 PM A CNA came and told this nurse that the resident just left with his [family member] to the hospital. Note documented by LVN H. Review of Resident #1's Facility Self-Report dated 06/15/24 reflected: It was reported to Administrator on 6/15/24 that Resident #1 and the Assistant Dietary Manager had a verbal altercation. It was then reported to that the resident said that the Assistant Dietary Manager hit him in the chest. When the Administrator interviewed Resident #1 , he said the Assistant Dietary Manager also threw his walker and grabbed him by the throat. The Assistant Dietary Manager was interviewed and he denied ever putting a hand on the resident. The Administrator interviewed staff and residents that were in the dining room and kitchen when the altercation happened. In all of the Administrator interviews, everyone stated that they never saw the Assistant Dietary Manager put his hands on Resident #1. They also all said that it was the resident who was the aggressor, yelling and cursing at the kitchen staff. Investigation findings were unconfirmed because there was no witnesses that ever saw the Assistant Dietary Manager touch or hit the resident. In all interviews the witnesses stated Resident #1 was the aggressor and the one that was yelling and cursing. The Assistant Dietary Manager was allowed to come back to work from suspension. 1. Staff was in-serviced on abuse, neglect and dealing with aggressive behavior. 2. The Assistant Dietary Manager was allowed to return to work. 3. Resident #1 was presented a Behavior contract. Staff Witness Statements from the incident reflected: Resident #1 - The resident went to the kitchen to get double portions and the kitchen told him that they would send him another tray. He left and went back upstairs, and they could not find the tray. He came back downstairs and told them again that his tray was not up there. They told him that they would get him another tray once they finish with the other residents. He was standing in the door to the kitchen when he said the Assistant Dietary Manager came at him saying we are not going to do this Resident #1. Resident #1 then said that the Assistant Dietary Manager grabbed his walker and threw it about 10 feet. He then said that the Assistant Dietary Manager grabbed his neck and hit him in the chest. Resident #1 then stated that he took his shirt off to point at his chest that he had a pacemaker and then put his arms to his side and started saying that he did not touch anyone. Assistant Dietary Manager - Resident #1 was cursing at the cook about getting double portions. The Assistant Dietary Manager came to the door and asked the resident to not cuss at the employees. He stepped back into the kitchen and the resident called him a bitch. The Assistant Dietary Manager stated that he asked the resident, what you just said to me? The Assistant Dietary manager then said that he never put a hand on him. The Assistant Dietary Manager then stated that the resident tried to hit him but did not hit him. The resident then took his shirt off and started yelling that people were touching him. Dietary Aide I - He was working in the kitchen when Resident #1 came to the kitchen and was asking for more food. He stated that the resident started yelling at the cook and stating that he did not get double portions. The Dietary Aide I got the resident another plate and the resident still kept yelling at the staff. Dietary Aide I went and got the Assistant Dietary Manager to help with the resident, so they could finish the trays for the other residents. Dietary Aide I then said the Assistant Dietary Manager asked the resident to step out of the doorway to the kitchen. Resident #1 continued to yell and cuss at the Assistant Dietary Manager. The resident was getting more aggressive, and they tried to calm him down. Dietary Aide I stated that he never saw the Assistant Dietary Manager touch or hit Resident #1. Dietary Aide J - He stated that he never saw the Assistant Dietary Manager hit or touch Resident #1. He then stated that Resident #1 was the aggressor during the altercation. CNA K - see attached statement. (No statement attached.) Review of Resident #1's Hospital Records, dated 06/15/24, reflected the resident was an assault victim with a right chest wall contusion (bruise), neck strain, back strain, and contusion on his left ankle. There was no police report for 06/15/24. There was no facility incident report for 06/15/24. There was no resident assessment for 06/15/24. There was no trauma assessment for 06/15/24. The Surveyor requested the police report on 08/09/24 at 3:45 PM from the police department. An observation and interview with Resident #1 on 08/08/24 at 1:25 PM revealed he said he was assaulted on 06/15/24 by the Assistant Dietary Manager. He said he was supposed to get extra food and went down to get it and the Assistant Dietary Manager got in his face and threw his walker. He said it took 4-5 people to get the Assistant Dietary Manager off of the resident. Resident #1 said he was scared of him and did not feel comfortable eating food from him. The resident said he had bruises on his neck and chest on 06/15/24 and went to the hospital. He said they took images of his chest and pacemaker. He said the right side of his chest was still sore. The resident said he currently was ordering take-out food and his RP complained because it was $100/day. The resident said his food was almost always messed up. Resident showed the Surveyor a piece of over-cooked, dry bacon and said all three of his meals were messed up. The resident said he thought his walker was messed up because the Assistant Dietary Manager threw it. The resident said when he would go to the kitchen and see him, they whispered about him. The resident said he did not feel safe getting his food from the Assistant Dietary Manager. The Administrator walked over during the conversation and the resident showed the Administrator the piece of bacon. The Administrator said, ok and walked away. An interview on 08/09/24 at 1:15 PM with the RP for Resident #1 revealed he arrived to the facility on [DATE] and he saw that the resident had a large red mark on his right chest and shoulder. He said the police did a scene report. The RP said following the incident the resident was afraid to eat the facility food. He said he took the resident to the hospital. An interview on 08/08/24 at 1:15 PM with the Assistant Dietary Manager revealed on 06/15/24 an incident occurred. He said on Resident #1's tickets he was supposed to get large portions. The resident would say he did not get them, but he did. He said on 06/15/24, Resident #1 came to the kitchen and had a tray with him. The resident also had a tray upstairs, and a 3rd one that the cook had. The Assistant Dietary Manager said when saw the resident he was arguing with the cook even though he had 3 trays. The resident was riled up, cussing, and the Assistant Dietary Manager took the tray from the resident. The resident told him he was, nothing but a bitch anyway. The Assistant Dietary Manager said he turned around, walked back to the resident and asked what he said. He repeated, you're nothing but a bitch. The Assistant Dietary Manager told Resident #1 that he was not going to call him a bitch. The Assistant Manager said he was angry and yelling back at the resident and the other staff was trying to keep both him and the resident calm. The resident ran up on the Assistant Dietary Manager and changed his mind and moved back. The Assistant Dietary Manager said he raised his voice at the resident and Resident #1 called the police. The Assistant Dietary Manager said he told the resident he was not going to be threatening his staff. The Assistant Dietary Manager said there was another incident when the resident came to the kitchen, but when he saw the Assistant Dietary Manager, the resident left. He is a headache, and he is one of a kind. The Assistant Dietary Manager said he had been trained to de-escalate behaviors and that is why he stepped into the situation. He said he did not receive any disciplinary action but was suspended pending investigation. He said [NAME] L no longer worked at the facility and the Dietary Manager was off on 06/15/24. An interview on 08/08/24 at 1:35 PM with Dietary Aide J revealed he had worked at the facility for 2 months. He said on 06/15/24, he was washing the dishes and heard Resident #1 yelling and being mean to the staff. He said he went to the front and the Assistant Dietary Manager and the resident were cursing at each other and were in each other's face. Dietary Aide J aid it got to a point where the argument was dying down and then the resident called the Assistant Dietary manager a bitch. The resident started cursing at all of the kitchen staff and the Assistant Dietary Manager responded and got louder. The Assistant Dietary Manager was upset. He was standing in the doorway and they were close to each other. Dietary Aide J went to grab the resident and was told not to put his hands on him. Dietary Aide J stood by the resident's right shoulder and was facing the Assistant Dietary Manager to separate them. He said the Assistant Dietary Manager did not calm the situation, and he did not see them touch each other. Dietary Aide J said the Assistant Dietary Manager should have calmed down and let the situation go because the resident was about to leave by himself. The resident had a history of lashing out and then walking away. The police showed up 15 minutes later and the Assistant Dietary Manager left for the day. Dietary Aide J said he had to sign a paper but did not receive any in-services following the incident. An interview on 08/08/24 at 3:00 PM with CNA K revealed she had worked at the facility since 2022. She said on 06/15/24 Resident #1 got his tray and he said he did not get double portions. [NAME] L looked at his tray and said that he did receive double portions. The Assistant Dietary Manager came in and told the resident to step out of the kitchen. Resident #1 called the Assistant Dietary Manager the N word and stupid. The Assistant Dietary Manager was standing in the door of the kitchen. Resident #1 said he would slap the fuck out of the Assistant Dietary Manager. CNA K said she told the resident to come to her and to wait for his tray. Resident #1 reached across CNA K and tried to punch the Assistant Dietary Manager. CNA K said she told the Assistant Dietary Manager to back off and to walk away. CNA K said she got the tray for Resident #1. CNA K said the Assistant Dietary Manager escalated the situation and that she had to step in between them and back up Resident #1 from the Assistant Dietary Manager. She said the Assistant Dietary Manager should have walked away. An interview on 08/12/24 at 2:30 PM with LVN H revealed she was the nurse for Resident #1 on 06/15/24. She said she was told there was an incident in the kitchen and dining room and that Resident #1 went in the kitchen and was insulting staff and calling them names. She said the LVN Weekend Supervisor was handling the situation. She said when the resident came back to her following the altercation he said he needed to get his medications. Resident told her that he went to the kitchen to get food and he was attacked and insulted by staff. LVN H said she did not know if anyone attacked him because he was always making up stories. She said the resident told her he went to the hospital, but she did not assess him before he left or when he got back. She said the resident was wearing a shirt. She said she did not believe that anyone attacked him and she did not know why he was a resident in the facility. She said she did not complete an incident report because she was not there when it happened. An interview on 08/12/24 at 4:15 PM with the LVN Weekend Supervisor revealed she did not work the weekend of 06/15/24. An interview on 08/08/24 at 3:20 PM with the Psychiatrist NP revealed she had been seeing Resident #1 for a couple of months. She said he spoke to her about the incident on 06/15/24 where he was confronted by the kitchen staff for wanting food. Resident #1 said that his friend had been providing him money so that he did not have to eat at the facility. He said he did not trust the food the kitchen gave him. An interview on 08/08/24 at 2:10 PM with the Administrator revealed on 06/15/24, he got a call the afternoon or evening that the Assistant Dietary Manager and the Resident #1 had the altercation. He said when he arrived, the police were wrapping up their investigation and gave him the police report number. The Administrator said he did not get the police report. He said Resident #1 left the facility with his friend. The Administrator said he interviewed the staff in the dining room and interviewed the resident when he came back. The Administrator called the Assistant Dietary Manager and suspended him. The Administrator said he found in his interviews with staff the common denominator was that Resident #1 was the aggressor. He was loud and arguing with the cook and he did not feel he got double portions. He kept trying to go in the kitchen with his walker. He said the staff got the Assistant Dietary Manager and asked him to please not go in the kitchen. Resident #1 yelled more and took his shirt off and thought he was ready to fight the Assistant Dietary Manager. The Administrator said staff did not see the Assistant Dietary Manager touch Resident #1. Resident #1 said he took his shirt off and said he had a pacemaker. The Assistant Dietary Manager denied throwing the walker and no one observed him throw the walker. Resident #1 said he was going to the hospital to have his pacemaker checked out, but he did not know if he actually went to the hospital. The Administrator said staff were supposed to de-escalate situations and re-direct residents and remove them form the situation. The Administrator said staff were not supposed to yell at residents and staff had to separate the Assistant Dietary Manager and Resident #1, because Resident #1 was being aggressive. He said he suspended the Assistant Dietary Manager but felt the Assistant Dietary Manager handled the situation appropriately. The Administrator said the resident said he was going to the hospital, but he did not think he went. An interview on 08/09/24 at 2:50 PM with the Medical Director revealed Resident #1 was his resident. He said he knew the resident had frequent altercations and was only aware of the resident's most recent hospitalization on 06/20/24. He said he did not know what the hospital records for 06/15/24 said. He said he did not expect the facility to do an assessment on the resident following the incident on 06/15/24 if they did not know he went to the hospital. He said maybe the resident got the bruise if he went out earlier in the day. He said he did not find the facility was at fault and had no proof that a physical altercation occurred. He said he did not expect that the facility would have done a more thorough investigation if they did not know he went to the hospital. An interview was attempted on 08/12/24 at 6:19 PM with Dietary Aide I, but he did not return the call of the surveyor. Record review of the facility's policy, Abuse Prevention and Prohibition Program, revised 10/24/22, reflected: I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Administrator was notified of the Immediate Jeopardy on 08/09/24 at 5:24PM due to the above failures and provided the IJ template to Corporate DON. A Plan of Removal was requested. The facility's plan of removal was accepted on 08/08/24 at 5:40 PM and included the following: 1. The administrator submitted a self-report to HHSC regarding the incident on 6/15/2024. Intake #511237 2. Attending Physician for involved resident was notified of the incident by the nurse on 8/9/2024. 3. On 8/9/2024, Attending Physician was notified of medical records received on 8/9/24. 4. Director of nursing conducted a trauma assessment with male resident on 8/10/24 , trauma assessment finding was normal. If assessment was abnormal, physician would be notified and EMR updated to reflect interventions. 5. Assistant Dietary Manager was immediately suspended on 6/15/24. 6. The affected resident went to the hospital for assessment and evaluation 06/15/2024. 7. Witness statements were obtained by the Administrator 06/15/2024. 8. Witnesses involved were reinterviewed on 8/8/24 and 8/10/24 9. Safe surveys (series of questions for residents to identify possible Abuse/Neglect) were completed by Social Worker and other Facility management staff with interview able residents on 6/17/24 and 8/9/24, 8/10/24. The non interviewable resident received a complete head to toe assessment on 8/11/2024. Any negative findings were immediately investigated, physician and responsible party notified and EMR with interventions. 10. The affected resident was referred to [psych hospital] for psychological assessment and to be picked up on services if needed on 8/9/2024. 11. Assistant Dietary Manager employment with the facility has been terminated on 8/8/2024 12. Staff re-educated on abuse/neglect and how to deescalate and respond to any incidents involving residents/staff or any alleged perpetrators on 08/08/2024 13. Staff re-educated on how to respond with incidents involving staff to resident inappropriate behaviors on 08/09/2024. 14. Resident EMR was updated to include scanned hospital records on 8/9/24 15. Resident care plan was updated on 8/10/24 16. Resident Medical DX was updated 8/10/24 17. Facility Administrator was terminated effective 8/10/2024 In-Service conducted Administrator and Director of Nursing (after re-educated below) re-educated facility staff on: 1. On 8/9/24 Director of Nursing and Administrator were re-educated by Regional Director of Operations on Abuse & Neglect Policy, verbal, physical, sexual abuse and implementation of appropriate interventions to ensure residents are not afraid and feel safe. Administrator and DON were also re-educated on de-escalation of residents with behaviors. 