**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview the facility failed to ensure residents were provided supervision and assistive devices to prevent accidents for 1 (Resident #1) of 12 residents reviewed for accidents. The facility failed to provide supervision to prevent the elopement of Resident #1. The facility failed to have a monitoring tool in place for when residents were outside in the back patio area. Resident #1 was outside in the back patio area, unsupervised by staff for approximately 34 minutes, and was found near the facility building walking without her wheelchair near a ravine and busy street. An IJ Immediate Jeopardy (IJ) was identified on 02/16/24. The IJ template was provided to the facility on [DATE] at 3:01 PM. While the IJ was removed on 02/17/24, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated as the facility was continuing to monitor it's plan for effectiveness. These failures could place residents at risk for the outside in the back patio are unsupervised of elopement or injuries. Findings include: Record review of Resident #1's face sheet dated 02/09/24, revealed, admission on [DATE] to the facility. Record review of Resident #1's most recent facility history and physical in the system dated 09/12/22, revealed, a [AGE] year-old female (present age [AGE] years old) was diagnosed with Alzheimer (a brain disorder that gets worse over time) Dementia ( impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and atrial fibrillation (a type of arrhythmia, or abnormal heartbeat). Record review of Resident #1's quarterly MDS dated [DATE], revealed, Resident #1 made poor decisions and cues/ supervision was required, regarding daily tasks; had wandering behaviors that occurred daily; required a wheelchair for mobilization; had 1 fall with major injury since admit. Resident #1 was on oxygen therapy. Record review of Resident #1's care plan dated 1/19/2024, revealed, she was at a risk for elopement, as evidenced by impaired safety awareness, wanders aimlessly. Supervise closely and make regular compliance rounds whenever resident was in room. Determine the reason the resident was attempting to elope. Was the resident looking for something or someone? Does it indicate the need for more exercise? Intervene as appropriate. Distract resident from elopement attempts by offering pleasant diversions, structed activities, food, conversation, television, books. If the resident was exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. Record review of Resident #1's Elopement Risk Assessment, dated 01/20/2024, revealed she had previous attempts to leave the facility, documented as one or more times in the last week. Record review of the Fall assessment dated [DATE], revealed, she was disoriented x3, at all times, she had 1-2 falls within the past 3 months, she was chair bound, and had balance problems while standing or walking. During an interview on 02/09/24 at 8:50 AM with the Maintenance Director, he stated Resident #1 had eloped from the back patio area and was found near the corner in the parking lot of the facility building. Maintenance Director stated residents are able to go outside to the back patio area that enclosed from 8AM-8PM unsupervised as the back patio black gates were locked with a pad lock. Maintenance Director stated the dining room doors have an alarm system but not the back black gate door as they will only open when the fire door alarm goes off. During an interview on 02/09/24 at 9:58AM, with LVN A, she stated Resident #1 was a wanderer and has a history of elopements. LVN A stated Resident #1 had an elopement on 02/06/24. LVN A stated there were not assessments or document in progress notes or anywhere else until 02/08/24 as DON stated she was going to put the incident information in the system but had not until 02/8/24. LVN A stated residents were able to go outside using the dining area door to go outside in the back patio area due where it was secured (Back patio black gate had a pad lock on it). LVN A stated when Resident #1 had an elopement the door alarm(s) did not sound. LVN A stated Resident #1 was outside the building near hallway 1, at the corner. LVN A stated Resident #1 was crying and had emotional distress and was swinging at the Housekeeper who found her. LVN A stated Resident #1 was standing but had unsteady gait and history of falls. LVN A stated Resident #1 has a wheelchair and staff try to keep her in her wheelchair to prevent falls. LVN A stated she could not remember when the last time was, she had seen Resident #1. LVN A stated there was a risk to Resident #1 being outside of the enclosed back patio area of Resident #1 falling in the ravine and possibly breaking something. LVN A stated the weather on 02/06/24, outside was below 50 degrees with Resident #1 was wearing a jacket and sneakers who was non-verbal. During an interview on 02/09/24 at 10:23 AM, with LVN B, she stated Resident #1 has a history of elopements and had an elopement on 02/06/24. LVN B stated staff responded to Resident #1's elopement and saw her outside the enclosed back patio area near the dumpsters. LVN B stated the Housekeeper found her and was being hit by Resident #1. LVN B stated they were not alerted as the door alarms did not go off. LVN B stated Resident #1 being outside of the enclosed back patio area could have been a risk to her as she could have gotten an injury. LVN B stated she did not know for how long Resident #1 was outside. During an interview on 02/09/24 at 10:42 AM, with the Housekeeper, she stated she went to go throw a trash bag at around 11:00 AM, in the dumpster when she turned around and saw Resident #1 standing up without her wheelchair near the corner of the building near hallway 1. The Housekeeper stated Resident #1's wheelchair was in the back patio area. The Housekeeper stated the sun was out and it was fresh outside. The Housekeeper stated Resident #1 was wearing pants and a blouse with no jacket on and her baby (doll). The Housekeeper stated Resident #1 was hitting her as she tried to assist Resident #1 back to her wheelchair in the back patio area. The Housekeeper stated she could not remember if the back patio door was open or closed. The Housekeeper stated there was a risk to Resident #1 with falling and there was a street nearby and could risk Resident #1 walking into oncoming traffic. The Housekeeper stated there was no door alarm going off to let staff know a resident had left the facility. During an interview on 02/09/24 at 11:04AM, with Housekeeping Director, she stated she received a call form Housekeeper letting her know that Resident #1 was outside of the facility. The Housekeeping Director stated Resident #1's wheelchair was inside the back patio area with the gate door closed. The Housekeeping Director stated she saw the Central Supply going to help out the Housekeeper with Resident #1 who was standing up outside of the enclosed back patio area. The Housekeeping Director stated Central Supply helped Resident #1 get back to her wheelchair. The Housekeeping Director stated there was a risk for Resident #1 knowing she was a in wheelchair and walking she could have fallen and injured herself. The Housekeeping Director stated the door alarms did not go off alerting facility staff that a resident or someone had left the facility. During an interview on 02/09/24 at 11:51 AM, with Central Supply, he stated he heard yelling outside of his office. Central Supply stated Resident #1's wheelchair was stuck in between the gate holding the gate door open. Central Supply stated the Housekeeper was holding Resident #1 between the storage and dumpster 1. Central Supply stated the back patio gate door did not have an alarm and did not hear door alarms going off. Central Supply stated the Housekeeping Director went to go get help while he went to get the wheelchair. Central Supply stated Resident #1 was wearing jeans, sweater or long sleeve (not sure), and shoes. Central Supply stated it was cold and had rained in the morning but was not raining at the time of the incident. Central Supply stated Resident #1 did not look like she had an injury. Central Supply stated there was a risk to Resident #1 of getting hurt. During an interview on 02/09/24 at 1:05 PM, with CNA W, she stated Resident #1 was being bought back into the back patio area on her wheelchair. CNA W stated Resident #1 was wearing a white shirt sweater type of blouse with jeans and pink/white shoes, with her baby (doll) wrapped up in a clothing protector. CNA W stated it was cold and windy at that time and had rained earlier in the day. CNA W stated she did not hear the door alarms going off. CNA W stated when Resident #1 was brought in she had dry clothes. CNA W stated there could have been a risk of Resident #1 wandering off all the way to the street and going into oncoming traffic. CNA W stated Resident #1 had a history of elopements. During an interview on 02/09/24 at 1:20 PM, with SCNA C, he stated the weather was a gloomy overcast with no wetness or rain. SCNA C stated Resident #1 was wearing jeans with a blue wind breaker and white shoes. SCNA C stated Resident #1 does wander off and tries to exit through the exit doors. SCNA C stated Resident #1 has a wandering stance type and her back was off set. SCNA C stated there was a risk and danger of Resident #1 walking into traffic and of fall over the brick wall into the ravine to her death. During an interview on 02/09/24 at 1:46 PM, with Receptionist, she stated Resident #1 was trying to escape all morning with trying to push the front door open and trying to stand up from her wheelchair. The Receptionist stated that LVN A and LVN B told her that Resident #1 was agitated due to receiving a shower and gets like that. The Receptionist stated the facility staff had tried redirecting Resident #1 with