2. Staff in-service was initiated on 8/9/24. Staff members are being re-educated to report all allegations of abuse immediately upon notification to the Administrator who is the abuse coordinator. Re-education has an emphasis on de-escalation of residents with behaviors according to policy and resident safety with emphasis on creating an environment where residents do not feel afraid. Staff will complete an Abuse & Neglect competency posttest at time of in-servicing. 3. Staff are being re-educated by the Director of Nursing on 08/09/2024 to recognize signs of a resident being abused and early recognition of residents that do not feel safe. All such suspicions must immediately be reported to the Administrator or Director of Nursing. 4. Staff were re-educated by the administrator/Director of Nursing or designee on de-escalation techniques when working with residents on 8/9/2024. 5. Staff were re-educated by the administrator/Director of Nursing or designee on de-escalation techniques including employees and residents involving inappropriate behaviors on 8/9/2024. 6. Facility nurses were re-educated 8/9/2024 to ensure residents are assessed and incident reports are completed following abuse allegations. 7. Facility staff were also re-educated by the administrator on implementation of interventions to ensure resident safety. Re-education was initiated on 8/9/2024. 8. The expected completion date will be 8/10/2024. Staff who have not been trained on Abuse & Neglect/ De-escalation will not be allowed to work until they have completed required in-services. 9. An interim administrator has been appointed and will start 8/12/2024. He will be educated on this Plan of removal and facility Abuse and neglect policy before he starts functioning as the facility administrator. Once a permanent facility Administrator is appointed, they will also be educated on this Plan of removal and the facility Abuse and Neglect policy. Implementation of Changes Staff will immediately inform the Administrator or Director of Nursing immediately when made aware of any abuse allegation. The administrator or director of nursing will ensure implementation of interventions for resident safety. A quick reference sheet of interventions has also been provided to staff and posted at the nurse's station. Alleged perpetrators will immediately be placed on one-on-one monitoring pending investigation and physician direction. If Alleged perpetrator is a staff member, Administrator, Director of Nursing or designee will immediately suspend perpetrator and will be asked to leave the facility immediately. All staff identified as an alleged perpetrator cannot return to work until approved by Regional Director of Operations or designee. The victim will be immediately assessed for injury, safety awareness, physician notification and continue to be monitored pending investigation and physician direction. Victim's Medical records will be updated to reflect any changes as needed. In the absence of the Administrator abuse allegations will be reported to the Director of Nursing. All allegations and incidents will be reviewed to the daily IDT team meeting to review for resident assessment and completion of an incident report. The Regional Director of Operations and Regional Nurse Consultant will be responsible for implementation of the process and will review the process weekly X3 months by reviewing safe surveys, grievance forms and staff interviews. Weekly review will be documented on Abuse Coordinator Review Log. Monitoring 1. Administrator/DON or designee will complete daily reviews of each incident to make sure residents are assessed, incident reports are completed, and interventions are put in place during daily IDT meetings. 2. Social worker/RN Supervisor will complete five safe surveys per day for two weeks then one per day for one month on interviewable residents to ensure safety X2 months. 3. 5 Non interviewable residents will receive a head-to-toe physical assessment daily for two weeks then one per week X2 months. 4. The administrator and Director of Nursing will interview five staff members per day for two weeks then one staff member per day for one month for return demonstration for types of abuse and reporting requirements and appropriate interventions. Findings will be documented on Abuse & Neglect monitoring form X2 months. 5. The facility Administrator/DON or designee will conduct random employee surveys on de-escalation daily x2 weeks, weekly x2 then monthly thereafter. 6. RDO and RNC will review and monitor all allegations and incidents for propriate implementation of interventions x4 months. 7. RDO or RNC will review grievances weekly which are in the facility grievance binder for three months to monitor for appropriate interventions x4 months. 8. Any adverse outcomes will be reported to the monthly QAPI Committee meeting with the Medical Director. Involvement of Medical Director The Medical Director was notified about the immediate Jeopardy on 8/9/2024. Involvement of QA On August 9th, 2024 an Ad Hoc QAPI meeting was held with the facility administrator, medical director, director of nursing, and social services director to review the plan of removal. Who is responsible for the implementation of the process? The Regional Director of Operations and Regional Nurse consultant will be responsible for the implementation of the new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 8/9/2024. The facility's implementation of the IJ Plan of Removal was verified on 08/12/24 through the following: Record reviews of the Facility in-services started on 08/08/24 through 08/12/24 reflected in-services were given to over 50 employees prior to the start of their shift. The in-services included information on abuse and neglect, de-escalation of behaviors, keeping incidents to only a small number of people, speaking calmly during situations, protecting the resident, and validating the resident's concerns. Safe surveys, staff post-tests, the reference sheet of quick interventions posted at each nurse's station, and Resident #1's updated care plan and diagnosis list was reviewed. An interview on 08/12/24 at 4:50 PM with Resident #1 and his RP revealed he was happy that the Assistant Dietary Manager and Administrator were no longer working at the facility. He said it would take time for him to feel comfortable again. An interview with the Regional Director of Operations on 08/12/24 at 7:00 PM revealed LVN H, the Assistant Dietary Manager, and the Administrator were terminated from employment. Interviews on 08/12/24 from 11:05 AM to 7:00 PM with 16 staff from all shifts (Cook M, Dietary Manager, Dietary Aide N, CNA O, CNA P, CNA Q, CNA U, CNA R, CNA S, CNA T, LVN U, LVN V, LVN W, RN X, RN Y, and LVN Z) revealed they were in-serviced on the facility's abuse policy, types of abuse, de-escalation of behaviors, when to report abuse, who to report abuse to, how to protect a resident during an abusive situation, and what to do if a resident reported they did not feel safe. The staff acknowledged that they received the in-services said they also took a post-test. An interview with the DON on 08/12/24 at 5:45 PM revealed his role in the Plan of Removal was to participate in all interventions for problems identified. He would be implementing interventions, educating staff, care planning, documentation, and notification. He said he had spoken with the staff and explained that they were there to help the residents and not think of them as problems. He said he was teaching the staff to listen to resident concerns and address them. The DON said he would complete daily reviews of each incident to make sure residents were assessed, incident reports were completed, and interventions were put in place. The DON said he or the Administrator would interview five staff members per day for two weeks then one staff member per day for one month for return demonstration for types of abuse and reporting requirements and appropriate interventions. Findings would be documented on Abuse & Neglect monitoring form X2 months. The DON said all incidents were reported to him so he could confirm proper steps were taken and followed. He said he read the 24-hour report daily to ensure no issues were missed with IDT. He said his plan for Resident #1 was to visit him daily. The DON said failure to follow abuse and neglect policies and failure to do investigations could put the resident's life in danger. An interview on 08/12/24 at 6:45 PM with the Interim Administrator revealed it was his first day as Administrator. He said his role in the POR was to be the Abuse Coordinator. He said he would make sure all in-services and all allegations were reported to him. If a resident[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of resident's, establish policies and procedures to investigate any such allegations for two (Residents #2 and #1) of eight residents reviewed for abuse. The facility failed to implement their abuse, neglect, and exploitation policy to ensure Resident #2 was safe from sexual abuse when Resident #3 was found by facility staff in her bed on 07/06/2024. The facility failed to follow their policy by not initiating criminal sexual abuse procedures when Resident #2 lacked the decision-making capacity to consent to a sexual act. The facility failed to contact law enforcement for further direction on the incident, after the incident occurred. The facility failed to implement their abuse, neglect, and exploitation policy to ensure Resident #1 was free from verbal and physical abuse by the Assistant Dietary Manager. The failed to conduct a thorough investigation for Resident #1's allegation of abuse. An Immediate Jeopardy (IJ) was identified on 08/08/24 at 5:00 PM and on 08/09/24 at 5:00 PM . The IJ template was provided to the facility on [DATE] at 5:44PM and on 08/09/24 at 5:24 PM and signed by the Administrator. While the IJ was removed on 08/12/2024 at 7:05PM, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. These failures could place all residents at risk for victimization, abuse, and psychosocial harm. Findings Include: Record Review of the facility's policy titled, Abuse Prevention and Prohibition Program revealed a date of 10/24/2022. Facility policy revealed that, the facility will treat allegations as criminal sexual abuse wherein the facility determines that the resident does not have the decision-making capacity to consent to the sexual act. The proper authorities and individuals are notified immediately or within two hours including but not limited to . law enforcement. The resident is provided with the medical treatment and emotional support necessary to prevent further deterioration of his/her health and wellbeing. The resident is transported to the hospital or other destination as instructed by law enforcement. Record Review of the facility's policy revealed a section titled, Prevention. This section revealed that, The facility conducts an ongoing review an analysis of abuse incidents and implements corrective actions to prevent future occurrences of abuse Resident assessments and Care Planning are preformed to monitor resident needs. Record Review of Resident #2's Quarterly MDS assessment with an ARD of 05/24/2024 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2 diagnoses included: Alzheimer's Disease, Age-Related Physical Debility, and Alcohol Abuse. Resident #2 had a BIMS score of 11 indicating a moderately impaired cognition. Resident #2 had disorganized thinking and no potential indicators of psychosis but did have a behavioral presence of wandering. Record Review of Resident #2's Comprehensive Care Plan, dated 08/08/2024, revealed the following: Focus- [Resident #2] had impaired cognitive function/dementia or impaired thought processes r/t Dementia. Goal- [Resident #2] will develop skills to cope with cognitive decline and maintain safety by the review date. Interventions/Tasks- [Resident #2] needs assistance with all decision making. Focus- [Resident #2] has a communication problem. Goal- [Resident #2] will be able to make basic needs known on a daily basis through the review date. Interventions/Tasks- Anticipate and meet needs, focus on a word, or phrase that makes sense, or responds to the feeling resident is trying to express. Record Review of Resident #2's comprehensive care plan did not reveal any alternations or interventions that were put into place for Resident #2 after the incidents occurred on 07/06/2024 and 04/25/2024. Record Review of Resident #3's admission MDS with an ARD of 06/26/2024 revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #3's diagnoses included: Alcohol Dependence with Withdrawal, Unspecified Tremors and Generalized Muscle Weakness. Resident #3 had a BIMS score of 14 indicating no cognitive impairment. Resident #3 had no potential indicators of psychosis or wandering. Record review of the facility's investigation report, dated 07/14/2024, revealed that the incident occurred on 07/06/2024 at 10:30 pm between two facility resident's, Resident #2 and Resident #3. Witness statements revealed that LVN A was completing her rounds when she witnessed Resident #2 on top of Resident #3. LVN A left the room and got LVN B as a witness to return to the room. Upon return to Resident #2's room, LVN A and LVN B revealed that they saw Resident #3 sitting on the side of Resident #2's bed. Resident #3 proceeded to get up from the bed, pulled up his pants, and fastened his belt. Facility investigation report revealed that Resident #3 had the capacity to make informed decisions. The facility did not indicate if Resident #2 had the capacity to make informed decisions. Provider response from the facility's investigation report revealed that the facility separated both residents and Resident #3 was asked to return to his room. A head-to-toe assessment was attempted but declined by Resident #2. MD, Family (did not indicate who), and facility Ombudsman were notified, safe survey rounds were completed by the facility. Facility investigation findings revealed the facility was unable to substantiate the findings. The facility concluded that Resident #3 was discharged to the community on 07/10/2024 and that the facility will continue to support Resident #2. Facility investigation report revealed that the local law enforcement was not notified and Resident #2 was not sent out to the hospital for a SANE (Sexual Assault Nurse Examination) at any time during or at the conclusion of the investigation. Record review of document titled, [Facility Name] Incidents by Incident Type dated for 08/08/2024 revealed that an incident report was initiated by the facility on 07/06/2024 for Resident #2, but not for Resident #3. Incident report for Resident #2 revealed a date of 07/06/2024 at 9:56 PM and incident category of , Other Incidents. Incident report for Resident #2 revealed to be crossed out which indicated the incident report to be deleted. Review of document revealed no other incident report initiated for Resident #2. Record review of a document titled, Progress Notes with a date of 07/07/2024, revealed that the nurse was going for her ward rounds during shift change and entered Resident #2's room where she observed Resident #2 and a male resident in a sexual position. The incident at that time was reported to the DON, Administrator, and Weekend Supervisor. Resident #2's sons were notified, and a message was left. Resident #2's NP (Nurse Practioner) was notified. Record review of a document titled, Progress Note, dated for 07/07/2024 revealed that Resident #2 refused a skin assessment to be performed. Record review of a document titled, Progress Note, dated for 07/08/2024 revealed that Resident #2 refused a skin assessment to be performed. Record review of Resident #2's document titled, Progress Note, dated for 07/09/2024 revealed that labs were ordered. Resident #2 continued to attempt to go downstairs via elevator, staff continued to re-direct and educate. Record review of a document titled, Trauma Screen, dated for 07/08/2024 revealed that Resident #2 did not reveal any signs of trauma after the incident. The document revealed that during the trauma screen interview Resident #2, laughed anxiously when [she was] asked about the incident that occurred on Saturday. Record review of a document titled, Psychiatric Subsequent Assessment revealed a date of Service of 07/22/2024 for Resident #2. Document revealed the reason for the referral [for psychiatry services] was anxiety and worrying and the chief complaint was possible abuse. Document revealed that staff witnessed Resident #2 in an intimate position with another resident. Mental Status Examination revealed that Resident #2's thought process was illogical, associations and thought content was unable to be assessed as Resident #2 was non-verbal. Resident #2's insight and judgement were both poor. Record Review of Resident #3's document titled, Nurse Administration Record revealed an order that stated, Resident to be on one on one observation, every shift for observation. Order start date 07/06/24 at 2301 and D/C (Discontinue) date of 07/17/24 at 0913. Interview with LVN A on 08/10/2024 at 3:12PM revealed that she was the nurse for Resident #2 on 07/06/2024. LVN A revealed that she walked into Resident #2's room and observed Resident #2 on top of Resident #3 in bed. LVN A revealed that she did not witness penetration as there was not enough light in the room. LVN A revealed that she alerted LVN B for a witness. LVN A revealed that they both saw Resident #3 pulling up his pants and fastening his zipper while still in Resident #2's room. LVN A revealed that Resident #3 exited Resident #2's room and she alerted the Weekend Supervisor of the incident. LVN A revealed that Resident #2 was placed on every 15-minute checks but was unaware there was not a physician order or alternation to Resident #2's plan of care. LVN A revealed that Resident #2 did not have the capacity to consent, and wandered constantly, but was easily re-directed. Interview with LVN B on 08/06/2024 at 1:14 PM revealed that she was the nurse for Resident #2 on 07/06/2024. LVN B revealed that she did not witness Resident #3 enter Resident #2's room. She revealed that LVN A alerted her during her rounds that she discovered Resident #2 on top of Resident #3. When she arrived to the room, she saw Resident #3 with his shirt unbuttoned, belt unbuckled and pants unbuttoned. LVN B revealed she alerted the Weekend Supervisor who alerted the Administrator. LVN B stated that Resident #2 was started on every 15- minute checks but could not state if Resident #3 began any enhanced monitoring that night. LVN B revealed that this behavior for Resident #2 was off her baseline. LVN B revealed that Resident #2 did not have the capacity to consent. LVN B revealed that Resident #3 resided on the first floor of the facility and Resident #2 resided on the second floor of the facility . LVN B revealed that residents had access to utilize the elevator from top to bottom floor at any time of the day and night without restriction. Interview with LVN C on 08/12/2024 at 11:34 AM revealed that she was the nurse for Resident #3 on 07/07/2024 from 6AM-10PM. LVN C was unsure why the one-on-one monitoring order did not start the night the incident occurred as per the NAR the order started on 07/06/24. LVN C revealed she did sign off on the one-to-one monitoring order, but no staff member was continuously monitoring Resident #3. LVN C revealed she and her CNA had other resident's they had to take care of and attend to their needs. LVN C revealed she did observe Resident #3 throughout her shift as she could. LVN C was unable to reveal documentation for Resident #3's location during her assigned shifts or reveal if Resident #3 had access to Resident #2 during her assigned shifts. LVN C revealed that residents did have access to utilize the elevator from top to bottom floor at any time of the day and night without restriction. Interview with RN D on 08/12/2024 at 3:42 PM revealed that she was the nurse for Resident #3 on 07/08/24, 07/09/24 and 07/10/24. RN D revealed that she was aware the order stated one-to-one monitoring and she signed off on the order during those shifts but revealed that Resident #3 was not on one-to-one monitoring during that time. RN D revealed that herself and her CNA had other resident's assigned to them during those shifts and were unable to perform one to one monitoring for Resident #3 and attend to the other resident's' needs. RN D did not reveal if she alerted the DON or physician of their inability to meet Resident #3's needs per the physician's order. RN D revealed that every time Resident #3 was in the hallway, she would monitor him. RN D was unable to reveal documentation for Resident #3's location during her assigned shifts or reveal if Resident #3 had access to Resident #2 during her assigned shifts. RN D revealed that resident's did have access to utilize elevators from the top to bottom floor at any time of the day and night without restriction. RN D revealed a risk of not following physicians' orders would be enlarging an issue already present for that resident. Interview with RN E on 08/09/2024 at 4:00 PM revealed that she was the nurse for Resident #3 on 07/07/2024 during the 10PM-6AM shift as indicated on Resident #3's MAR. RN E revealed that she did sign off on the one-to-one monitoring order, and that she and her CNA had multiple resident's that night and were unable to monitor the resident on a one-to-one basis throughout the shift. RN E did not reveal if she alerted the DON or physician of their inability to meet Resident #3's needs per the physician's order. RN E revealed she did check on Resident #3 periodically throughout her shift. RN E was unable to reveal documentation for Resident #3's location during her assigned shifts or reveal if Resident #3 had access to Resident #2 during her assigned shifts. RN E stated she was unaware of what the one-to-one order constituted. RN E revealed that resident's had access to utilize the elevator from the top to bottom floor at any time of the day and night without restriction. Interview with LVN F on 8/12/2024 at 10:00 AM revealed that she did not remember Resident #3 or signing off on the one-to-one monitoring order. LVN F revealed that she did not remember having a resident on any type of enhanced monitoring. LVN F revealed she never worked with just one resident before or seen any other staff member be assigned to just one resident for enhanced monitoring. LVN F revealed that resident's had access to utilize the elevator from the top to bottom floor at any time of the day and night without restriction. Interview with the LVN Weekend Supervisor on 08/08/2024 at 12:49 PM revealed that she was the nurse supervisor on the weekends for the facility. The LVN Weekend Supervisor revealed that she was alerted by LVN A and B that Resident #2 and Resident #3 were caught having intercourse. The LVN Weekend Supervisor revealed that no staff member witnessed penetration since the room was dark at the time of discovery. Resident #3 left Resident #2's room independently but reported to staff that Resident #2 wanted to go with him to his room. The LVN Weekend Supervisor revealed she was unaware if Resident #3 was placed on enhanced monitoring on 07/06/2024 and could not remember receiving an order from the medical director for enhanced monitoring. The LVN Weekend Supervisor revealed that Resident #2's cognition varies and she had severe deficits in her short-term memory. Interview with RP #1 on 08/08/2024 at 10:25 am revealed that she was aware of the incident that occurred between Resident #2 and Resident #3. RP #1 revealed that she was told by staff that Resident #2 was found in bed with a male resident. RP #1 revealed that she was shocked by the event as that was not like Resident #2's baseline behavior. RP #1 revealed that she visited Resident #2 the next day, 07/07/2024 and Resident #2 did not reveal any physical markings or changes in behavior. RP #1 revealed that she was unaware Resident #2 refused to go to the hospital after the incident occurred for further examination and was not aware Resident #2 refused head-to-toe assessments after the incident occurred. RP #1 revealed she requested the facility to ensure that Resident #2 had no more contact with Resident #3. RP #1 revealed she was unsure what interventions were put into place or what the outcome of the facility investigation was. RP #1 was aware that Resident #3 discharged from the facility. RP #1 was unaware of what interventions were put into place to prevent repeated victimization of Resident #2. RP#1 revealed she was aware of the incident that occurred on 04/25/24 between Resident #2 and a male staff member, but was not aware of any interventions that were put into place to protect Resident #2 from further victimization. RP #1 revealed she was aware Resident #2 has been on psychiatric services, admission date to psychiatric services unknown by RP #1. Interview with RP #2 on 08/08/2024 at 10:50 am revealed that he was the Power of Attorney for Resident #2. RP #2 revealed that he was unaware of the incident that occurred between Resident #2 and Resident #3. RP #2 revealed that he was alerted of the incident back in April of 2024 between Resident #2 and a male staff member. RP #2 revealed that he was unsure of what interventions were put into place to prevent repeated victimization of Resident #2. RP #2 revealed that he would defer to Resident #2's medical team to determine Resident #2's decision making abilities and abilities to consent. RP #2 revealed he was not alerted by the facility that Resident #2 refused to go to the hospital or refused head-to-toe assessments. RP #2 revealed that he was unaware that the facility investigated the incident or what the outcome of the investigation was. Interview with NP #4 on 08/08/2024 at 3:22 PM revealed that she had been the Psychiatric Nurse Practitioner for Resident #2 for a year and half. NP #4 revealed that she worked with the facility and Resident #2 for medication management related to her behaviors. NP #4 revealed that she was alerted by the facility of the event that occurred between Resident #2 and Resident #3 and the facility requested an updated evaluation. NP #4 revealed that there were no medication adjustments performed or changes in behaviors for Resident #2 after the incident. NP #4 revealed that Resident #2 reacted impulsively, is not aware of the potential consequences related to her actions, and lacks the foresight to make safe and sound decisions. NP #4 was not aware of any interventions that the facility took after the incident occurred for Resident #2. NP #4 revealed that she was not referred for services for Resident #3 and was not familiar with his care. Interview with MD G on 08/12/2024 at 9:10 AM revealed that she had been the attending physician for Resident #2 for two years. MD G revealed that she was alerted of the incident between Resident #2 and Resident #3 by the Administrator. MD G revealed the Administrator stated to her that Resident #2 and Resident #3 were found engaging in a sexual act, but no penetration was confirmed. MD G revealed after the incident she ordered labs and requested psych services for Resident #2. MD G revealed she did not order for Resident #2 to go to the hospital for a SANE. MD G revealed she could not remember if she did order enhanced monitoring for Resident #2 after the incident, but it was her expectation of the facility to contact her or her Nurse Practitioner to receive an order for any type of enhanced monitoring before initiating. MD G revealed she was unaware the facility initiated enhanced monitoring for Resident #2 without a physician's order. MD G revealed it is her expectation of the facility to call her or her Nurse Practioner for any changes or alterations in their resident's plan of care. MD G revealed that she spoke with the facility's psych provider for Resident #2 and confirms that Resident #2 does not have the capacity to consent or make safe and sound decisions independently. MD G revealed she did not discuss with the facility after the incident occurred about resident #2's ability to consent. Interview with the Facility Social Worker on 08/08/2024 at 11:27 AM revealed that she was alerted of the incident between Resident #2 and Resident #3 on the Monday following the incident as the incident occurred on a weekend. The Social Worker revealed that she interviewed Resident #2 on 07/08/24 to conduct a trauma informed screening. She revealed that Resident #2 had no alternations in behavior or physical markings after the incident. She revealed that Resident #2 had no signs of trauma, but she did indicate in the trauma screening that Resident #2 had anxious responses when asked about the incident. She revealed that Resident #2 stated, they only kissed and did not want to discuss the incident anymore. The Social Worker revealed she interviewed Resident #3 and he stated to the Social Worker that he was in love with Resident #2. The Social Worker revealed that she believed that Resident #2's cognitive and judgement abilities are related to the situation. The Social Worker confirmed that Resident #2 was on continued psychiatry and psychology services. The Social Worker revealed that she was unsure of what interventions were put into place for Resident #2 or Resident #3 after the incident occurred. She revealed that Resident #3 was issued a NOMNC (Notice of Medicare Non-Coverage) for a discharge date of 07/10/2024 based on his therapy progress. The Social Worker revealed that Resident #2 was in a similar incident back in April 2024 with a male staff member. The male staff member was terminated from the facility and the facility's investigation revealed that the male staff member kissed the resident. The Social Worker could not reveal any interventions or alterations that were put into place for Resident #2 to prevent repeated victimization after this incident. Interview with the DON on 08/12/2024 at 5:47 PM revealed that he was alerted of the incident between Resident #2 and Resident #3 on 07/06/2024 by facility staff. The DON revealed that he was alerted that Resident #2 was found on top of Resident #3, there was no evidence of penetration, but suspicion of a sexual position. The DON revealed that Resident #2 and Resident #3 were separated from one another and both resident's were placed on enhanced monitoring. The DON revealed that Resident #2 was not sent out to the hospital for further examination or law enforcement was not contacted as there were no indicators of sexual coercion or force. The DON revealed that Resident #2 was in a similar incident back in April 2024 with a male staff member. The male staff member was terminated from the facility and the facility's investigation revealed that the male staff member kissed the resident. The DON could not reveal any interventions or alterations that were put into place for Resident #2 to prevent repeated victimization after this incident. The DON revealed that it was his expectation that the nursing staff would reach out to the physician for orders and direction after an incident involving possible sexual abuse occurs. The DON revealed that facility staff did not reach out to MD G for enhanced monitoring orders, but instead used nursing judgement. The DON revealed that he was unsure why Resident #3's orders were for one-to-one monitoring every shift as he was certain they were for Every 15-minute checks. The DON revealed he was unaware the nursing staff for Resident #3 was not executing the orders as written and ordered by the Medical Director. The DON revealed that he was unsure if Resident #2 and Resident #3 had contact with one another due to the order not being executed per physicians' orders. The DON revealed that there was not an additional staff member assigned to Resident #3 for one-to-one monitoring as he thought the orders were for 15-minute checks, which he revealed could be completed without an additional staffed nurse or CNA (Certified Nursing Assistant). The DON revealed that it was his expectation for staff, when, executing a one-to-one monitoring order, that the resident would be kept in proximity of that assigned staff member at all times during the duration directed in the order. The DON revealed that he was unsure why Resident #2's care plan did not reveal any alterations or interventions that were put into place after this incident and the incident that occurred on 04/25/2024 with a male staff member. The DON revealed risks for not following physicians' orders would be inadequate care delivery. Interview with the Administrator on 08/08/2024 at 2:20 PM revealed that he was first alerted of the incident on 07/06/2024 by LVN Weekend Supervisor that Resident #2 was caught in bed with Resident #3. There was an assumption of intercourse at that time, but the Administrator revealed that they only kissed based on the facility investigation. The Administrator revealed that the two residents were separated after the incident and placed on enhanced monitoring but was unsure if the physician gave the order for enhanced monitoring for either resident. Resident #2's [family members] were contacted after the incident occurred. The Administrator revealed he reported the incident to the state survey agency but did not contact law enforcement as he viewed the incident as consensual between both residents. The Administrator revealed that Resident #2 refused head to toe assessments and she was not sent out to the hospital for further examination as the incident was considered consensual. The Administrator was asked on what basis he believed the event was consensual between the two residents given MD G and NP #4's statements, the Administrator revealed it was in his opinion that Resident #2 had the ability to consent. The Administrator revealed that Resident #2 was in a similar incident back in April 2024 with a male staff member. The male staff member was terminated from the facility and the facility's investigation revealed that the male staff member kissed the resident. The Administrator could not reveal any interventions or alterations that were put into place for Resident #2 to prevent repeated victimization after this incident. The Administrator revealed that this sexual behavior for Resident #2 was typical of her baseline and labeled Resident #2 as hypersexual. The Administrator was asked on what basis of information did he conclude that Resident #2 was hyper-sexual, he directed the surveyor back to NP #4. The Administrator revealed that Resident #3 was discharged from the facility on 07/11/2024. The Administrator did not give any risks for not executing physicians' orders properly or risks for not identifying or alternating resident's plan of care after incidents of victimization occur. On 08/08/2024 at 5:44PM an Immediate Jeopardy (IJ) was identified. The Administrator and Director of Nursing was notified. The Administrator was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. The facility's Plan of Removal was accepted on 08/11/2024 at 4:34 PM and included: 1. Administrator submitted a self-report to HHSC regarding the incident on 7/6/24 Intake #516319 2. Attending Physician for involved residents was notified of the incident on 7/6/24. 3. Social Worker conducted a trauma assessment with female resident on 7/8/24. 4. Male resident was placed on 1:1 monitoring by facility staff 7/6/24. 5. Male resident has been discharged from facility on 7/10/24. 6. Licensed Nurse tried to conduct a head-to-toe assessment on female resident, but she refused even after several attempts on 7/6/24 an on 7/7/24. 7. Female resident refused to go out to the hospital for further evaluation on 7/6/24. 8. The Director of Nursing began obtaining witness statements from staff. On 7/6/24. 9. Safe surveys (series of questions for residents to identify possible Abuse/Neglect) were completed by Social Worker and other Facility management staff with interview able residents on 7/9/24. 