getting her drinks and her baby (doll) to calm down but was not calming down. The Receptionist stated the Administrator and DON were also present in the front lobby area and they did not comment on what was going on with Resident #1 being agitated. The Receptionist stated LVN A and LVN B went to talk Resident #1 to her hall but ended up coming back to the dining area. The Receptionist stated at that time in the dining area there were no facility staff present and most of the residents in the dining area were not alert residents. The Receptionist stated she was notified by the Housekeeping Director that Resident #1 was outside of the facility. The Receptionist stated she notified the facility via the intercom of Resident #1 being outside of the facility. The Receptionist stated Resident #1 looked dry and clean. During an interview on 02/09/24 at 2:01 PM, with CNA X, she stated she heard Resident #1 was found outside of the facility by Housekeeper. CNA X stated Resident #1 looked dry and it was cloudy outside. CNA X stated Resident #1 always tries to get up and walk and the facility staff ha to assist her to sit back down on her wheelchair to prevent falls. CNA X stated there was a risk to Resident #1 being outside the facility such as falling and getting hurt. During an interview on 02/09/24 at 2:15 PM, with the Activities Director, she stated she was doing her Champion Rounds (Random untimed hallway rounds that supervisory staff are assigned too to check on the residents) and was not in the dining area. Activities Director stated she did not hear the door alarms ring when Resident #1 eloped from the facility. Activities Director stated she found out due to facility staff talking about Resident #1 being found outside of the facility. Activities Director stated Resident #1 has history of standing up from her wheelchair. Activities Director stated it was fresh outside, cloudy, but not rainy. Activities Director stated Resident #1 could have fall and hurt herself or grabbed a piece of trash from dumpsters or floor. During an interview on 02/09/24 at 2:35 PM, with Assistant Activities, she stated the kitchen guy had told her that Resident #1 was outside if the facility. Assistant Activities stated the activities department was not doing activities during the time Resident #1 had her elopement. Assistant Activities stated Resident #1 was able to walk but with difficult without her wheelchair. Assistant Activities stated Resident #1 was wearing a sweater with tennis shoes and was combed with no injuries noted. Assistant Activities stated there was a risk of Resident #1 falling being outside of the facility. Assistant Activities stated the door alarm did not ring letting facility staff know someone was outside of the facility. Assistant Activities stated the purpose of the door alarms was for the safety and protection of the facility residents and to let the facility staff know when someone was outside. During an interview on 02/09/24 at 2:59 PM, with the Administrator, she stated Resident #1 did not get out of the premises even though Resident #1 exited the enclosed back patio area. The Administrator stated the Housekeeper found Resident #1. The Administrator stated Central Supply heard Resident #1 yelling and went to go help the Housekeeper. The Administrator stated Resident #1 was only outside for minutes but could not confirm this. The Administrator stated Central Supply had seen Resident #1 outside in the back patio area before she had gone outside of the enclosed back patio area. The Administrator stated Central Supply got Resident #1's wheelchair who was standing up and opened the back patio gate and prompted Resident #1 to go ahead and sit down on it. The Administrator stated Resident #1 was at the corner of the building near hallway 1 by the dumpsters. The Administrator stated there was a street near the facility and a ravine. The Administration stated Resident #1 had no steady gait (a pattern of walking that's unstable). The Administrator stated Resident #1 was assessed and was noted not to have any injuries. The Administrator stated she would consider the elopement to be serious in nature (serious problems or situations that are very bad and cause people to be worried or afraid). The Administrator stated that staff did not keep track of residents when they were in the back patio area alone because the back patio black gate was locked with a keypad lock. The Administrator stated the weather outside on 02/06/24 was a high of 50 degrees, fresh, and not raining or windy. The Administrator stated Resident #1 was wearing jeans, a long sleeve shirt, and shoes. The Administrator stated Resident #1 was not wet. The Administrator stated the back patio black gate did not go off as it was not connected to the fire alarm system. During an interview on 02/09/24 at 4:05 PM, with the DON, she stated the Housekeeping Director went to grab her and notified he that Resident #1 was found outside. The DON stated Resident #1 was near the dumpster and back door gate. The DON stated the facility staff already responding to Resident #1 being outside of the back patio area was trying to prompt Resident #1 to sit down on her wheelchair as she was standing up. The DON stated the Housekeeper had told her that she was throwing the trash when she turned around and she Resident #1 standing up at the corner of the building near hallway 1. The DON stated Housekeeper called the Housekeeping Director for help with Resident #1. The DON stated Central Supply heard Resident #1 yelling and went to check it out and found the Housekeeper with Resident #1. The DON stated she was not sure if the facility had placed an alarm on the back patio door gate. The DON stated when residents go to the back patio area alone there were no tools for monitoring the residents to ensure their safety because the back patio black gate was locked. The DON stated she assessed Resident #1 who had not injuries. The DON stated the door codes to the facility where changed, the facility staff were in-serviced to go outside with a resident who wanted or went outside int eh back patio area, and they would have a sign out sheet. The DON stated the alarm did not go off and did not say why it did not go off. During an interview on 02/12/24 at 1:23 PM, with LVN AF, she stated facility residents were allowed to go outside in the back patio area by themselves and there was no monitor tool in place to ensure the residents safety when outside in the back patio area . LVN AF stated if the door alarm goes off the facility staff had to respond to it and check the perimeter of the facility. Observation of on 02/12/24 at 1:30 PM of the facility back patio area revealed that it was enclosed. There were to black gates with keypads. Black gate doors were closed and locked. There was not pad lock with key hooked and door knock. During an interview on 02/12/24 at 1:50 PM, with LVN AH, she stated there was nothing in place to monitor residents when they were in the back patio area left alone. LVN AH stated she was in-serviced on when an alarm door rings and what to do. LVN AH stated when facility staff go outside that they had to make sure the door was shut behind them. During an interview on 02/12/24 at 3:18 PM, with the Administrator, she stated the door codes were switched out. The Administrator stated the only staff who had the codes to the back patio gate was the Administrator and the Maintenance Director. The Administrator stated the facility staff were in-service on 02/09/24 on not leaving residents alone outside in the back patio area and had to be monitored. The Administration stated the facility staff were also in-serviced with not sharing the door codes with family, visitors, or residents. During an interview on 02/15/24 at 10:28 AM, with ADON G, she stated there was no monitoring tool in place for residents who went to the back patio area alone. ADON G stated there could be a risk of elopement, injury, and anything because there was no way to monitor the residents when they were outside in the back patio area alone. During an interview on 02/15/24 at 3:48 PM with the Medical Director, he stated he was notified of Resident #1's elopement. The Medical Director stated Resident #1 needed to have her wheelchair as she was demented and had multiple falls in the past where she broke her shoulder. The Medical Director stated Resident #1 would have benefited from using the wheelchair. The Medical Director stated having any resident that was demented outside could be a risk of hurting themselves. The Administrator and DON were informed on 02/16/24 at 3:01 PM, that an Immediate Jeopardy (IJ) had been identified and a copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested. 02/16/24 at 5:19 PM - Area Director of operations submitted 1st Plan of Removal. 02/16/24 at 6:27 PM - Facility was notified of the 1st denied Plan of Removal. 02/16/24 at 7:51 PM - Administrator submitted 2nd Plan of Removal. 02/17/24 at 11:12 AM - Facility notified of 2nd denied Plan of Removal. 