10. Both residents were referred to [psych provider] for psychological assessment and to be picked up on services if needed on 7/9/24 11. Female resident was placed on 1 on 1 on 8/8/24 12. Female resident seen by [psych provider] services on 8/9/24 13. New Safe Surveys completed on 8/9/24 and 8/10/24 14. Facility Administrator was terminated effective 8/10/2024 15. Referrals for female resident's alternate placement on an all-female unit have been sent out, female resident's [family member] agreed to the plan of discharge on [DATE] 16. The female residents plan of care and EMR was updated on 08/08/2024 to reflect that this resident will remain on one-to-one supervision until resident is discharged . 17. A facility wide audit on residents with dementia, PTSD or history of sexual violence was completed by Director of Nursing on 08/11/2024. No other residents were identified to be at risk for victimization at this time. A trauma assessment will be completed on all new residents to identify those at risk of victimization and alternate/appropriate placement will be immediately sought for those that are at risk. 18. Reviewed current Abuse and Neglect Policy to ensure it is appropriate for staff to follow and protect residents from abuse and neglect on 8/8/24. In-Service conducted. The Director of Nursing/Designee (after re-educated below) re-educated facility staff on: 1. On 8/8/24 Director of Nursing and Administrator were re-educated on Abuse & Neglect Policy and implementation of appropriate interventions to ensure resident safety by Regional Director of Operations. 2. Staff in-service was initiated on 8/8/24. Staff members are being re-educated to report all allegations of abuse immediately upon notification to the Administrator who is the abuse coordinator. Staff will complete an Abuse & Neglect competency posttest at time of in-servicing. 3. Facility staff were also re-educated by the administrator on implementation of interventions to ensure resident safety. Re-education was initiated on 8/8/2024. 4. The expected completion date will be 8/9/2024. Staff who have not been trained on Abuse & Neglect will not be allowed to work until they have completed required in-services. 5. In - service/ ADHOC QAPI completed with Medical Director on 8/9/24 on abuse and neglect policy. 6. An interim administrator has been appointed and will start 8/12/2024. He will be educated on this Plan of removal and facility Abuse and neglect policy before he starts functioning as the facility administrator. Once a permanent facility Administrator is appointed, they will also be educated on this Plan of removal and the facility Abuse and Neglect policy. 7. Social worker was re-educated by Regional Director of Operations on 8/11/2024 to complete a trauma assessment on all new residents to identify those at risk of victimization and immediately seek alternate/appropriate placement for those identified to be at risk. 8. The Regional Director of Operations and Director of Nursing re-educated facility staff on enhanced monitoring and expectations. Re-educated completed on 8/11/2024. Implementation of Changes: Staff will immediately inform the Administrator or Director of Nursing immediately when made aware of the any abuse allegation. The administrator or director of nursing will ensure implementation of interventions for resident safety. A quick reference sheet of interventions has also been provided to staff and posted at the nurse's station. In the absence of the Administrator, abuse allegations will be reported to the Director of Nursing. The Regional Director of Operations and Regional Nurse Consultant will be responsible for implementation of the process and will review the process weekly X3 months by reviewing safe surveys, grievance forms and staff interviews. Weekly review will be documented on Abuse Coordinator Review Log. Monitoring: 1. Administrator/DON or designee will complete daily reviews of each incident for proper interventions during daily IDT meetings. 2. Social worker/RN Supervisor will complete five safe surveys per day for two weeks then one per day for one month on interviewable residents to ensure safety x 2 months 3. 5 Non interviewable residents will receive a head-to-toe physical[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to ensure alleged violations were thoroughly investigated for 2 (Residents #1 and #2) of 6 residents reviewed for resident abuse. The facility failed to ensure Resident #1's abuse allegation from 06/15/24 was thoroughly investigated. The facility failed to ensure Resident #2's abuse allegation was thoroughly investigated for 07/26/24. An Immediate Jeopardy (IJ) was identified on 08/09/24 at 5:00 PM. The IJ template was provided to the facility on [DATE] at 5:24PM and signed by the Administrator. While the IJ was removed on 08/12/2024 at 7:05PM, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. This failure placed residents at risk for serious injuries, abuse, and serious harm due to their allegations not being thoroughly investigated. Findings included: 1. Record Review of Resident #1's admission MDS Assessment, dated 05/19/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. He was cognitively intact. He did not have any behaviors. His diagnoses included stroke, heart failure, and hemiplegia (paralysis of one side of the body.) Review of Resident #1's Care Plans , not dated, reflected: Resident had a history of making false allegations/inaccurate statements as evidenced by previously accusing/stating: Makes up stories of falling, explained the same fall with different version to other nurses Interventions: If statements were determined to be inaccurate, staff will reorient and redirect as needed with reassurance and reality orientation. Listen openly to allegations/inaccurate statements and offer clarification as needed. Resident had potential to demonstrate verbally abusive behaviors related to ineffective coping skills, and poor impulse control. Interventions: Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess resident's coping skills and support system. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Evaluate for side effects of medications. Provide positive feedback for good behavior. Emphasize the positive aspects of compliance. Psychiatric/Psychogeriatric consult as indicated. Record review of Resident #1's Progress Notes, dated 06/15/24 at 7:20 pm reflected: Resident came to the nursing station to complain that he requested a double portion, but he was served with one portion of meal at dinner. He was offered another tray of dinner, but he refused and said that he was going downstairs. 7:26 PM Nurse was notified by the weekend supervisor that the resident wanted to go into the kitchen, but he was prevented from going in and he started altercation with the kitchen personnel. It was reported that the resident called the police. The resident came upstairs and said get my meds ready because I'm going out. Nurse had his medication prepared but the resident never came back to take his scheduled night medication. 8:15 PM A CNA came and told this nurse that the resident just left with his [family member] to the hospital. Note documented by LVN H. Review of Resident #1's Facility Self-Report dated 06/15/24 reflected: It was reported to Administrator on 6/15/24 that Resident #1 and the Assistant Dietary Manager had a verbal altercation. It was then reported to that the resident said that the Assistant Dietary Manager hit him in the chest. When the Administrator interviewed Resident #1 , he said the Assistant Dietary Manager also threw his walker and grabbed him by the throat. The Assistant Dietary Manager was interviewed and he denied ever putting a hand on the resident. The Administrator interviewed staff and residents that were in the dining room and kitchen when the altercation happened. In all of the Administrator interviews, everyone stated that they never saw the Assistant Dietary Manager put his hands on Resident #1. They also all said that it was the resident who was the aggressor, yelling and cursing at the kitchen staff. Investigation findings were unconfirmed because there was no witnesses that ever saw the Assistant Dietary Manager touch or hit the resident. In all interviews the witnesses stated Resident #1 was the aggressor and the one that was yelling and cursing. The Assistant Dietary Manager was allowed to come back to work from suspension. 1. Staff was in-serviced on abuse, neglect and dealing with aggressive behavior. 2. The Assistant Dietary Manager was allowed to return to work. 3. Resident #1 was presented a Behavior contract. Staff Witness Statements from the incident reflected: Resident #1 - The resident went to the kitchen to get double portions and the kitchen told him that they would send him another tray. He left and went back upstairs, and they could not find the tray. He came back downstairs and told them again that his tray was not up there. They told him that they would get him another tray once they finish with the other residents. He was standing in the door to the kitchen when he said the Assistant Dietary Manager came at him saying we are not going to do this Resident #1. Resident #1 then said that the Assistant Dietary Manager grabbed his walker and threw it about 10 feet. He then said that the Assistant Dietary Manager grabbed his neck and hit him in the chest. Resident #1 then stated that he took his shirt off to point at his chest that he had a pacemaker and then put his arms to his side and started saying that he did not touch anyone. Assistant Dietary Manager - Resident #1 was cursing at the cook about getting double portions. The Assistant Dietary Manager came to the door and asked the resident to not cuss at the employees. He stepped back into the kitchen and the resident called him a bitch. The Assistant Dietary Manager stated that he asked the resident, what you just said to me? The Assistant Dietary manager then said that he never put a hand on him. The Assistant Dietary Manager then stated that the resident tried to hit him but did not hit him. The resident then took his shirt off and started yelling that people were touching him. Dietary Aide I - He was working in the kitchen when Resident #1 came to the kitchen and was asking for more food. He stated that the resident started yelling at the cook and stating that he did not get double portions. The Dietary Aide I got the resident another plate and the resident still kept yelling at the staff. Dietary Aide I went and got the Assistant Dietary Manager to help with the resident, so they could finish the trays for the other residents. Dietary Aide I then said the Assistant Dietary Manager asked the resident to step out of the doorway to the kitchen. Resident #1 continued to yell and cuss at the Assistant Dietary Manager. The resident was getting more aggressive, and they tried to calm him down. Dietary Aide I stated that he never saw the Assistant Dietary Manager touch or hit Resident #1. Dietary Aide J - He stated that he never saw the Assistant Dietary Manager hit or touch Resident #1. He then stated that Resident #1 was the aggressor during the altercation. CNA K - see attached statement. (No statement attached.) Review of Resident #1's Hospital Records, dated 06/15/24, reflected the resident was an assault victim with a right chest wall contusion (bruise), neck strain, back strain, and contusion on his left ankle. There was no police report for 06/15/24. There was no facility incident report for 06/15/24. There was no resident assessment for 06/15/24. There was no trauma assessment for 06/15/24. The Surveyor requested the police report on 08/09/24 at 3:45 PM from the police department. An observation and interview with Resident #1 on 08/08/24 at 1:25 PM revealed he said he was assaulted on 06/15/24 by the Assistant Dietary Manager. He said he was supposed to get extra food and went down to get it and the Assistant Dietary Manager got in his face and threw his walker. He said it took 4-5 people to get him off of him. Resident #1 said he was scared of him and did not feel comfortable eating food from him. The resident said he had bruises on his neck and chest on 06/15/24 and went to the hospital. He said they took images of his chest and pacemaker. He said the right side of his chest was still sore. The resident said he currently was ordering take-out food and his RP complained because it was $100/day. The resident said his food was almost always messed up. Resident showed the Surveyor a piece of over-cooked, dry bacon and said all three of his meals were messed up. The resident said he thought his walker was messed up because the Assistant Dietary Manager threw it. The resident said when he would go to the kitchen and see him, they whispered about him. The resident said he did not feel safe getting his food from the Assistant Dietary Manager. The Administrator walked over during the conversation and the resident showed the Administrator the piece of bacon. The Administrator said ok and walked away. An interview on 08/08/24 at 1:15 PM with the Assistant Dietary Manager revealed on 06/15/24 an incident occurred. He said on Resident #1's tickets he was supposed to get large portions. The resident would say he did not get them, but he did. He said on 06/15/24, Resident #1 came to the kitchen and had a tray with him. The resident also had a tray upstairs, and a 3rd one that the cook had. The Assistant Dietary Manager said when saw the resident he was arguing with the cook even though he had 3 trays. The resident was riled up, cussing, and the Assistant Dietary Manager took the tray from the resident. The resident told him he was, nothing but a bitch anyway. The Assistant Dietary Manager said he turned around, walked back to the resident and asked what he said. He repeated, you're nothing but a bitch. The Assistant Dietary Manager told Resident #1 that he was not going to call him a bitch. The Assistant Manager said he was angry and yelling back at the resident and the other staff was trying to keep both him and the resident calm. The resident ran up on the Assistant Dietary Manager and changed his mind and moved back. The Assistant Dietary Manager said he raised his voice at the resident and Resident #1 called the police. The Assistant Dietary Manager said he told the resident he was not going to be threatening his staff. The Assistant Dietary Manager said there was another incident when the resident came to the kitchen, but when he saw the Assistant Dietary Manager, the resident left. He is a headache, and he is one of a kind. The Assistant Dietary Manager said he had been trained to de-escalate behaviors and that is why he stepped into the situation. He said he did not receive any disciplinary action but was suspended pending investigation. He said [NAME] L no longer worked at the facility and the Dietary Manager was off on 06/15/24. An interview on 08/08/24 at 1:35 PM with Dietary Aide J revealed he had worked at the facility for 2 months. He said on 06/15/24 he was washing the dishes and heard Resident #1 yelling and being mean to the staff. He said he went to the front and the Assistant Dietary Manager and the resident were cursing at each other and were in each other's face. Dietary Aide I said it got to a point where the argument was dying down and then the resident called the Assistant Dietary manager a bitch. The resident started cursing at all of the kitchen staff and the Assistant Dietary Manager responded and he got escalated. The Assistant Dietary Manager was upset. He was standing in the doorway and they were close to each other. HE went to grab the resident and was told not to put my hands on him. He stood by the resident's right shoulder and was facing the Assistant Dietary Manager to separate them. He said the Assistant Dietary Manager did not calm the situation, and he did not see them touch each other. Dietary Aide J said the Assistant Dietary Manager should have calmed down and let the situation go because the resident was about to leave by himself. The resident had a history of lashing out and then walking away. The police showed up 15 minutes later and the Assistant Dietary Manager left for the day. Dietary Aide J said he had to sign a paper but did not receive any in-services following the incident. An interview on 08/08/24 at 3:00 PM with CNA K revealed she had worked at the facility since 2022. She said on 06/15/24 Resident #1 got his tray and he said he did not get double portions. [NAME] L looked at his tray and said that he did receive double portions. The Assistant Dietary Manager came in and told the resident to step out of the kitchen. Resident #1 called the Assistant Dietary Manager the N word and stupid. The Assistant Dietary Manager was standing in the doorway of the kitchen. Resident #1 said he would slap the fuck out of the Assistant Dietary Manager. CNA K said she told the resident to come to her and told the resident he had to wait for his tray. Resident #1 reached across CNA K and tried to punch the Assistant Dietary Manager. CNA K said she told the Assistant Dietary Manager to back off and to walk away. CNA K said she got the tray for Resident #1. CNA K said the Assistant Dietary Manager escalated the situation and that she had to step in between them and back up Resident #1 for the Assistant Dietary Manager. She said the Assistant Dietary Manager should have walked away. An interview on 08/12/24 at 2:30 PM with LVN H revealed she was the nurse for Resident #1 on 06/15/24. She said she was told there was an incident in the kitchen and dining room and that Resident #1 we went in the kitchen and was insulting staff and calling them names. She said the LVN Weekend Supervisor was handling the situation. She said when the resident came back to her following the altercation he said he needed to get his medications. Resident told her that he went to the kitchen to get food and he was attacked and insulted by staff. LVN H said she did not know if anyone attacked him because he was always making up stories. She said the resident told her he went to the hospital, but she did not assess him before he left or when he got back. She said the resident was wearing a shirt. She said she did not believe that anyone attacked him and she did not know why he was a resident in the facility. She said she did not complete an incident report because she was not there when it happened. An interview on 08/12/24 at 4:15 PM with the LVN Weekend Supervisor revealed she did not work the weekend of 06/15/24. An interview on 08/08/24 at 2:10 PM with the Administrator revealed on 06/15/24, he got a call the afternoon or evening that Resident #1 and the Assistant Dietary Manager had the altercation. He said when he arrived the police were wrapping up their investigation and gave him the police report number. The Administrator said he did get the police report. He said Resident #1 left the facility with his friend. The Administrator said he interviewed the staff in the dining room and interviewed the resident when he came back. The Administrator called the Assistant Dietary Manager and suspended him. The Administrator said he found in his interviews with staff the common denominator was that Resident #1 was the aggressor. He was loud and arguing with the cook and he did not feel he got double portions. He kept trying to go in the kitchen with his walker. He said the staff got the Assistant Dietary Manager and asked him to please not go in the kitchen. Resident #1 yelled more and took his shirt off and thought he was ready to fight the Assistant Dietary Manager. The Administrator said staff did not see the Assistant Dietary Manager touch Resident #1. Resident #1 said he took his shirt off and said he had a pacemaker. The Assistant Dietary Manager denied throwing the walker and no one observed him throw the walker. Resident #1 said he was going to the hospital to have his pacemaker checked out. The Administrator said staff were supposed to de-escalate situations and re-direct residents and remove them form the situation. The Administrator said staff were not supposed to yell at residents and staff had to separate the Assistant Dietary Manager and Resident #1, because Resident #1 was being aggressive. He said he suspended the Assistant Dietary Manager but felt the Assistant Dietary Manager handled the situation appropriately. The Administrator said the resident said he was going to the hospital, but he did not think he went. An interview on 08/09/24 at 12:05 PM with the DON revealed he did not know that there was no assessment or incident report for Resident #1 for 06/15/24. He said he did not know about the results of the hospital records for 06/15/24. An interview on 08/09/24 at 12:15 pm Administrator revealed the facility did not do an assessment because Resident #1 left, and the facility did not do incident reports for verbal aggression. An interview on 08/09/24 at 2:50 PM with the Medical Director revealed Resident #1 was his resident. He said he knew the resident had frequent altercations and was only aware of the resident's most recent hospitalization on 06/20/24. He said he did not know what the hospital records for 06/15/24 said. He said he did not expect that the facility would have done a more thorough investigation if they did not know he went to the hospital. Record review of the facility policy, Abuse Prevention and Prohibition Program, revised 10/24/22, reflected: I. VI. Investigation A. The Facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts. i. The Facility has protocols for investigations of theft/misappropriation of resident property abuse. B. If the Administrator receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, injuries of an unknown source or crime, the Administrator or designee, may appoint a member of the Facility's management team (the Investigator) to investigate the alleged incident. i. If the investigation is delegated, the Administrator provides the Investigator with any supporting documents related to the alleged incident. C. The Investigator may take some or all of the following steps: i. Reviews all relevant documentation; ii. Reviews the resident's medical record to determine events preceding the alleged incident; iii. Interviews the person(s) making the incident report; iv. Interviews any witnesses to the alleged incident; v. Interviews the resident (as medically appropriate); vi. Interviews the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; vii. Interviews Facility Staff members who have had contact with the resident during the period of the alleged incident . The Administrator was notified of the Immediate Jeopardy on 08/09/24 at 6:10 PM due to the above failures and provided the IJ template to Corporate DON. A Plan of Removal was requested. The facility's plan of removal was accepted on 08/11/24 at 4:35 PM and included the following: 1. Administrator submitted a self-report to HHSC regarding the incident on 06/15/2024. Intake #511237 2. Attending Physician for involved residents was notified of the incident by the nurse on 08/09/2024. 3. Social worker conducted a trauma screen with male resident on 8/10/2024, trauma screen finding was normal. If trauma screen had been abnormal, physician would be notified and EMR updated to reflect interventions. 4. Assistant Dietary Manager was immediately suspended on 6/15/24. 5. A copy of the residents' hospital records has been obtained and reviewed by the Director of Nursing and residents attending physician on 8/9/2024. 6. A new online request for a copy of the police report was submitted on 8/10/2024 by the administrator. 7. A complete head to toe assessment was completed on the resident on 8/10/2024. 8. Witness statements were obtained by the Administrator on 6/15/2024. 9. Witnesses reinterviewed on 8/8/24 and 8/10/24 10. Safe surveys (series of questions for residents to identify possible Abuse/Neglect) were completed by Social Worker and other Facility management staff with interview able residents on 08/09/2024. The non interviewable resident received a complete head to toe assessment on 08/09/2024. Any negative findings were immediately investigated, physician and responsible party notified and EMR with interventions. 11. Affected resident was referred to [psych hospital] for psychological assessment and to be picked up on services if needed on 06/21/2024. 12. Assistant Dietary Manager employment with the facility was terminated on 8/08/2024. 13. Trauma screen completed by the social worker on 8/10/24 post record review, results were normal. 14. Resident seen by Team Health psychologist on 8/10/24. 15. Hospital records reviewed and uploaded on 8/8/24 by the Medical Records Director. 16. Physician notification of hospital records received on 8/9/24 by the Director of Nursing. 17. Care plan updated to reflect receipt of hospital records on 8/10/24, MDS coordinator. 18. Medical dx updated to reflect hospital records on 8/10/24 , by MDS coordinator. 19. New incident report completed on 8/10/24, the Director of Nursing. 20. Facility Administrator was terminated effective 8/10/24 In-Service conducted Director of Nursing or designee (after re-educated below) re-educated facility staff on: 1. On 8/9/24 Director of Nursing and Administrator were re-educated by the Regional Director of Operations on Abuse & Neglect Policy, verbal, physical, sexual abuse and implementation of appropriate interventions to ensure residents are not afraid and feel safe. Administrator and Director of Nursing were also re-educated on how to complete thorough investigation of incidents including completion of assessments, offering resident treatment, obtaining hospital records and obtaining police reports. 2. Post test completed with Administrator and DON on thoroughly investigating Abuse and neglect on 8/9/24 3. Staff in-service by the Administrator, DON or designee was initiated on 8/9/24. Staff members are being re-educated to report all allegations of abuse immediately upon notification to the Administrator who is the abuse coordinator. Re-education has an emphasis on De-escalation. Preventing abuse also involving staff and resident safety with emphasis on creating an environment where residents do not feel afraid. Staff will complete an Abuse & Neglect competency posttest at time of in-servicing. 4. Staff are being re-educated by the Administrator, DON or designee to recognize signs of a resident being abused and early recognition of residents that do not feel safe. All such suspicions must immediately be reported to the Administrator or Director of Nursing on 8/9/24 5. Facility nurses were re-educated 8/9/2024 to ensure residents are assessed and incident reports are completed following abuse allegations. 6. Facility staff were also re-educated by the administrator on implementation of interventions to ensure resident safety. Re-education was initiated on 8/9/2024. 7. The expected completion date will be 8/10/2024. Staff who have not been trained on Abuse & Neglect will not be allowed to work until they have completed required in-services. 8. An interim administrator has been appointed and will start 8/12/2024. He will be educated on this Plan of removal and facility Abuse and neglect policy before he starts functioning as the facility administrator. Once a permanent facility Administrator is appointed, they will also be educated on this Plan of removal and the facility Abuse and Neglect policy. Implementation of Changes The regional Director of Operations and the Regional Nursing Consultant will review all incidents and allegations to ensure thorough investigations are completed daily x3 months then weekly their after. Staff will immediately inform the Administrator or Director of Nursing immediately when being made aware of the any abuse allegation. The administrator or director of nursing will ensure implementation of interventions for resident safety. A quick reference sheet of interventions has also been provided to staff and posted at the nurse's station. Alleged perpetrators will immediately be placed on one-on-one monitoring pending investigation and physician direction. The victim will be immediately assessed for injury, safety awareness, physician notification and continue to be monitored pending investigation and physician direction. Victim's Medical records will be updated to reflect any changes as needed. In the absence of the Administrator abuse allegations will be reported to the Director of Nursing. All allegations and incidents will be reviewed to the daily IDT team meeting to review for resident assessment and completion of an incident report. The Regional Director of Operations and the Regional Nurse Consultant will be responsible for implementation of the process and will review the process daily X3 months then weekly their after by reviewing safe surveys, grievance forms and staff interviews. Weekly review will be documented on Abuse Coordinator Review Log. Monitoring 1. Administrator/DON or designee will complete daily reviews of each incident to make sure residents are assessed, incident reports are completed, and interventions are put in place during daily IDT meetings. 2. Social worker/RN Supervisor will complete five safe surveys per day for two weeks then one per day for one month on interviewable residents to ensure safety X2 months. 3. 5 Non interviewable residents will receive a head-to-toe physical assessment daily for two weeks then one per week x2 months. 4. The administrator and Director of Nursing will interview five staff members per day for two weeks then one staff member per day for one month for return demonstration for types of abuse and reporting requirements and appropriate interventions. Findings will be documented on Abuse & Neglect monitoring form x2 months. 5. RDO and RNC will review and monitor all allegations and incidents for appropriate implementation of interventions x3 months. 6. RDO or RNC will review grievances weekly which are in the facility grievance binder for three months to monitor for appropriate interventions x4 months. 7. Any adverse outcomes will be reported to the monthly QAPI Committee meeting with the Medical Director. Involvement of Medical Director The Medical Director was notified about the immediate Jeopardy on 8/9/2024. Involvement of QA On August 9th, 2024 an Ad Hoc QAPI meeting was held with the facility administrator, medical director, director of nursing, and social services director to review the plan of removal. Who is responsible for the implementation of the process? The Regional Director of Operations and Regional Nurse Consultant will be responsible for the implementation of the new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 8/9/2024 The facility's implementation of the IJ Plan of Removal was verified through the following: Record reviews of the Facility in-services started on 08/08/24 through 08/12/24 reflected all in-services were reviewed and were given to over 50 employees. The remaining employees were to be in-serviced prior to the start of their shift. The in-services included information on abuse and neglect, de-escalation of behaviors, keeping incidents to only a small number of people, speaking calmly during situations, protecting the resident, and validating the resident's concerns, resident assessments, and completing thorough investigations. Resident #1's documentation and assessments reflected in the plan of removal were reviewed and in the electronic heal record. Safe surveys were reviewed, the quick reference sheet was posted at the nurse's station, and the QAPI meeting sign-in sheet for 08/09/24 was reviewed. An interview on 08/12/24 at 4:50 PM with Resident #1 and his RP revealed he was happy that the Assistant Dietary Manager and Administrator were no longer working at the facility. He said it would take time for him to feel comfortable again. An interview with the Regional Director of Operations on 08/12/24 at 7:00 PM revealed LVN H, the Assistant Dietary Manager, and the Administrator were terminated from employment. Interviews on 08/12/24 from 11:05 AM to 7:00 PM with 16 staff from all shifts (Cook M, Dietary Manager, Dietary Aide N, CNA O, CNA P, CNA Q, CNA U, CNA R, CNA S, CNA T, LVN U, LVN V, LVN W, RN X, RN Y, and LVN Z) revealed they were in-serviced on the facility abuse policy, types of abuse, de-escalation of behaviors, when to report abuse, who to report abuse to, how to protect a resident during an abusive situation, what to do if a resident reported they did not feel safe, and when to complete assessments. The said they received all in-services and completed the post-tests. An interview with the DON on 08/12/24 at 5:45 PM revealed his role in the Plan of Removal was to participate in all interventions for problems identified. He would be implementing interventions, educating staff, care planning, documentation, and notification. He said he had spoken with the staff and explained that they were there to help the residents and not think of them as problems. He said he was teaching the staff to listen to resident concerns and address them. The DON said he would complete daily reviews of each incident to make sure residents were assessed, incident reports were completed, and interventions were put in place. The DON said he/Administrator would interview five staff members per day for two weeks then one staff member per day for one month for return demonstration for types of abuse and reporting requirements and appropriate interventions. Findings would be documented on Abuse & Neglect monitoring form X2 months. The DON said all incidents were reported to him so he could confirm proper steps were taken and followed. He said he read the 24-hour report daily to ensure no issues were missed with IDT. He said his plan for Resident #1 was to visit him daily. The DON said failure to follow abuse and neglect policies and failure to do investigations could put the resident's life in danger. An interview on 08/12/24 at 6:45 PM with the Interim Administrator revealed it was his first day as Administrator. He said his role in the POR was to be the Abuse Coordinator. He said he[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for each resident that included measurable objectives and time frames that met the resident's medical, nursing and mental needs for two (Resident #2 and Resident #1) out of 3 residents reviewed for care plans. The facility failed to identify individualized interventions and objectives in the comprehensive care plan for Resident #2, after Resident #2 was involved in an alleged sexual abuse incident with a male staff member on 04/25/2024. The facility failed to protect Resident #2 who was a prior victim of abuse and unable to give consent for sexual activity. The facility failed to identify individualized interventions and objectives in the comprehensive care plan for Resident #2 after Resident #2 was involved in a sexual abuse incident with a male resident on 07/06/2024. This failure could place residents at risk for repeated victimization. After administrative review, an IJ was identified on 08/22/24. The Administrator and Regional Director of Operations were notified and an IJ template was provided on 08/22/24 at 9:54 AM. While the IJ was removed on 08/12/2024 at 7:05PM, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. Findings Included: Record Review of Resident #2's Quarterly MDS assessment with an ARD of 05/24/2024 revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2's diagnoses included: Alzheimer's Disease, Age-Related Physical Debility, and Alcohol Abuse. Resident #2 had a BIMS score of 11 indicating a moderately impaired cognition. Resident #2 had disorganized thinking, no potential indicators of psychosis, but did have a behavioral presence of wandering. Record Review of Resident #2's care plan reviewed on 08/08/2024 reflected it did not include Resident #2's involvement with the incidents that occurred on 07/06/2024 and 04/25/2024. Resident #2's care plan did not include any measurable objectives or interventions that were put into place for Resident #2 after the incidents occurred. Record review of the facility's investigation report for the incident that occurred between Resident #2 and Resident #3, dated 07/14/2024, revealed that the incident occurred on 07/06/2024 at 10:30pm between two facility residents, Resident #2 and Resident #3. Witness statements revealed that LVN A was completing her rounds when she witnessed Resident #2 on top of Resident #3. LVN A left the room and got LVN B as a witness to return to the room. Upon return to Resident #2's