02/17/24 at 11:50 AM - Administrator was notified of approved Plan of Removal. The Plan of Removal revealed the facility took the following actions: Interventions: All present facility staff were in-serviced by the Administrator/ADO on the following: o No residents to be left unsupervised in the patio area. Completion date: 2/16/2024 o Maintenance Director/Designee will ensure that the back door leading to the patio area is closed at all times and a code to enter and exit the building. Completion date: 2/16/2024 o Staff will not share the code with residents. Completion date: 2/16/2024 All staff not in service on 2/16/2024 in person or on the phone will be in service before the start of their shift to be completed and monitored by the facility administrator/ADO. On 2/7/24, the maintenance director of the facility did the following: o Changed the patio gate code. o Changed the back door leading to the patio area code. New staff will be in service during orientation. The medical director, was notified of this plan on 2/16/2024, and an off-cycle QAPI plan was initiated regarding this event, with a completion date of 2/16/2024 at 5 pm. This affected Resident #1 and had the potential to affect 27 other residents with wandering/exit-seeking behaviors. Monitoring: The Maintenance Director/Designee will monitor Monday-Friday and Maintenance Assistance will monitor weekends the patio daily to ensure no unsupervised residents are on the patio. On 02/17/24 at 11:55 AM Verification phase began with the facility approved Plan of Removal. During an interview on 02/17/24 at 11:57 AM, with the Administrator and Area Director of Operations, the Administrator stated the present facility staff were in-serviced regarding, No Residents to be left unsurprised in the patio area. The Area Director of operations stated all facility staff not present were called and in-serviced regarding, No Resident to be left unsurprised in the patio area. The Administrator stated all facility staff were in-serviced by 02/16/24. The Administrator stated facility staff not present, during the in-service will not be allowed to resume their duties until in-serviced. The Administrator stated the Maintenance Director was in-serviced with monitoring the facility doors Monday-Friday to ensure they were closed, every 2 hours and to change out the code (not share it). The Administrator stated the Area Director of Operations will be using a monitoring tool to ensure the Administrator and Maintenance Director were checks the facility doors every 2 hours. The Administrator stated on 02/17/24 all in-services provided to facility staff had to be communicate back to the presenter acknowledging they understood what was being in-serviced on. The Administrator stated quizzes were given and examples had to be provided by the in-service-e confirming understanding of the material. The Administrator stated new employee would be in-serviced on during orientation. The Area Director of Operation stated on 02/16/24 at 4:40 PM the Medical Director was notified of the Immediate Jeopardy, commenting that the facility will have to get better. The Administrator stated the facility had 27 wandering/exit seeking residents who were audited and will have assessments and care plans updated for each. During an interview on 02/17/24 at 12:42 PM, with LVN P , he stated, he had received an in-service on the door alarms. LVN P stated the facility staff were to respond to door alarms going off, do a head count of the residents, and check the outside of the facility for any resident(s). LVN P stated another in-service was to not leave residents outside in the back patio area alone. LVN P stated during the in-service it was asked, What do you do if a resident was seen outside in the back patio area by themselves? and it had to be answered. LVN P stated that the in-servicer did test his knowledge on the material by asking him questions and giving him a quiz on it. LVN P stated they were also in-serviced with not sharing the code with visitors or residents. During an interview on 02/17/24 at 12:48 PM, with LVN Q, he stated, he received an in-service on not leaving a resident outside alone in the back patio area. LVN Q stated that a facility staff member had to be with the resident at all times outside. LVN Q stated they were told not to share the code with family or residents. LVN Q stated he was asked questions about the in-service he had received and had to answer them. During an interview on 02/17/24 at 12:42 PM, with LVN I, she stated, she had received several in-services such as not leaving a resident unattended outside in the back patio area. LVN I stated she was in-serviced on door alarms. LVN I stated she had to respond to door alarms as soon as they went off. LVN I stated a code orange had to be called if a resident was missing for more than 30 minutes, a head count had to be done, and the police notified. LVN I stated they were in-serviced not to share the codes with visitors, family, and residents. LVN I stated she was questioned on the in-service like it was a test. During an interview on 02/17/24 at 1:15 PM, with MA R, she stated, she was in-serviced on the facility doors having to be closed when they or someone exits. MA R stated that she was in-serviced on not leaving a resident alone in the back patio area and a staff had to be with them. MA R stated she was questioned on what was in-serviced. During an interview on 02/17/24 at 1:23 PM, with ADON G, she stated, she had received an in-service on not leaving a resident outside alone in the back patio area. ADON G stated if a resident was outside the facility staff would have to immediately go outside and be with the resident. ADON G stated she was in-serviced on not giving the code to the residents, family, and visitors. ADON G stated she did not have the code to the back patio gate. ADON G stated she was questioned over the in-service(s) of not sharing the codes, closing the exit doors behind them, and not leaving a resident alone outside by themselves to check her knowledge. During an interview on 02/17/24 at 1:31 PM, with CNA T, she stated, an in-service of not sharing the door codes with residents nor family or visitors. CNA T stated resident could not be left alone outside in the back patio area and a staff had to be with them when outside. CNA T stated she was questioned over the material being presented. During an interview on 02/17/24 at 1:43 PM, with CNA U, she stated, she was in-serviced on when residents were in the back patio area. CNA U stated if residents want to go outside then a staff member had to go outside with them. CNA U stated if a resident was seen outside alone then the staff would have to go outside and stay with the resident until relieved or the resident came inside. CNA U stated she had received a quiz on the in-service. During an interview on 02/17/24 at 1:52 PM, with LVN V, she stated, she had received an in-service on residents could not be alone in the back patio area. LVN V stated facility staff had to go outside and stay with the resident. LVN V stated the exit doors had to be closed if a staff went outside and they had to ensure it was closed. LVN V stated she was in-serviced on not sharing the code with family, residents, or visitors. LVN V stated she was asked questions about the in-services. Observation on 02/17/24 at 2:32 PM, heard and saw facility staff checking the door alarms in the back dining area. Maintenance Director was seen going to each hallway and inspecting each door and making sure the door alarms rang. Record review of the facility Monitoring Tools dated 02/17/24, revealed, the following: Change back gait code do not share with staff Staff will not share the code with residents or families or visitors The back door leading to the patio area was to be closed at all times, a code was needed to enter and exit the building No resident was to be left unsupervised in the patio area Record review of the facility Monitoring Tools dated 02/17/24, revealed, the following: Monitoring Backdoor Patio Door - Maintenance Director will monitor the back door every 2 hours during the day Monday-Friday for a week, then daily for a week, then randomly. Monitoring Chart (Patio Door) - Frequency of monitoring: Every 2 hours. In-Services - The Administrator will audit all new employee filles to ensure in-services are being completed. After the Plan or Removal and Monitoring: The Administrator was informed the Immediate Jeopardy was removed on 02/17/24 at 3:35 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility's need to reevaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to implement written policies that prohibit and prevent abuse for one (Resident #2) of four residents reviewed for abuse The facility failed to implement their abuse policy when they failed to report, investigate and protect residents from further potential abuse when Resident #2 made an allegation of sexual abuse An IJ Immediate Jeopardy (IJ) was identified on 02/16/24. The IJ template was provided to the facility on [DATE] at 3:01 PM. While the IJ was removed on 02/17/24, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern as the facility was continuing to monitor its plan for effectiveness. This failure could place all residents at risk for sexual abuse/exploitation and other abuses by not immediately following the facility policy and procedure manual of recognizing, reporting, investigating, allegations of sexual abuse/exploitation and other abuses. Findings Include: Record review of the facility Abuse/Neglect policy and procedure manual dated 03/29/18, revealed, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. It was each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Sexual Abuse: Non-consensual sexual contact of any type with a resident. Reporting - Any person having reasonable cause to believe an elderly or incapacitated adult was suffering from abuse, neglect, or exploitation must report this to the DON, Administrator, state and or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated persons. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriate of resident properly or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet criteria of Provider Letter 19-17 dated 07/10/19. Investigation - Comprehensive investigations will be the responsibility of the administrator and or the Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. Record review of Resident #2's face sheet dated 02/13/24, revealed admission on [DATE] to the facility. Record review of Resident #2's most recent facility history and physical in the system dated 12/21/20, revealed a [AGE] year-old female (present age [AGE] year-old) diagnosed with Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes), Vascular Dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage, and cachexia (a complicated metabolic syndrome related to underlying illness and characterized by muscle mass loss with or without fat mass loss). Record review of Resident #2's quarterly MDS dated [DATE], revealed a moderate impaired cognition BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements) score of 11 to be able to make daily decision and recall information. Resident #2 needed partial/moderate (half the help) assistance from nursing staff to help in showering/bathing. Resident #2 was diagnosed with Non-Alzheimer's Dementia, muscle wasting, lack of coordination, and muscle weakness (no muscle strength). Record review of Resident #2's care plan dated 12/19/20, revealed for bathing she required two staff for assistances. Care plan dated 12/19/20 revealed impaired cognitive function or impaired thought processes due to Dementia. Engage the resident in simple, structed activities that avoid overly demanding tasks. Monitor/document/report to medical doctor any changes in cognitive function, specially changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding other, level of consciousness, mental status. Record review of Resident #2's [NAME] (documentation on the facility system that CNAs use to view resident care) dated 02/17/24, revealed bathing: requires staff x2 for assistance. Record review of Resident #2's shower report dated 02/02/24 at 8:16 PM and 02/09/24 at 5:57 PM, revealed CNA H had showered/bathed Resident #2. Record review of CNA H's time sheet dated 02/02/24 and 02/09/24, revealed he had been working on Resident #2's shower days on Friday 02/02/24 and 02/09/24. Resident #2 showers on Mondays, Wednesdays and Fridays of every week. Record review of Resident #2's Weekly Assessments, Event Note Assessments, all other Assessments dated 02/12/24, revealed, from 02/02/24 to 02/13/24 did not indicate any assessments were conducted for the sexual abuse/exploitation allegation of Resident #2. Record review of Resident #2's Progress Notes dated 02/12/24 revealed, from 02/02/24 to 02/13/24, did not indicate any assessments were conducted or any information regarding the sexual abuse/exploitation allegation of Resident #2. Record review and observation of text message provided to surveyor between LVN F, LVN E, and DON 02/02/24 at 5:17 PM read as follows: LVN F when you get a chance can you go talk to Resident #2, she told the Business Office Assistant that when CNA H or CNA O bath her they do something to her. At 5:25 PM - LVN F stated, Yes I will. At 5:28 PM - DON stated, thank you, let me know what she says. At 6:08 PM - LVN F stated, Resident #2 says she feels CNA H touches her inappropriately when he's bathing her. At 6:13 PM - DON stated, OMG (oh my god). LVN F stated, Shouldn't the Social Worker and Administrator have interviewed Resident #2. I feel like that's serious allegations. LVN E stated, Resident #2 says that when CNA H's washing her he washes her Parts and she feels him put his fingers inside of her. DON - stated she would talk to her on Monday (unknown which Monday). LVN F stated, No one came to help out. Nothing else follows in the text message in regard to the sexual abuse/exploitation outcry from Resident #2. During an interview on 02/12/24 at 4:42 PM, with LVN F, he stated that he had received a text message on 0202/24 from the DON revealing that Resident #2 was stating CNA H was touching her in her private parts during shower/bath time. LVN F stated he and LVN E went to go speak with Resident #2 on 02/02/24 after he received the text message from the DON; in which she told them that CNA H was touching her and would stick his fingers inside of her when he showered her and did not want CNA H to shower her anymore. LVN F stated he thought it was a serious allegation and thought the Administrator and Social Worker would be the ones to go interview Resident #2 regarding her allegation. During an interview on 02/12/24 at 5:12 PM with LVN E, she stated the DON had sent LVN F a text message wanting for LVN F to go speak to Resident #2 about her allegation. LVN E stated that she went with LVN F to go talk to Resident #2 in which she stated that CNA H had touched her in her private parts. LVN E stated the DON and Administrator should have been the ones to go and interview Resident #2. LVN E stated Resident #2 claimed that CNA H would penetrate her through the shower chair and would go underneath the bottom of the shower chair. During an interview on 02/13/24 at 1:00 PM with Resident #2, she stated she had reported to LVN F that Resident #2 had been touching her down there when CNA H showers her. Resident #2 stated CNA H will put on his music and dance while he showers her. Resident #2 stated she did not have strength and was weak to fight back against CNA H. Resident #2 stated this happened everytime CNA H would shower her. Resident #2 stated she did not want CNA H around her and did not feel safe around him. Resident #2 stated she had not reported at first due to feeling embarrassed. During an interview on 02/13/24 at 1:35 PM with the DON, she stated that Resident #2 had made an outcry of sexual abuse/exploitation to the Business Office Assistant on 02/02/24. The DON stated the Business Office Assistant was told by Resident #2 that CNA H had touched Resident #2 in her private area. The DON stated she had instructed LVN F to go and speak with Resident #2 regarding the sexual abuse/exploitation outcry and report back to her what she had said. The DON stated she was still working on the investigation. The DON stated she had not done any assessments on Resident #2. The DON stated LVN E had done a body assessment for Resident #2, but it was not documented. The DON stated if it was not documented it did not happen. The DON stated she could not recall the exact date of Resident #2's sexual abuse/exploitation outcry. The DON stated she had not imputed anything into the computer. The DON stated there was no reason for the delay for not documenting and doing an assessment on Resident #2. The DON stated she would consider an outcry of sexual abuse/exploitation to be very important. The DON stated CNA H was not suspended and was still working at the facility and would not be able to answer why CNA H was not suspended. The DON stated CNA H was still working after the incident and there still existed a risk to the resident(s) of being sexually abuse/exploited. The DON stated it had not been reported to state survey agency and had no reason for the delay to notify state survey agency. The DON stated the Administrator was to report abuse and neglect allegations/incidents. The DON stated she had not reported it to the Administrator and said she had no explanation why she did not report it to her. During an interview on 02/13/24 at 2:55 PM with the Administrator, she stated she was unaware of the alleged allegation from Resident #2 of sexual abuse/exploitation. The Administrator stated she was just notified right now of the sexual abuse/exploitation outcry for Resident #2 from LVN F. The Administrator stated she was told by LVN F that Resident #2 had alleged CNA H had touched her inappropriately. The Administrator stated LVN F told the DON about what Resident #2 had alleged. The Administrator stated she was not told by the DON what Resident #2 had alleged. The Administrator stated once an outcry of an allegation has been made, it needed to be reported to the Abuse Coordinator which was her. The Administrator stated she would take measures to talk to the resident and see what had happened as well as suspend the staff to ensure the safety of the Resident #2 until the conclusion of the investigation. The Administrator stated there could be a risk if the outcome was proven correct in that CNA H did do the sexual abuse/exploitation. The Administrator stated she had sent CNA H home immediately as soon as she found out. The Administrator stated she still needed to go speak to Resident #2. The Administrator stated she did not know if a body assessment was conducted for Resident #2. The Administrator stated she did not report it to state survey agency as she was not notified of the sexual abuse/exploitation allegation. The Administrator stated facility staff were trained on abuse, neglect, and exploitation and facility staff did not follow the facility abuse policy protocol for reporting. The Administrator stated it would have been protocol for the nurses to do a body assessment. During an interview on 02/13/24 at 4:35 PM with the Social Worker, she stated she was just notified of the alleged allegation made of sexual abuse/exploitation from Resident #2 and was conducting interviews with the facility residents. The Social Worker stated Resident #2 had told her that she had reported CNA H. The Social Worker stated Resident #2 told her that CNA H touches her in her private parts and when he wipes her that he sticks his fingers in her. The Social Worker stated Resident #2 commented that CNA H puts on the music and begins to dance to it while he was showering her. The Social Worker stated Resident #2 had not reported it when it was happening because she felt embarrassed to report it and ashamed to tell her (family member). The Social Worker stated Resident #2 did not feel safe when CNA H was working at the facility. During an interview on 02/16/24 at 2:08 PM with the Administrator, she stated that law enforcement was not notified on 02/02/24. The Administrator stated during the investigation a head-to-toe assessment of Resident #2 was done by LVN F and LVN E indicating no harm to Resident #2. The Administrator stated the facility only contacts the police if there was harm. The Administrator