room, LVN A and LVN B revealed that they saw Resident #3 sitting on the side of Resident #2's bed. Resident #3 proceeded to get up from the bed, pulled up his pants, and fastened his belt. Facility investigation report revealed that Resident #3 had the capacity to make informed decisions. The facility did not indicate if Resident #2 had the capacity to make informed decisions. Provider response from the facility's investigation report revealed that the facility separated both residents and Resident #3 was asked to return to his room. A head-to-toe assessment was attempted, but declined by Resident #2. MD, Family (did not indicate who), and facility Ombudsman were notified, safe survey rounds were completed by the facility. Facility investigation findings revealed the facility was unable to substantiate the findings. The facility concluded that Resident #3 was discharged to the community on 07/10/2024 and that the facility will continue to support Resident #2 . Facility investigation report revealed that the local law enforcement was not notified and Resident #2 was not sent out to the hospital for a SANE (Sexual Assault Nurse Examination) at any time during or at the conclusion of the investigation. Interview with LVN A on 08/10/2024 at 3:12 PM revealed that she was the nurse for Resident #2 on 07/06/2024. LVN A revealed that she walked into Resident #2's room and observed Resident #2 on top of Resident #3 in bed. LVN A revealed that she did not witness penetration as there was not enough light in the room. LVN A revealed that she alerted LVN B for a witness. LVN A revealed that they both saw Resident #3 pulling up his pants and fastening his zipper while still in Resident #2's room. LVN A revealed that Resident #3 exited Resident #2's room and she alerted the Weekend Supervisor of the incident. LVN A revealed that Resident #2 was placed on every 15-minute checks, but was unaware there was not a physician order or alternation to Resident #2's plan of care. LVN A revealed that Resident #2 does not have the capacity to consent, Resident #2 wanders constantly, but is easily re-directed. LVN A revealed that she was unsure of what interventions were put in place to protect Resident #2 from repeated victimization. LVN A revealed she could not recall the incident between Resident #2 and a male staff member. Interview with LVN B on 08/06/2024 at 1:14 PM revealed that she was the nurse for Resident #2 on 07/06/2024. LVN B revealed that she did not witness Resident #3 enter Resident #2's room, she revealed that LVN A alerted her during her rounds that she discovered Resident #2 on top of Resident #3. When she arrived to the room she saw Resident #3 with his shirt unbuttoned, belt unbuckled and pants unbuttoned. LVN B revealed she alerted the Weekend Supervisor who alerted the Administrator. LVN B stated that Resident #2 was started on every 15 minute checks, but could not state if Resident #3 began any enhanced monitoring that night. LVN B revealed that this behavior for Resident #2 was off her baseline. LVN B revealed that Resident #2 does not have the capacity to consent. LVN B revealed she was unsure of what interventions or alterations were made to Resident #2's plan of care to protect her from repeated victimization. LVN B revealed she was not familiar with the incident between Resident #2 and a male staff member and did remember any details of the incident. Interview with RP #1 on 08/08/2024 at 10:25 am revealed that she was aware of the incident that occurred between Resident #2 and Resident #3. RP #1 revealed that she was told by staff that Resident #2 was found in bed with a male resident. RP #1 revealed that she was shocked by the event as that was not like Resident #2's baseline behavior. RP #1 revealed that she visited Resident #2 the next day, 07/07/2024 and Resident #2 did not reveal any physical markings or changes in behavior. RP #1 revealed that she was unaware Resident #2 refused to go to the hospital after the incident occurred for further examination and was not aware Resident #2 refused head-to-toe assessments after the incident occurred. RP #1 revealed she requested the facility to ensure that Resident #2 had no more contact with Resident #3. RP #1 revealed she was unsure what interventions were put into place or what the outcome of the facility investigation was. RP #1 was aware that Resident #3 discharged from the facility. RP #1 was unaware of what interventions were put into place to prevent repeated victimization of Resident #2. RP#1 revealed she was aware of the incident that occurred on 04/25/24 between Resident #2 and a male staff member, but was not aware of any interventions that were put into place to protect Resident #2 from further victimization. RP #1 revealed she was aware Resident #2 has been on psychiatric services, admission date to psychiatric services unknown by RP #1. Interview with RP #2 on 08/08/2024 at 10:50 am revealed that he was the Power of Attorney for Resident #2. RP #2 revealed that he was unaware of the incident that occurred between Resident #2 and Resident #3. RP #2 revealed that he was alerted of the incident back in April of 2024 between Resident #2 and a male staff member. RP #2 revealed that he was unsure of what interventions were put into place to prevent repeated victimization of Resident #2. RP #2 revealed that he would defer to Resident #2's medical team to determine Resident #2's decision making abilities and abilities to consent. RP #2 revealed he was not alerted by the facility that Resident #2 refused to go to the hospital or refused head-to-toe assessments. RP #2 revealed that he was unaware that the facility investigated the incident or what the outcome of the investigation was. Record review of a document titled, Progress Notes, with a date of 04/27/2024 revealed a late entry note for 04/25/2024. Document revealed that the DON notified RP #2 for Resident #2 to notify him regarding an incident that occurred of inappropriate behavior from staff. DON notified [family member] that the employee was not in the facility at that time and the matter was pending investigation. Record review of a document titled, Health Status Note, with a date of 4/27/2024 revealed a late entry note from 04/25/2024. Document revealed that Resident #2 was inappropriately touched on the lips by a staff member. Resident #2 reported that the staff member, was her friend and friends do kiss. Interview with the Administrator on 08/08/2024 at 2:20PM revealed that Resident #2 was in a similar incident on 04/25/2024 with a male staff member. The male staff member was terminated from the facility and the facility's investigation revealed that the male staff member kissed the resident. The Administrator could not reveal any interventions or alterations that were put into place for Resident #2 to prevent repeated victimization after this incident. The Administrator revealed that the facility takes an interdisciplinary approach for care plans and no singular individual is responsible for updating each residents' care plan needs. Interview with Social Worker on 08/12/2024 at 10:02AM revealed that the MDS Nurse was responsible for ensuring that each care plan is personalized. The Social Worker revealed that the while the facility does take an interdisciplinary approach to care planning, the MDS Nurse is responsible for ensuring the data and information is inputted into the care plan. The Social Worker revealed that if the MDS Nurse was out of the facility, the DON or ADON would be responsible for care planning any interventions or objectives. The Social Worker revealed a risk for not personalizing or creating interventions after incidents occur for residents's would be a lapse of care for the resident. Interview with MDS Nurse on 08/12/2024 at 9:28AM revealed that she was the only MDS Nurse in the facility. MDS Nurse revealed that there is an interdisciplinary approach to care plans and care planning and it is the responsibility of all interdisciplinary leadership to ensure care plans are accurate and reflect the resident's current needs. The MDS Nurse revealed that she was off during the incidents that occurred between Resident #2 and Resident #3 and Resident #2 and a male staff member. The MDS revealed during the time she was off, the interdisciplinary team is responsible for updating all resident's plan of care as the facility takes an interdisciplinary approach to care plans. The MDS Nurse revealed that each resident was discussed in a weekly meeting and alterations to their plan of care are discussed during those meetings. The MDS Nurse revealed that she was unsure why Resident #2's care plan did not reflect the two incidents that occurred on 04/25/24 and 07/06/24 or any interventions that were put into place. The MDS Nurse could not reveal any alterations that were made to Resident #2's plan of care or any risks to the residents for not personalizing resident's plan of care or creating interventions after incidents occur. Interview with DON on 08/12/2024 at 5:47PM revealed that care plans should be personalized according to the resident's current needs. The DON revealed that the facility does take an interdisciplinary approach when it comes to care planning. The DON revealed that it is the responsibility of himself and the Administrator to ensure care plans are up to date and reflect the resident's current needs. The DON revealed he was unsure why Resident #2's care plan did not reflect the incidents that occurred on 07/06/24 and 04/25/24. The DON revealed Resident #2's care plan should have been updated to reflect all interventions that were put into place after the incidents occurred. The DON revealed a risk to not personalizing resident's plan of care or creating interventions after incidents occur are the opportunity for missed care. A Comprehensive Care Plan/Care Plans policy was requested by the surveyor to the RDO on 08/12/24 at 7:45AM. The facility did not present a current policy on Care Plans/Comprehensive Care Plans. Record Review of the facility's policy titled, Abuse Prevention and Prohibition Program revealed a date of 10/24/2024. Facility policy contained a section titled, Prevention and revealed that, The facility conducts an ongoing review and analysis of abuse incidents and implement corrective actions to prevent future occurences of abuse Resident Assessments and Care Planning are preformed to monitor resident needs. Record Review of the facility's MDS Coordinator- LVN/LPN Job Description dated December 2023 revealed that the MDS Nurse will assist the DON or designee with identification of physician orders and verbal reports to assure the MDS and care plan are reflective of those changes. After administrative review, an IJ was identified on 08/22/24. The Administrator and Regional Director of Operations were notified. The Administrator and Regional Director of Operations were provided with the IJ template on 08/22/24 at 9:54AM. The facility's Plan of Removal was accepted on 08/11/2024 at 4:34 PM and included: Identify responsible staff/what actions taken: 1. Administrator submitted a self-report to HHSC regarding the incident on 07/06/2024. Intake #516319 2. Attending physician for involved residents was notified of the incident on 07/06/2024. 3. Social Worker conducted trauma assessment with female resident on 07/08/2024. 4. Male resident was placed on 1:1 monitoring by facility staff on 07/06/2024. 5. Male resident was discharged from the facility on 07/10/2024. 6. Licensed Nurse tried to conduct a head-to-toe assessment on female resident, but she refused even after several attempts on 07/06/2024 and on 07/07/2024. 7. Female resident refused to go to the hospital for further evaluation on 07/06/2024. 8. The Director of Nursing began obtaining witness statements from staff on 07/06/2024. 9. Safe surveys (series of questions for residents to identify possible Abuse/Neglect) were completed by Social Worker and other Facility management staff with interview able residents on 07/09/2024. 10. Both residents were referred to [psych provider] for psychological assessment and to be picked up on services if needed on 07/09/2024. 11. Female Resident care plan was updated on 8/10/24. 12. Female resident is on one on one as of 8/8/24. 13. Female seen by Psychologist on 8/9/24. 14. Orders are clarified to specify what is expected of one on one 8/10/24. 15. Facility Administrator was terminated effective 8/10/2024. 16. Referrals for female resident's alternate placement on an all-female unit have been sent out, female resident's [family member] agreed to the plan of discharge on [DATE]. 17. The female residents plan of care and EMR was updated on 08/08/2024 to reflect that this resident will remain on one-to-one supervision until resident is discharged . 18. A facility wide audit on residents with dementia, PTSD or history of sexual violence was completed by Director of Nursing on 08/11/2024. No other residents were identified to be at risk for victimization at this time. A trauma assessment will be completed on all new residents to identify those at risk of victimization and alternate/appropriate placement will be immediately sought for those that are at risk. In-Service conducted: Administrator and Director of Nursing (after re-educated below) re-educated facility staff on: 1. On 8/8/24 Director of Nursing and Administrator were re-education on Abuse & Neglect Policy and implementation of appropriate individualized interventions to ensure resident safety by Regional Director of Operations. 2. Staff in-service was initiated on 8/8/24. Staff members are being re-educated to report all allegations of abuse immediately upon notification to the Administrator who is the abuse coordinator. Staff will complete an Abuse & Neglect competency posttest at time of in-servicing. 3. Facility staff were also re-educated by the administrator on implementation of interventions to ensure resident safety. Re-education was initiated on 8/8/2024. 4. The expected completion date will be 8/9/2024. Staff who have not been trained on Abuse & Neglect will not be allowed to work until they have completed required in-services. 5. An interim administrator has been appointed and will start 8/12/2024. He will be educated on this Plan of removal and facility Abuse and neglect policy before he starts functioning as the facility administrator. Once a permanent facility Administrator is appointed, they will also be educated on this Plan of removal and the facility Abuse and Neglect policy. 6. Social worker was re-educated by Regional Director of Operations on 8/11/2024 to complete a trauma assessment on all new residents to identify those at risk of victimization and immediately seek alternate/appropriate placement for those identified to be at risk. 7. The Regional Director of Operations and Director of Nursing re-educated facility staff on enhanced monitoring and expectations. Re-educated completed on 8/11/2024. Implementation of Changes: Staff will immediately inform the Administrator/DON or designee immediately when made aware of the any abuse allegation. The administrator/director of nursing or designee will ensure implementation of interventions for resident safety. A quick reference sheet of interventions has also been provided to staff and posted at the nurse's station. In the absence of the Administrator, abuse allegations will be reported to the Director of Nursing. The Regional Director of Operations and the Regional Nurse Consultant will be responsible for implementation of the process and will review the process weekly X3 months by reviewing safe surveys, grievance forms and staff interviews. Weekly review will be documented on Abuse Coordinator Review Log. Monitoring: 1 Administrator/DON or designee will complete daily reviews of each incident for proper individualized interventions during daily IDT meetings. 2. Social worker/RN Supervisor will complete five safe surveys per day for two weeks then one per day for one month on interviewable residents to ensure safety X2 months. 3. 5 Non interviewable residents will receive a head-to-toe physical assessment daily for two weeks then one per week X2 months. 4. The administrator and/or Director of Nursing will interview five staff members per day for two weeks then one staff member per day for one month for return demonstration for types of abuse and reporting requirements and appropriate interventions. Findings will be documented on Abuse & Neglect monitoring form. Staff interviews will continue for x2 months. 5. RDO and RNC will review and monitor all allegations and incidents for propriate implementation of interventions x3 months. 6. RDO or RNC will review grievances weekly which are in the facility grievance binder for three months to monitor for appropriate interventions then monthly thereafter. 7. RDO or RNC will review care plans post investigation to verify individualized care plans concerning allegations of abuse to prevent repeated victimization daily X4 week, then weekly X4 and monthly thereafter. 