stated both LVN F and LVN E did the body assessment but was only verbally communicated but there was not documentation of the incident or assessment. During an interview on 02/16/24 at 2:26 PM with LVN F, he stated he was never told to do a body assessment on Resident #2. LVN F stated there was no body assessment done on 02/02/24. LVN F stated he would have to have had a physician order or a directive from his DON to conduct the body assessment which there were none of. LVN F stated he was not trained or certified on assessing residents who claim sexual abuse/exploitation. LVN F stated he did not know what to look for. LVN F stated if he was looking for anything it would be bruises or marks on Resident #2. LVN F stated he recommended for Resident #2 to have been sent out to the hospital to have a rape kit done. LVN F stated on 02/13/24 he was told to go assess Resident #2. During an interview on 02/16/24 at 2:39 PM with LVN E, she stated she was never told to do a head-to-toe body assessment on Resident #2 on 02/02/24. LVN E stated she quickly checked Resident #2's thigh and opened up her brief to see if there was any bruises or marks but did not know what to look for as she was not trained or certified to conduct a sexual assessment on a resident. LVN E stated when a resident claims sexual abuse/exploitation that they were sent out to the hospital to go get checked out. LVN E stated on 02/13/24, she was directed to go assess Resident #2. During an interview on 02/17/24 at 5:02 PM with the Regional Nurse, she stated the facility nurses were not trained or certified to do sexual assessments but could assess the resident externally to see if there was any bruises or markings. Record review of the facility's Documentation policy and procedure manual dated 2003 revealed, Documentation was the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has a legal requirement regarding accuracy and completeness, legibility, and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessments, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets weekly, daily, monthly, discharge). Goal- The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. The facility will ensure that information was comprehensive and timely and properly signed. Document completed assessments in a timely manner and per policy. Complete documentation in narrative nursing notes as needed in a timely manner. Daily documentation x72 hours will be required for each shift for new admissions, during and following an acute episode, following an incident, and during physiologic, mental, or emotional changes or instability. Record review of the facility Event Reporting: Completion Of (Regional Nurse stated this was the facility's accident policy) policy and procedure not dated revealed, Investigation: The investigation should be completed by the DON/Administrator or designee. The investigation report documents a though investigation of the events of the reported Event including person, equipment, and materials that were involved. The investigation report must include what actions were taken to prevent subsequent Events and signatures of the individuals as indicated on the form. The facility will complete an Event report on variances that occur with the facility. Variances include falls, skin tears, bruises, abrasions, lacerations, fractures, choking, burns, elopement, or behavior that affects others. Record review of the facility Bath, Tub/Shower policy and procedures dated 2003, revealed, The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. The resident will experience improved comfort and cleanliness by bathing. Become familiar with type and pattern of bathing, assistance or aids needed, skin condition, presence of dress or casts. Remain with the resident if he was weak or assistance was needed in washing. The Administrator and DON were informed on 02/16/24 at 3:01 PM, that an Immediate Jeopardy (IJ) had been identified and a copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested. 02/16/24 at 5:19 PM - Area Director of operations submitted 1st Plan of Removal. 02/16/24 at 6:27 PM - Facility was notified of the 1st denied Plan of Removal. 02/16/24 at 7:51 PM - Administrator submitted 2nd Plan of Removal. 02/17/24 at 11:12 AM - Facility notified of 2nd denied Plan of Removal. 02/17/24 at 11:50 AM - Administrator was notified of approved Plan of Removal. The Plan of Removal revealed the facility took the following actions: Interventions: One on One in-service on Abuse Reporting with the Administrator, DON, and Social Worker by Area Director of Operation on 2/13/2024 at 4:30 pm Staff working with Alleged perpetrators have been interviewed by ADO. The resident is doing ok; no distress was noted, and the resident was able to voice concerns. The alleged perpetrator was suspended on 2/13/2024 at 4:30 pm, pending the outcome of the investigation. Investigation completed on 2/14/2024. Resident safety surveys were initiated by the social worker on 2/13/2024, and no abuse incidents have been reported. Completion date of 2/13/2024 DON was suspended on 2/16/24 at 4:30 pm, pending the outcome of the investigation. The following in-services were initiated on 2/13/2024 by Administrator/ADO: Any staff member not present or in-service on 2/13/2024 will not be allowed to assume their duties until in-service. o All Staff Abuse/Neglect Abuse/Neglect Reporting Who to Report Abuse/Neglect to All in-serviced staff will need to be able to articulate back on reporting any abuse allegation and to whom to report. Completion date 2/17/2024 o The administrator/designee will assess and monitor understanding by quizzing and providing examples on in-services. New staff will be in service during orientation. Any employees who are allegedly involved in any abuse will be suspended pending investigation. The medical director was notified of the immediate jeopardy situation on 2/16/2024 at 4:40. Monitoring The administrator will report any abuse allegations, investigate, and submit findings to the Area Director and Risk Management for review. The administrator will submit documentation of the investigation with Resident and Staff interviews, as well as weekly follow-up interviews with staff and residents x 4 weeks to ensure resident safety/satisfaction with the outcome of the investigation. The Area Director will monitor abuse allegations reported and check the real-time system, which monitors keywords like abuse x 4 weeks' documentation and PCC for any incidents and accidents. The QA committee will review findings of abuse allegations and investigations monthly and make changes to the system as needed. On 02/17/24 at 11:55 AM Verification phase began with the facility approved Plan of Removal. During an interview on 02/17/24 at 11:57 AM with the Administrator and Area Director of Operations, the Area director of Operations stated on 02/13/24 at 4:30 PM she had already in-serviced the Administrator, DON, and Social Worker regarding Abuse Reporting. The Administrator stated on 02/13/24 at 4:30 PM CNA H was suspended pending the outcome of the investigation for Resident #2. The Area Director of Operations stated on 02/16/24 at 4:30 PM the DON was suspended pending the outcome of the investigation. The Area Director of Operations stated the facility had completed the investigation on 02/14/24, for Resident #2 and was found to be unconfirmed. The Administrator stated on 02/13/24 a Safety Survey of the residents was conducted by the Social Worker and found no abuse incidents had been reported by the residents. The Administrator stated the facility was moving forward with termination of CNA H with unrelated issues to the alleged allegation. The Administrator stated Resident #2 stated she was doing fine, able to voice concerns, and no distress was noted. The Administrator and Area Director of Operations stated on 02/13/24 an in-service was initiated by both Administrator and Area Director of Operations for Abuse/Neglect, Abuse/Neglect Reporting, and Who to report Abuse/Neglect too. The Administrator stated facility staff not present, during the in-service will not be allowed to resume their duties until in-serviced. The Administrator stated on 02/17/24 all in-services provided to facility staff had to be communicate back to the presenter acknowledging they understood what was being in-serviced on. The Administrator stated quizzes were given and examples had to be provided by the in-service-e confirming understanding of the material. The Administrator stated new employees would be in-serviced on during orientation. The Administrator stated all alleged employees involved in an allegation will be suspended pending the outcome of the investigation. The Area Director of Operation stated on 02/16/24 at 4:40 PM the Medical Director was notified of the Immediate Jeopardy, commenting that the facility will have to get better. The Area Director of Operation stated the Administrator was to report any and all allegations of abuse and submit all documentation for investigations conducted which would be reviewed by Area Director of Operations and Risk Management. The Area Director of Operations stated the Administrator was also to submit interviews with staff and residents related to investigations four times a week to ensure safety/satisfaction outcomes. The Area Director of Operations stated the facility system will be checked for key words like abuse four times a week for incidents or accidents that might have happened or have been documented. The Administrator stated an off-cycle Quality Assurance meeting was held on 02/16/24 at 5:00 PM, regarding the Immediate Jeopardy and follow ups will be held monthly to see if adjustments are needed to abuse allegations and investigations. During an interview on 02/17/24 at 12:42 PM with LVN P, he stated, he had received an in-service on abuse. LVN P stated that any kind abuse had to be reported to the Administrator immediately. LVN P stated during the in-service it was talked about the 5 different types of abuses such as emotional, verbal, physical, sexual, and financial abuse to include injuries of unknown origin. LVN P stated that the in-servicer did test his knowledge on the material by asking him questions and giving him a quiz on it. During an interview on 02/17/24 at 12:48 PM with LVN Q, he stated, he received an in-service on abuse and neglect. LVN Q stated as soon as an alleged allegation was made or suspect, it must be reported immediately to the Administrator. LVN Q stated he was asked questions about the in-service he had received and had to answer them. During an interview on 02/17/24 at 12:42 PM with LVN I, she stated, she had received several in-services such as abuse. LVN I stated she was told of the different types of abuses and if she saw or suspected abuse happening who to report it to. LVN I stated she had to report abuse to the Administrator who was the Abuse Coordinator. LVN I stated she was questioned on the in-service like it was a test. During an interview on 02/17/24 at 1:15 PM with MA R, she stated, she was in-serviced on abuse and neglect. MA R stated any suspected or seen abuse had to be report to the Abuse Coordinator which was the Administrator. MA R stated she was questioned on what was in-serviced. During an interview on 02/17/24 at 1:23 PM with ADON G, she stated, she had received an in-service regarding abuse and neglect. ADON G stated they told her what constitutes abuse and neglect and who to report it to. ADON G stated abuse was reported to the Administrator immediately. ADON G stated she was questioned over the in-service(s) of abuse to check her knowledge. During an interview on 02/17/24 at 1:31 PM with CNA T, she stated, an in-service of abuse was given to her. CNA T stated it entailed what abuse was and the different types. CNA T stated she was questioned over the material being presented. CNA T stated any kind of abuse had to be reported immediately to the Administrator. During an interview on 02/17/24 at 1:43 PM with CNA U, she stated, she was in-serviced on abuse regarding the different types of abuse. CNA U stated staff were to report if someone talks bad or physically hits a resident. bad or physically hits them. CNA U stated it had to be reported to the Administrator. CNA U stated she had received a quiz on the in-service. During an interview on 02/17/24 at 1:52 PM with LVN V, she stated, she had received an in-service on abuse and neglect on 02/16/24. LVN V stated to report anything the facility staff felt was abuse and who to report it to. LVN V stated it was to be reported to the Abuse Coordinator which was the Administrator. LVN V stated she was asked questions about what they felt it was reportable and why. Record review of the facility Monitoring Tools dated 02/17/24, revealed, the following: In-Services - The Administrator will audit all new employee filles to ensure in-services are being completed. Ensure Quizzes are being completed - Administrator will gather quiz sheet 3 per day. Record review of the facility In-services dated 02/13/24, 02/14/24, 02/16/24 revealed, the following: Abuse Reporting/Investigation Abuse and Neglect After the Plan or Removal and Monitoring: The Administrator was informed the Immediate Jeopardy was removed on 02/17/24 at 3:35 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern as the facility was continuing to monitor it's plan for effectiveness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed ensure alleged violations involving abuse, including sexual abuse/exploitation are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #2) of 4 residents reviewed for reporting. The facility failed to report Resident #2's sexual abuse/exploitation in which Resident #2 claimed CNA H had touched in her private parts and when wiping would stick his fingers inside her when he showered her to the Administrator, to other officials, and to State Survey Agency. An IJ Immediate Jeopardy (IJ) was identified on 02/16/24. The IJ template was provided to the facility on [DATE] at 3:01 PM. While the IJ was removed on 02/17/24, the facility remained out of compliance at a at a severity level of potential for more than minimal harm and a scope of pattern as the facility was continuing to monitor it's plan for effectiveness. This failure could place all residents at risk for sexual abuse/exploitation by not immediately reporting allegations of sexual abuse/exploitation to the proper authorities at the facility, other officials, and state survey agency. Findings Include: Record review of Resident #2's face sheet dated 02/13/24, revealed admission on [DATE] to the facility. Record review of Resident #2's most recent facility history and physical in the system dated 12/21/20, revealed a [AGE] year-old female (present age [AGE] year-old) diagnosed with Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes), Vascular Dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage, and cachexia (a complicated metabolic syndrome related to underlying illness and characterized by muscle mass loss with or without fat mass loss). Record review of Resident #2's quarterly MDS dated [DATE], revealed a moderate impaired cognition BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements) score of 11 to be able to make daily decision and recall information. Resident #2 needed partial/moderate (half the help) assistance from nursing staff to help in showering/bathing. Resident #2 was diagnosed with Non-Alzheimer's Dementia, muscle wasting, lack of coordination, and muscle weakness (no muscle strength). Record review of Resident #2's care plan dated 12/19/20, revealed for bathing she required two staff for assistances. Care plan dated 12/19/20 revealed impaired cognitive function or impaired thought processes due to Dementia. Engage the resident in simple, structed activities that avoid overly demanding tasks. Monitor/document/report to medical doctor any changes in cognitive function, specially changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding other, level of consciousness, mental status. Record review of Resident #2's [NAME] (documentation on the facility system that CNAs use to view resident care) dated 02/17/24, revealed bathing: requires staff x2 for assistance. Record review of Resident #2's shower report dated 02/02/24 at 8:16 PM and 02/09/24 at 5:57 PM, revealed CNA H had showered/bathed Resident #2. Record review of CNA H's time sheet dated 02/02/24 and 02/09/24, revealed he had been working on Resident #2's shower days on Friday 02/02/24 and 02/09/24. Resident #2 showers on Mondays, Wednesdays and Fridays of every week. Record review of Resident #2's Weekly Assessments, Event Note Assessments, all other Assessments dated 02/12/24, revealed, from 02/02/24 to 02/13/24 did not indicate any assessments were conducted for the sexual abuse/exploitation allegation of Resident #2. Record review of Resident #2's Progress Notes dated 02/12/24 revealed, from 02/02/24 to 02/13/24, did not indicate any assessments were conducted or any information regarding the sexual abuse/exploitation allegation of Resident #2. Record review and observation of text message provided to surveyor between LVN F, LVN E, and DON 02/02/24 at 5:17 PM read as follows: LVN F when you get a chance can you go talk to Resident #2, she told the Business Office Assistant that when CNA H or CNA O bath her they do something to her. At 5:25 PM - LVN F stated, Yes I will. At 5:28 PM - DON stated, thank you, let me know what she says. At 6:08 PM - LVN F stated, Resident #2 says she feels CNA H touches her inappropriately when he's bathing her. At 6:13 PM - DON stated, OMG (oh my god). LVN F stated, Shouldn't the Social Worker and Administrator have interviewed Resident #2. I feel like that's serious allegations. LVN E stated, Resident #2 says that when CNA H's washing her he washes her Parts and she feels him put his fingers inside of her. DON - stated she would talk to her on Monday (unknown which Monday). LVN F stated, No one came to help out. Nothing else follows in the text message in regard to the sexual abuse/exploitation outcry from Resident #2. During an interview on 02/12/24 at 4:42 PM, with LVN F, he stated that he had received a text message on 0202/24 from the DON revealing that Resident #2 was stating CNA H was touching her in her private parts during shower/bath time. LVN F stated he and LVN E went to go speak with Resident #2 on 02/02/24 after he received the text message from the DON; in which she told them that CNA H was touching her and would stick his fingers inside of her when he showered her and did not want CNA H to shower her anymore. LVN F stated he thought it was a serious allegation and thought the Administrator and Social Worker would be the ones to go interview Resident #2 regarding her allegation. During an interview on 02/12/24 at 5:12 PM with LVN E, she stated the DON had sent LVN F a text message wanting for LVN F to go speak to Resident #2 about her allegation. LVN E stated that she went with LVN F to go talk to Resident #2 in which she stated that CNA H had touched her in her private parts. LVN E stated the DON and Administrator should have been the ones to go and interview Resident #2. LVN E stated Resident #2 claimed that CNA H would penetrate her through the shower chair and would go underneath the bottom of the shower chair. During an interview on 02/13/24 at 1:00 PM with Resident #2, she stated she had reported to LVN F that Resident #2 had been touching her down there when CNA H showers her. Resident #2 stated CNA H will put on his music and dance while he showers her. Resident #2 stated she did not have strength and was weak to