8. Any adverse outcomes will be reported and reviewed during the monthly QAPI Committee meeting with the Medical director. Involvement of Medical Director: The Medical Director was notified about the immediate Jeopardy on 8/8/2024. Involvement of QA: On August 9th, 2024 an Ad Hoc QAPI meeting was held with the Facility Administrator, Medical Director, Director of Nursing, and Social Services Director to review the plan of removal. Who is responsible for implementation of process? The Regional Director of Operations and Regional Nurse consultant will be responsible for the implementation of the new process. On 08/12/2024 at 8:30AM the surveyor began monitoring the facility's Plan of Removal. Record Review of Resident #2's Comprehensive Plan of Care dated 08/12/204, revealed the following: Focus- [Resident #2] has a psychosocial well-being problem (actual or potential) r/t alleged Sexual Assault Goal- [Resident #2] will demonstrate adjustment to nursing home placement by/through review date. Interventions- Assist/encourage/support resident to set realistic goals, Resident will be provided 1 on 1 care/supervision until discharge, continue psych services (psychology and psychiatry) Focus- [Resident #2] is an alleged SA victim r/t perpetrator observed kissing her. Male resident observed in [Resident #2's] room. Goal- [Resident #2] will be free from sexual assault through review date. Interventions- [Resident #2] is on 1-on-1 care until alternate placement, psych consult. Review of document titled, Trauma Screen with a date of 08/12/2024 revealed that a trauma screen was conducted with Resident #2. Trauma screen revealed that Resident #2 does have a history of trauma related events in her life and that Resident #2 stated the trauma experience she has is bearing five kids. Review of document titled, Progress Notes dated for 08/08/2024 revealed a new order was initiated for Resident #2 to monitor her on one to one monitoring. Review of several documents titled, Progress Notes, one note dated for 08/09/2024, three notes dated for 08/10/2024, one note dated for 08/11/2024 and one note dated for 08/12/2024 revealed that resident #2 was on one-to-one monitoring. Observation on 08/11/2024 at 11:45AM revealed Resident #2 in her room with a staff member stationed outside the door documenting her location. Observation on 08/12/2024 at 11:05AM revealed Resident #2 in the facility courtyard with a staff member close by documenting her location. Observation on 08/12/2024 at 1:24PM revealed Resident #2 in the facility gym with a staff member close by documenting her location. Interview with the Regional Director of Operations on 08/12/2024 at 10:00AM revealed that the MDS nurse was re-educated on care plans, appropriate interventions and goals. Interviews with 16 staff members who worked all shifts on 08/12/2024 at 11:09AM to 08/12/2024 at 5:30PM revealed: Staff were able to show return demonstration that they were in-serviced regarding the plan of removal, sexual abuse prevention and identification, how to identify residents who are at risk of increased victimization and plan of care alterations for Resident #2. Staff was able to verbalize that the abuse coordinator is now the Interim Administrator, and his contact number is posted around the facility. Staff was able to verbalize that the plan of care has been updated for Resident #2 to reflect 1:1 enhanced monitoring. Nursing staff was able to verbalize that after a sexual abuse incident or alleged incident occurs, they would immediately contact the abuse coordinator, physician for that resident, responsible party for that resident and the DON. Nursing staff was able to verbalize that after a sexual abuse incident or alleged incident occurs, they would ensure resident safety, report and being skin/psychosocial assessments. Staff Interviewed Included: [NAME] L, Dietary Manager, DA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, LVN U, LVN W, RN X, RN Y, LVN Z. Interview with the DON on 08/12/2024 at 6:05PM revealed that his role in the plan of removal was to participate in all interventions that are associated with all the problems that have been identified. DON revealed that the interventions included, educating staff, participating to ensure the care plan was in place and followed and communicating with physicians and other providers. DON revealed that he would complete a daily audit of all incidents and accidents and that he would review the 24 hour report daily with the interdisciplinary team every morning. DON revealed that the facility has been communicating with resident #2's family daily and that the family has decided to move the resident to an all-female memory care unit. During the Plan of Removal monitoring, Resident #2 was currently still residing in the facility and remained on 1:1 enhanced monitoring. Interview with the Interim Administrator on 08/12/2024 at 6:25PM revealed that he was the new administrator for the facility effective 08/12/2024. The Interim Administrator revealed that his role in the Plan of Removal was to ensure, along with the Regional Director of Operations, that the plan of removal was implemented effectively and efficiently. The Interim Administrator revealed that he had been in-serviced on the facility plan of removal and the facility ANE policy. The Interim Administrator revealed that he, along with the DON would complete daily reviews of each incident report to ensure that proper individualized interventions are implemented and in place. The Interim Administrator revealed he would also complete five staff member interviews for a two-month period for return demonstration of the in-serviced topics. The Interim Administrator revealed that his work would be audited by the Regional Director of Operations and Regional Nurse Consult to ensure compliance of the plan of removal. Interview with the Regional Director of Operations on 08/12/2024 at 7:00PM revealed that his role in the plan of removal was to oversee alongside the Regional Nurse Consult, the implementation of the plan of removal. The Regional Director of Operations revealed that his expectation for the Interim Administrator is to follow-up on all allegations thoroughly, investigate all allegations and take action when necessary The Regional Director of Operations revealed that alongside the Regional Nurse Consult they will monitor, and review care plans post investigation to ensure individualized interventions are put into place, review grievances weekly for three months and monitor and review all allegations and incidents for three months. The Interim Administrator and Regional Director of Operations were notified the Immediate Jeporady was removed on 08/12/24 at 7:05 PM, however the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of seven residents reviewed for improper transfers. The facility failed to ensure Resident #1 was transferred according to his Care Plan using a Hoyer. An Immediate Jeopardy (IJ) was identified on [DATE] at 03:56 PM. The IJ template was provided to the facility on [DATE] at 3:58 PM and signed by the Administrator. While the IJ was removed on [DATE] at 12:26 PM, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. These failures resulted in hospitalization due to an improper transfer whereas Resident #1 received a fracture and underwent surgery to repair the fracture. Findings included: Review of Resident #1's quarterly MDS assessment, dated [DATE], revealed he was an [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included Age-related Osteoporosis (bone disease that develops when bone mineral density and bone mass decreases,), Osteopenia (loss of bone density), Muscle Weakness (decrease in muscle strength), Lack of Coordination, Congestive Heart Failure (heart muscle does not pump blood well), Acute Respiratory Failure (he lungs can't release enough oxygen into your blood), etc. The MDS reflected Resident #1 had a BIMS (a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 13 indicating cognition was intact. The functional abilities and goals section indicated Resident #1 required extensive assist with bed mobility and transfers, mechanical lift with 2 persons. Review of Resident #1's care plan revised on [DATE] revealed Resident #1 had an ADL Self Care Performance Deficit r/t Dementia (loss of memory, language, problem-solving and other thinking abilities that are severe), Impaired balance (Loss of balance or unsteadiness), Limited Mobility (any physical impairment that impacts a person's ability to move around freely, easily, and without pain), Musculoskeletal impairment (conditions that can affect your muscles, bones, and joints), chronic pain (pain that lasts for over three months), COPD (chronic obstructive pulmonary disease), CHF (heart failure), abnormal posture (rigid body movements and chronic abnormal positions of the body), lack of coordination (problems coordinating how your muscles work), difficulty in walking, muscle wasting (thinning of muscle mass). Interventions included lying to sitting on bed side substantial/maximal assistance; sit to stand (not attempted due to medical condition or safety concerns); chair/bed-to-chair transfer dependent: Hoyer lift times 2 person assist, etc. Review of Resident #1's PT Sessions and Evaluations dated [DATE] under the Functional Mobility Assessment Section revealed, Transfers: Sit to stand and Chair/bed-to-chair transfer = Not attempted due to medical conditions or safety concerns. It also revealed, Amount of assist needed to sit at edge of bed: Current Value changed from Max (A) times 2 to Unable and Time patient can sit unsupported: Current Value changed from 20 seconds to Unable. Review of Resident #1's PT Encounter Summary dated [DATE], it revealed, We started our day as we usually do. Checked on the evaluations for the day, and reviewed notes as appropriate. After which, PT-student said she would go to round up patients to treat. I stayed at the gym to look over other documents due for the day. At 10:21am, PT-student called me saying she needed help. I asked where she was and said she's in [Resident #1]'s room. When I arrived in the room, PT-student was sitting on the floor beside [Resident #1]'s bed with Resident #1 beside her, laying on his back. I immediately alerted LVN A about [Resident #1]'s fall. LVN A went to the room with me to assess Resident #1. Resident #1 reported that his right hip hurts, there was also a scratch/abrasion on [Resident #1]'s right middle toe - but other than that, no other injuries were noted. I saw another staff member walk past and alerted her as well that we need help to get Resident #1 off the floor and then three male nurses arrived. The three male nurses attempted to get Resident #1 off the floor but was unable to. They put a Hoyer sling underneath and was able to use the Hoyer machine to lift Resident #1 off the floor. Resident #1 was positioned in bed, and I handed him the bed control so he can comfortably position himself. The bolster was put back in place, along with the 2 pillows underneath his calf, and the fall mat was returned beside his bed. We spoke to Resident #1 and made sure he was comfortable on his bed and asked if he needed anything else. We left the room and made sure his bedside table, bed control, and call light was within reach. I spoke to PT-student on the stairwell to clarify what happened. I have read her statement and it was what she told me as well. I educated PT-student on the indicators on how this particular patient was not appropriate for a 1-person transfer (PT-student has demonstrated good clinical judgement in the past that did not indicate anywhere near any kind of this incident happening or her missing these signs) 1) on ocular inspection, the patient was at least 6 feet tall, weighing at least 200 lbs; 2) There was no goal for transfers; 3) Patient required 2 person assist with supine side-lying activity due to poor trunk control and 2-/5 manual muscle testing of bilateral lower extremities - which we had always done together when treating him/we evaluated the patient together; and 4) There was a Hoyer sling on top of his wheelchair indicating patient was a Hoyer transfer. Review of Resident #1's Pain Evaluation dated [DATE] at 1:00 PM revealed his pain level was at a 3 and described as intermittent aching and he was given one HYDROcodone-Acetaminophen Oral Tablet 7.5-325 mg. Review of Resident #1's progress notes revealed: [DATE] at 10:35 AM eINTERACTS BAR Summary for Providers Situation: The Change in Condition/s reported on this CIC Evaluation are/were: Falls - At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 128/57 - [DATE] 07:35Position: Sitting l/arm - Pulse: P 61 - [DATE] 10:39 Pulse Type: Regular - RR: R 16 - [DATE] 12:36 - Temp: T 97.7 - [DATE] 12:36 Route: Forehead (non-contact) - Weight: W 222.0 lb - [DATE] 17:07 Scale: Wheelchair [DATE] at 11:25 General Progress Note: Resident alert and oriented, doing therapy session, including strengthening and mobility. unable to transfer from bed to w/c resident was ease down to the floor on his back. resident with history of pain on right hip call out pain on right knee and discomfort on his right hip; MD called immediate X-Ray obtained; Mar Updated. [FAM A] called with information; FAM A talked to [Resident #1] and resident stated that I did not have a fall, but I was put down in front on the Bed. Resident resting in bed with eyes opened. [DATE] at 11:35 General Progress Note: This nurse was alerted to room by Therapy Staff that resident was on the floor, upon entering room resident was lying on the floor on his back, head to toe assessment was performed, resident call out of pain to right hip and right knee, resident was transferred safely to bed, MD notified, order was given for immediate X-Rays to right hip, right knee, and right tibia and right fibula, PRN Medication Norco was administered, Responsible Party was notified. [DATE] at 12:34 Lab Note Text: X-Ray called immediately to [Company]: Order Number: 42947239 [DATE] at 2:27 PM General Progress Note: Notified NP of resident's X-Ray results which indicated acute fracture to right lower leg. Order given by NP to transfer resident to ER for further evaluation and treatment. Responsible Party was made aware. Review of the facility's Ad Hoc QAPI dated [DATE] revealed, Resident #1 sustained an assisted fall during a transfer with PT-student which resulted in a fracture to his right leg. An X-Ray was ordered, pain assessment completed, pain medication was given, and Resident #1 was sent to the ER. In an interview with FAM A on [DATE] at 01:15 PM, she stated she had a video of the PT-student in Resident #1's room and she attempted to pick him up without any help, a gait belt, nor a Hoyer. FAM A stated the PT-student dropped her father on the floor and he yelled out, he broke his leg, and she dismissed what he was saying. FAM A stated the PT-student told Resident #1 his leg was not broken; you are okay. The PT-student then moved his broken leg and kept telling him it was okay. FAM A stated the PT-student reported it as a minor incident. FAM A stated the facility called and told her what happened. FAM A stated she started reviewing the video and she could hear Resident #1 in the video and the transfer procedures were not followed. FAM A stated Resident #1 was scheduled for surgery tomorrow on [DATE]. Review of FAM A's video recording on her phone on [DATE] at 01:15 PM, revealed the PT-student attempted multiple times to pull Resident #1 to a standing position. The PT-student counted to three and attempted to pull Resident #1 up. On the fifth attempt, Resident #1 and the PT-student fell onto the floor. The PT-student used her cell phone and called the CI and informed her they had fallen and requested assistance. In an interview with ADON A on [DATE] at 02:30 PM, he stated during the morning meeting yesterday ([DATE]), he received a call from LVN A. LVN A informed him Resident #1 had fallen. ADON A stated he arrived upstairs Resident #1 had been placed back in bed. ADON A stated Resident #1 said it was a little incident. ADON A stated the roommate, Resident #2 chimed in and said, No one was going to move me because she just dropped him on the floor. ADON A stated LVN A told him a PT-student tried to transfer Resident #1 and in the middle of the transfer Resident #1 could not make it, so the PT-student eased him onto the floor. ADON A stated he called the DOR for a report and to come upstairs with the PT-student. ADON A stated three of the PT staff arrived at the room, and they explained it was a student that tried to transfer Resident #1 by herself. ADON A stated he called the MD and explained when he touched Resident #1's right foot he called out in pain. ADON A stated the doctor ordered an X-Ray on Resident #1's hip, knee and ankle. ADON A stated he told FAM A to review the camera and she came to the facility and spoke with the DON. ADON A stated the DON called him and said he just reviewed the video camera and to call 911 right away. ADON A stated he called the doctor back and informed her they would be sending Resident #1 out opposed to waiting on the X-Ray results. ADON A stated Resident #1 received a broken bone of the tibia going towards the ankle. In an interview with the ADM on [DATE] at 03:50 PM, he stated the fracture was confirmed the same day. The ADM stated it was a witnessed incident, nothing was mentioned of neglect and Resident #1 had a BIMS of 13. The ADM stated Resident #1 said he did not fall, but that is the great thing about videos because it can help cut through inconsistencies. The ADM stated Resident #1 lost his balance while the PT-student was trying to assist him. Review of Resident #1's hospital paperwork revealed, on Tuesday, [DATE] at 3:09 pm, patient presented with RLE (right lower extremity) pain. Patient was being transferred at his nursing facility when he was dropped. He has a deformity to the right anterior tibia. He denies hitting his head and LOC (level of consciousness). In an interview with Resident #2 on [DATE] at 11:00 AM, he stated he did not see anything due to the curtain being pulled. Resident #2 stated he heard Resident #1 crash on the floor, and he could see Resident #1 a little beneath the curtain. Resident #2 stated he did not see the staff that entered the room, but he heard all the commotion. In an interview with the DON on [DATE] at 11:25 AM, he stated the ADON reported to him on [DATE] that Resident #1 sustained a fall. The DON stated the ADON said it was an assisted fall on a failed transfer from Resident #1's bed to chair. The DON stated he instructed the ADON to assess Resident #1 properly and report it to the MD. The DON stated FAM A walked into his office and showed him a video. The DON stated he watched the video of the transfer, which was really an assisted fall. The DON stated he did not have the heart to watch the video and it broke him to see what he saw. The DON stated it was a difficult position for the resident. The DON stated he stopped the conversation with FAM A and had his staff call 911. The DON stated EMS arrived before FAM A left his office. The DON stated an X-Ray had already been completed in-house. The DON stated after Resident #1 arrived at the hospital, the