fight back against CNA H. Resident #2 stated this happened everytime CNA H would shower her. Resident #2 stated she did not want CNA H around her and did not feel safe around him. Resident #2 stated she had not reported at first due to feeling embarrassed. During an interview on 02/13/24 at 1:35 PM with the DON, she stated that Resident #2 had made an outcry of sexual abuse/exploitation to the Business Office Assistant on 02/02/24. The DON stated the Business Office Assistant was told by Resident #2 that CNA H had touched Resident #2 in her private area. The DON stated she had instructed LVN F to go and speak with Resident #2 regarding the sexual abuse/exploitation outcry and report back to her what she had said. The DON stated she was still working on the investigation. The DON stated she had not done any assessments on Resident #2. The DON stated LVN E had done a body assessment for Resident #2, but it was not documented. The DON stated if it was not documented it did not happen. The DON stated she could not recall the exact date of Resident #2's sexual abuse/exploitation outcry. The DON stated she had not imputed anything into the computer. The DON stated there was no reason for the delay for not documenting and doing an assessment on Resident #2. The DON stated she would consider an outcry of sexual abuse/exploitation to be very important. The DON stated CNA H was not suspended and was still working at the facility and would not be able to answer why CNA H was not suspended. The DON stated CNA H was still working after the incident and there still existed a risk to the resident(s) of being sexually abuse/exploited. The DON stated it had not been reported to state survey agency and had no reason for the delay to notify state survey agency. The DON stated the Administrator was to report abuse and neglect allegations/incidents. The DON stated she had not reported it to the Administrator and said she had no explanation why she did not report it to her. During an interview on 02/13/24 at 2:55 PM with the Administrator, she stated she was unaware of the alleged allegation from Resident #2 of sexual abuse/exploitation. The Administrator stated she was just notified right now of the sexual abuse/exploitation outcry for Resident #2 from LVN F. The Administrator stated she was told by LVN F that Resident #2 had alleged CNA H had touched her inappropriately. The Administrator stated LVN F told the DON about what Resident #2 had alleged. The Administrator stated she was not told by the DON what Resident #2 had alleged. The Administrator stated once an outcry of an allegation has been made, it needed to be reported to the Abuse Coordinator which was her. The Administrator stated she would take measures to talk to the resident and see what had happened as well as suspend the staff to ensure the safety of the Resident #2 until the conclusion of the investigation. The Administrator stated there could be a risk if the outcome was proven correct in that CNA H did do the sexual abuse/exploitation. The Administrator stated she had sent CNA H home immediately as soon as she found out. The Administrator stated she still needed to go speak to Resident #2. The Administrator stated she did not know if a body assessment was conducted for Resident #2. The Administrator stated she did not report it to state survey agency as she was not notified of the sexual abuse/exploitation allegation. The Administrator stated facility staff were trained on abuse, neglect, and exploitation and facility staff did not follow the facility abuse policy protocol for reporting. The Administrator stated it would have been protocol for the nurses to do a body assessment. During an interview on 02/13/24 at 4:35 PM with the Social Worker, she stated she was just notified of the alleged allegation made of sexual abuse/exploitation from Resident #2 and was conducting interviews with the facility residents. The Social Worker stated Resident #2 had told her that she had reported CNA H. The Social Worker stated Resident #2 told her that CNA H touches her in her private parts and when he wipes her that he sticks his fingers in her. The Social Worker stated Resident #2 commented that CNA H puts on the music and begins to dance to it while he was showering her. The Social Worker stated Resident #2 had not reported it when it was happening because she felt embarrassed to report it and ashamed to tell her (family member). The Social Worker stated Resident #2 did not feel safe when CNA H was working at the facility. During an interview on 02/16/24 at 2:08 PM with the Administrator, she stated that law enforcement was not notified on 02/02/24. The Administrator stated during the investigation a head-to-toe assessment of Resident #2 was done by LVN F and LVN E indicating no harm to Resident #2. The Administrator stated the facility only contacts the police if there was harm. The Administrator stated both LVN F and LVN E did the body assessment but was only verbally communicated but there was not documentation of the incident or assessment. During an interview on 02/16/24 at 2:26 PM with LVN F, he stated he was never told to do a body assessment on Resident #2. LVN F stated there was no body assessment done on 02/02/24. LVN F stated he would have to have had a physician order or a directive from his DON to conduct the body assessment which there were none of. LVN F stated he was not trained or certified on assessing residents who claim sexual abuse/exploitation. LVN F stated he did not know what to look for. LVN F stated if he was looking for anything it would be bruises or marks on Resident #2. LVN F stated he recommended for Resident #2 to have been sent out to the hospital to have a rape kit done. LVN F stated on 02/13/24 he was told to go assess Resident #2. During an interview on 02/16/24 at 2:39 PM with LVN E, she stated she was never told to do a head-to-toe body assessment on Resident #2 on 02/02/24. LVN E stated she quickly checked Resident #2's thigh and opened up her brief to see if there was any bruises or marks but did not know what to look for as she was not trained or certified to conduct a sexual assessment on a resident. LVN E stated when a resident claims sexual abuse/exploitation that they were sent out to the hospital to go get checked out. LVN E stated on 02/13/24, she was directed to go assess Resident #2. During an interview on 02/17/24 at 5:02 PM with the Regional Nurse, she stated the facility nurses were not trained or certified to do sexual assessments but could assess the resident externally to see if there was any bruises or markings. Record review of the facility's Abuse/Neglect policy and procedure manual dated 03/29/18 revealed, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. It was each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Sexual Abuse: Non-consensual sexual contact of any type with a resident. Reporting - Any person having reasonable cause to believe an elderly or incapacitated adult was suffering from abuse, neglect, or exploitation must report this to the DON, Administrator, state and or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated persons. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriate of resident properly or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet criteria of Provider Letter 19-17 dated 07/10/19. Record review of the facility's Documentation policy and procedure manual dated 2003 revealed, Documentation was the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has a legal requirement regarding accuracy and completeness, legibility, and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessments, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets weekly, daily, monthly, discharge). Goal- The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. The facility will ensure that information was comprehensive and timely and properly signed. Document completed assessments in a timely manner and per policy. Complete documentation in narrative nursing notes as needed in a timely manner. Daily documentation x72 hours will be required for each shift for new admissions, during and following an acute episode, following an incident, and during physiologic, mental, or emotional changes or instability. Record review of the facility Event Reporting: Completion Of (Regional Nurse stated this was the facility's accident policy) policy and procedure not dated revealed, Investigation: The investigation should be completed by the DON/Administrator or designee. The investigation report documents a though investigation of the events of the reported Event including person, equipment, and materials that were involved. The investigation report must include what actions were taken to prevent subsequent Events and signatures of the individuals as indicated on the form. The facility will complete an Event report on variances that occur with the facility. Variances include falls, skin tears, bruises, abrasions, lacerations, fractures, choking, burns, elopement, or behavior that affects others. Record review of the facility Bath, Tub/Shower policy and procedures dated 2003, revealed, The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. The resident will experience improved comfort and cleanliness by bathing. Become familiar with type and pattern of bathing, assistance or aids needed, skin condition, presence of dress or casts. Remain with the resident if he was weak or assistance was needed in washing. The Administrator and DON were informed on 02/16/24 at 3:01 PM, that an Immediate Jeopardy (IJ) had been identified and a copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested. 02/16/24 at 5:19 PM - Area Director of operations submitted 1st Plan of Removal. 02/16/24 at 6:27 PM - Facility was notified of the 1st denied Plan of Removal. 