results of the in-house X-Ray confirmed a fracture which was reported to FAM A and the doctor. The DON stated after the incident, they had started in-servicing and training on transfers, gait belt use, fall prevention and renewing competencies. The DON stated they had an Ad Hoc QAPI and addressed the concerns with the monitoring of transfers in place for 7 days, once a week for one month, and once a month for 3 months. The DON stated that Resident #1 was a Hoyer transfer. The DON stated the DOR reported the PT-student had gone to the floor to get different residents to bring down for therapy, but they were not ready. The DON stated the PT-student had entered Resident #1's room because he was on her schedule. The DON stated the PT-student started her field work at the facility on [DATE]. In an interview with the DOR on [DATE] at 11:50 AM, she stated the PT-student started her field work at the facility on [DATE]. The DOR stated the PT-student had already completed two 3-month rotations in Outpatient Care. The DOR stated universities sent students enrolled in this type of program anywhere within the United States. The DOR stated this had been the PT-student's first rotation in a long-term care setting. The DOR stated therapy followed the school's syllabus and the facility's Competency Checklist. The DOR stated the CI supervised and checked off the PT-student's completed tasks. The DOR stated after a student started, they received a tour of the facility and started shadowing their instructor (documentation, evaluations, treatments, etc.). The DOR stated the PT-student started treating Residents alongside the CI and each week they progressively increased her caseload. The DOR stated the PT-student saw half of the Residents and the CI tended to the other half. The DOR stated she observed the PT-student and the CI during Week 2 with less-complexed residents. The DOR stated the PT-student was never assigned to treat Resident #1 alone. The DOR stated Resident #1 was on the PT-student's schedule, but the PT-student and the CI had always provided services to him together in his room. The DOR stated the PT-student told them she had gone to get two different residents across the hall from Resident #1, but they were not ready. The DOR stated the PT-student had gone to see Resident #1, trying to salvage her day. The DOR stated the PT-student informed her Resident #1 said he wanted to get up and she said, Let's do it. The DOR stated the PT-student retrieved Resident #1's wheelchair and placed it at the edge of his bed and the goal was to stand Resident #1 up and place him in the wheelchair. The DOR stated the PT-student said Resident #1 could not make it and since the wheelchair was close, the goal was the wheelchair, and they went down. The DOR stated the PT-student participated in Resident #1's Therapy Care Plan and Goals on her second day. The DOR stated Care Plans were part of the PT-student's first evaluation. The DOR stated she did not foresee anything worse than a fracture due to the mechanics of the fall. In an interview on [DATE] at 12:25 PM, the RDOT stated PT-students were assigned via their recruiter. The RDOT stated after the student started, they followed a Competency Checklist. The RDOT stated the first couple of days was a lot of observations. The RDOT stated when the CI felt the PT-student was ready, they allowed them to participate in treatments and documentation. The RDOT stated the PT-student assisted with evaluations, progress notes, and discharges. The RDOT stated the PT-student was scheduled to graduate in [DATE]. The RDOT stated based on the CI's observation, she could give the PT-student as much work as the PT-student could handle. The RDOT stated they started with simpler cases and there were never any concerns with the PT-student. The RDOT stated they completed bed mobility, sitting on the edge of the bed, and worked on strengthening. The RDOT stated the PT-student got Resident #1 to the edge of the bed, got him ready, attempted to get him up with a lack of clinical judgement for sure, and it went south. The RDOT stated she did not know why the PT-student did it, especially if she tried multiple times without success. The RDOT stated Resident #1's transfer status was part of his PT evaluation. The RDOT stated the PT-student wrote a statement and was dismissed from the facility. The RDOT stated they reported the incident to the PT-student's school. In an interview on [DATE] at 01:00 PM with the CI, she stated she was not in the room when it happened. The CI stated the PT-student was supposed to round residents up and bring them down to therapy. The CI stated the PT-student entered Resident #1's room and attempted to complete his therapy in the room alone. The CI stated previously when she and the PT-student treated Resident #1, it was always the two of them and she was surprised the PT-student attempted to do it by herself. The CI stated the PT-student had been doing good and the PT-student thought she could do it on her own. The CI stated her, and the PT-student completed Resident #1's sessions in bed. The CI stated Resident #1 was a Hoyer transfer even when transferred to his wheelchair, the Hoyer would be used. The CI stated Resident #1's treatment was for him to sit on the side of the bed and that was why there was always two therapists present because he was just that weak. The CI stated she had worked at the facility over 5 years, and she never completed Resident #1's therapy by herself. The CI stated she spoke with the PT-student after the incident, and the PT-student stated she lowered the resident down to ease the fall. The CI stated the PT-student called her on the phone and said she needed help. The CI stated she arrived at the room and called out for nurse's assistance. The CI stated after a student started field training at the facility, the student would shadow her for one week to get oriented to paperwork, assessments, evaluations, etc. The CI stated she would complete a Competency Skills Checklist to make sure the PT-student was able to complete all tasks. The CI stated she would gradually give a PT-student more complex cases with less supervision. The CI stated the PT-student had already accomplished these tasks. The CI stated the PT-student was trained on gait belt use, proper transfer techniques, assessment of a resident, how to complete evaluations and treatments. The CI stated PT-students are not trained on Hoyer use due to it not being a skilled service, it was a Nursing task. The CI stated the PT-student was proactive with her learning and took on cases easily in which she demonstrated good clinical judgement. The CI stated they were flabbergasted by this incident. The CI stated the PT-student had trained at the facility for 5 weeks. The CI stated the PT-student related her [NAME] with real treatment well. The CI stated this had been a lapse in the PT-student's judgement. The CI stated the worse that could had happened was the resident could have received a head injury and died. Observation on [DATE] at 10:00 AM at [Hospital], Resident #1 was observed to be sleeping peacefully and not in pain. HRN awakened Resident #1 to speak with Surveyor. In an interview on [DATE] at 10:03 AM at [Hospital], Resident #1 stated he was okay and not in pain. Resident #1 stated the PT-student entered his room and attempted to stand him up. Resident #1 stated he was too heavy for the PT-student. Resident #1 stated he told the PT-student he weighed 220 lbs. Resident #1 stated the PT-student kept trying to stand him. Resident #1 stated they felled to the floor, and the PT-student had him twisted up. Resident #1 stated the PT-student dropped him, and it was painful. Resident #1 denied he told the PT-student he wanted to sit in his wheelchair. Resident #1 stated he never discussed his wheelchair with the PT-student. In an interview on [DATE] at 10:25 AM at [Hospital], the HRN confirmed Resident #1 was admitted on [DATE] at 3:09 pm. HRN stated Resident #1 had a fall at the nursing home and received a right ankle fracture. HRN stated Resident #1 had surgery on [DATE]. HRN stated there were no concerns listed by the doctor, nor the ER. HRN stated there was nothing medically going on except treatment of the fracture. HRN stated there was no timeframe for discharge because they were waiting for PT to evaluate Resident #1. HRN stated Resident #1 was unable to tolerate a lot of PT and required care when discharged . HRN stated she had been Resident #1's nurse since he admitted 3 days ago. HRN stated Wednesday morning ([DATE]), she told Resident #1 she needed to turn him to provide incontinent care and he was afraid and told her, Please do not drop me. HRN stated Resident #1 said she looked small like the girl that dropped him so he was scared she would drop him too. HRN stated she informed Resident #1 PT was going to stop by and was panicked because he feared being dropped. HRN stated the doctor notes from 6/13 stated [Resident #1] had been bed-bound status for almost one year. The Nursing Facility staff tried to get him to stand up and get into his wheelchair. During the past one year, the facility had used a Hoyer. [Resident #1] could not hold his balance, fell on the floor, and broke his right ankle. In an interview on [DATE] at 11:15 AM, the MD stated she was made aware Resident #1 fell. The MD stated Resident #1 had not experienced a recent change in condition. The MD stated she understood a PT-student was trying to do a transfer by herself. The MD stated Resident #1 was usually non-ambulatory and required extensive assistance due to weakness. The MD stated the PT-student should have requested assistance. The MD stated Resident #1 fell, received a fracture, and required surgery. In an interview with the PT-student on [DATE] at 11:15 AM, after exiting the facility, she stated she was familiar with Resident #1's care. The PT-student stated she had never treated Resident #1 alone; her CI was always with her. The PT-student stated it was her first time where she trained in a Long-Term Care setting. The PT-student stated she was familiar with Resident #1's mobility and strength and stated, I knew he had poor lower extremity strength, and he was 90% immobile and was in bed most of the time. The PT-student stated the only treatment she and her CI had completed with Resident #1 was sitting him on the side of the bed. The PT-student stated she had never sat Resident #1 on the side of the bed by herself. The PT-student stated she had never transferred Resident #1 to his wheelchair but stated this was what he wanted to do. The PT-student stated she attempted to move Resident #1 to his wheelchair because during the time of her being a student, she was given 100% supervision on Week 5 even though the goal did not need to be met until further along in her clinical rotation. The PT-student stated this was her first week doing things alone. The PT-student stated Resident #1 told her he wanted to get out of bed, and it was something him and her attempted and it went downhill from there. The PT-student stated she showed empathy for Resident #1 as he said he just wanted to kind of get up. The PT-student stated she attempted a technique she learned in school known as a Dependent Transfer where a resident does not have any strength at all, and you could swivel them into the chair. The PT-student stated she thought it was something she could attempt to do with Resident #1, but it was not the outcome of what happened. The PT-student stated it would have been safer to seek assistance prior to starting the transfer due to Resident #1's size, his height, and his diminished strength in his lower body. The PT-student stated she should had called for assistance. The PT-student stated she had access to Resident #1's Care Plan. The PT-student stated she had previously discussed with her CI that Resident #1required two-person assistance. The PT-student stated it had been an oversight in her own clinical judgment. The PT-student stated it was her judgment and her CI had previously told her if she was going to transfer Resident #1, he was a 2-person assist. The PT-student stated again it was a clinical oversight on her part. The PT-student stated for transfers, she was aware that Resident #1 was a 2-person assist. The PT-student stated 100% for sure she could say it was a mistake for her to attempt to transfer Resident #1 by herself. The PT-student stated she does not feel that anyone else was at fault, she just believed per her Syllabus she was more advanced. The PT-student stated she was made aware of Resident #1's condition. The PT-student stated she does not want to know or think about the worse that could have happened. Review of facility's policy titled Abuse Prevention and Prohibition Program dated [DATE], revealed: I. Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The Facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Review of facility's untitled policy titled Transfer of Residents it stated: Purpose: to provide the form of transfer best suited to the residents' needs and to maintain resident safety during the procedure. Policy I. A Licensed Nurse and/or the Director of Rehabilitation Services assess and determine lifting and transfer requirements and the procedure used for each resident. The procedure is recorded in the resident's Care Plan. II. Residents must be lifted or transferred according to the determined procedure. III. Residents who require assistance in transferring will be transferred using a gait/transfer belt or with a lift. V. Mechanical lift procedures are used on any resident unable to independently pivot or transfer. Procedure II. Assisting to Chair A. One Person Pivot Transfer (resident must be able to bear weight) An Immediate Jeopardy (IJ) was identified on [DATE] at 3:56 PM. The IJ template was provided to the facility on [DATE] 3:58 PM and signed by the Administrator. A plan of removal was requested at that time. The facility's plan of removal was accepted on [DATE] at 12:26 PM and reflected: Summary of Details which lead to outcomes. F689 Free of Accident Hazards/Supervision/Devices On [DATE] during a complaint survey at The Hillcrest of North Dallas at 18648 Hillcrest Road, Dallas, TX 75252. On [DATE] the HHSC surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The facility allegedly failed to provide supervisory services. When resident #1 was being transferred at his nursing facility he was dropped. Has a deformity to the R anterior tibia. The notification of the alleged immediate jeopardy states as follows: An [AGE] year-old male with a BIMS of 13 admitted to the facility on [DATE]. His diagnoses include Age-related Osteoporosis, Osteopenia, Muscle Weakness, Lack of Coordination, Dementia, Acute Respiratory Failure, etc. He required a Hoyer when transferring and two therapists at bedside during therapy. An in-house Stat X-Ray was performed, and he was sent out prior to the results. EMS transferred the resident to Medical City [NAME] where the hospital paperwork states he presented with RLE pain. Patient was being transferred at his nursing facility when he was dropped. Has a deformity to the R anterior tibia. Denies hitting his head and LOC. Identify residents who could be affected. All Residents who require assistance to be transferred have the potential to be affected. Identify responsible staff/ what action taken. 1. Physical Therapist Student was immediately removed from the facility. 2. We contacted the school and informed them that the Physical Therapist Student was being removed from the student fieldwork program and could not return to the facility. In-Service conducted. 1. Therapy staff was re-educated on mechanical lifts and gait belts appropriate transfer training, transfer status and protocol for falls which include do not move residents, call for assistance and have nurse to assess on [DATE]. 2. Education is being provided to nursing staff on fall prevention, and transfers with mechanical lifts and gait belts on [DATE]. 3. Education is being provided to nursing staff to check the KARDEX to know plan of care and transfer technique [DATE]. Implementation of Changes Change of policy for student supervision - Clinical supervisor must provide close, direct supervision and oversight to student clinicians Providing patient care in the following circumstances: To make an initial determination of competence. When a student clinician is performing assigned treatment or activity with a patient for the first time. When the student clinician is learning a new skill or technique. When the student clinician's performance assessment/evaluation identifies issues (e.g. conduct, clinical performance, capacity) with potential to interfere with delivery of competent, quality and ethical rehabilitative care. In all other treatment circumstances, the student clinician must be in line of sight of the clinical supervisor when providing direct patient care. The clinical supervisor should be available to intervene and/or correct student performance, as necessary. Director of Rehabilitation has been in-service on the new policy change [DATE]. Clinical Instructors have been in-serviced on the new policy change [DATE]. Audit of fall assessments and care plans are being completed and appropriate interventions will be put in place as needed by [DATE]. Therapy staff was re-educated on mechanical lifts and gait belts appropriate transfer training, transfer status and protocol for falls which include do not move residents, call for assistance and have nurse to assess on [DATE]. Education is being provided to nursing staff on fall prevention, and transfers with mechanical lifts and gait belts on [DATE]. Education is being provided to nursing staff to check the KARDEX to know plan of care and transfer technique [DATE]. Monitoring DOR/Designee will monitor staffing to ensure that any student therapist will be closely monitored to follow the new policy. DOR/Designee will review the effectiveness of this daily X 7 days and weekly X 4 weeks, then X 3 monthly, continued monitoring will be ongoing and report any adverse findings to the QAPI committee.