02/16/24 at 7:51 PM - Administrator submitted 2nd Plan of Removal. 02/17/24 at 11:12 AM - Facility notified of 2nd denied Plan of Removal. 02/17/24 at 11:50 AM - Administrator was notified of approved Plan of Removal. The Plan of Removal revealed the facility took the following actions: Interventions: One on One in-service on Abuse Reporting with the Administrator, DON, and Social Worker by Area Director of Operation on 2/13/2024 at 4:30 pm Staff working with Alleged perpetrators have been interviewed by ADO. The resident is doing ok; no distress was noted, and the resident was able to voice concerns. The alleged perpetrator was suspended on 2/13/2024 at 4:30 pm, pending the outcome of the investigation. Investigation completed on 2/14/2024. Resident safety surveys were initiated by the social worker on 2/13/2024, and no abuse incidents have been reported. Completion date of 2/13/2024 DON was suspended on 2/16/24 at 4:30 pm, pending the outcome of the investigation. The following in-services were initiated on 2/13/2024 by Administrator/ADO: Any staff member not present or in-service on 2/13/2024 will not be allowed to assume their duties until in-service. o All Staff Abuse/Neglect Abuse/Neglect Reporting Who to Report Abuse/Neglect to All in-serviced staff will need to be able to articulate back on reporting any abuse allegation and to whom to report. Completion date 2/17/2024 o The administrator/designee will assess and monitor understanding by quizzing and providing examples on in-services. New staff will be in service during orientation. Any employees who are allegedly involved in any abuse will be suspended pending investigation. The medical director was notified of the immediate jeopardy situation on 2/16/2024 at 4:40. Monitoring The administrator will report any abuse allegations, investigate, and submit findings to the Area Director and Risk Management for review. The administrator will submit documentation of the investigation with Resident and Staff interviews, as well as weekly follow-up interviews with staff and residents x 4 weeks to ensure resident safety/satisfaction with the outcome of the investigation. The Area Director will monitor abuse allegations reported and check the real-time system, which monitors keywords like abuse x 4 weeks' documentation and PCC for any incidents and accidents. The QA committee will review findings of abuse allegations and investigations monthly and make changes to the system as needed. On 02/17/24 at 11:55 AM Verification phase began with the facility approved Plan of Removal. During an interview on 02/17/24 at 11:57 AM with the Administrator and Area Director of Operations, the Area director of Operations stated on 02/13/24 at 4:30 PM she had already in-serviced the Administrator, DON, and Social Worker regarding Abuse Reporting. The Administrator stated on 02/13/24 at 4:30 PM CNA H was suspended pending the outcome of the investigation for Resident #2. The Area Director of Operations stated on 02/16/24 at 4:30 PM the DON was suspended pending the outcome of the investigation. The Area Director of Operations stated the facility had completed the investigation on 02/14/24, for Resident #2 and was found to be unconfirmed. The Administrator stated on 02/13/24 a Safety Survey of the residents was conducted by the Social Worker and found no abuse incidents had been reported by the residents. The Administrator stated the facility was moving forward with termination of CNA H with unrelated issues to the alleged allegation. The Administrator stated Resident #2 stated she was doing fine, able to voice concerns, and no distress was noted. The Administrator and Area Director of Operations stated on 02/13/24 an in-service was initiated by both Administrator and Area Director of Operations for Abuse/Neglect, Abuse/Neglect Reporting, and Who to report Abuse/Neglect too. The Administrator stated facility staff not present, during the in-service will not be allowed to resume their duties until in-serviced. The Administrator stated on 02/17/24 all in-services provided to facility staff had to be communicate back to the presenter acknowledging they understood what was being in-serviced on. The Administrator stated quizzes were given and examples had to be provided by the in-service-e confirming understanding of the material. The Administrator stated new employees would be in-serviced on during orientation. The Administrator stated all alleged employees involved in an allegation will be suspended pending the outcome of the investigation. The Area Director of Operation stated on 02/16/24 at 4:40 PM the Medical Director was notified of the Immediate Jeopardy, commenting that the facility will have to get better. The Area Director of Operation stated the Administrator was to report any and all allegations of abuse and submit all documentation for investigations conducted which would be reviewed by Area Director of Operations and Risk Management. The Area Director of Operations stated the Administrator was also to submit interviews with staff and residents related to investigations four times a week to ensure safety/satisfaction outcomes. The Area Director of Operations stated the facility system will be checked for key words like abuse four times a week for incidents or accidents that might have happened or have been documented. The Administrator stated an off-cycle Quality Assurance meeting was held on 02/16/24 at 5:00 PM, regarding the Immediate Jeopardy and follow ups will be held monthly to see if adjustments are needed to abuse allegations and investigations. During an interview on 02/17/24 at 12:42 PM with LVN P, he stated, he had received an in-service on abuse. LVN P stated that any kind abuse had to be reported to the Administrator immediately. LVN P stated during the in-service it was talked about the 5 different types of abuses such as emotional, verbal, physical, sexual, and financial abuse to include injuries of unknown origin. LVN P stated that the in-servicer did test his knowledge on the material by asking him questions and giving him a quiz on it. During an interview on 02/17/24 at 12:48 PM with LVN Q, he stated, he received an in-service on abuse and neglect. LVN Q stated as soon as an alleged allegation was made or suspect, it must be reported immediately to the Administrator. LVN Q stated he was asked questions about the in-service he had received and had to answer them. During an interview on 02/17/24 at 12:42 PM with LVN I, she stated, she had received several in-services such as abuse. LVN I stated she was told of the different types of abuses and if she saw or suspected abuse happening who to report it to. LVN I stated she had to report abuse to the Administrator who was the Abuse Coordinator. LVN I stated she was questioned on the in-service like it was a test. During an interview on 02/17/24 at 1:15 PM with MA R, she stated, she was in-serviced on abuse and neglect. MA R stated any suspected or seen abuse had to be report to the Abuse Coordinator which was the Administrator. MA R stated she was questioned on what was in-serviced. During an interview on 02/17/24 at 1:23 PM with ADON G, she stated, she had received an in-service regarding abuse and neglect. ADON G stated they told her what constitutes abuse and neglect and who to report it to. ADON G stated abuse was reported to the Administrator immediately. ADON G stated she was questioned over the in-service(s) of abuse to check her knowledge. During an interview on 02/17/24 at 1:31 PM with CNA T, she stated, an in-service of abuse was given to her. CNA T stated it entailed what abuse was and the different types. CNA T stated she was questioned over the material being presented. CNA T stated any kind of abuse had to be reported immediately to the Administrator. During an interview on 02/17/24 at 1:43 PM with CNA U, she stated, she was in-serviced on abuse regarding the different types of abuse. CNA U stated staff were to report if someone talks bad or physically hits a resident. bad or physically hits them. CNA U stated it had to be reported to the Administrator. CNA U stated she had received a quiz on the in-service. During an interview on 02/17/24 at 1:52 PM with LVN V, she stated, she had received an in-service on abuse and neglect on 02/16/24. LVN V stated to report anything the facility staff felt was abuse and who to report it to. LVN V stated it was to be reported to the Abuse Coordinator which was the Administrator. LVN V stated she was asked questions about what they felt it was reportable and why. Record review of the facility Monitoring Tools dated 02/17/24, revealed, the following: In-Services - The Administrator will audit all new employee filles to ensure in-services are being completed. Ensure Quizzes are being completed - Administrator will gather quiz sheet 3 per day. Record review of the facility In-services dated 02/13/24, 02/14/24, 02/16/24 revealed, the following: Abuse Reporting/Investigation Abuse and Neglect After the Plan or Removal and Monitoring: The Administrator was informed the Immediate Jeopardy was removed on 02/17/24 at 3:35 PM. The facility remained out of compliance at a at a severity level of potential for more than minimal harm and a scope of pattern as the facility was continuing to monitor it's plan for effectiveness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure violations are thoroughly investigated with results of the investigations presented to the administrator and to other officials in accordance with state law including to state survey agency, within 5 working days of the incident and if the alleged violation is verified appropriate corrective action must be taken for 1 (Resident #1) of 4 residents reviewed for incidents. The facility failed did not thoroughly investigate Resident #2's sexual abuse/exploitation in which Resident #2 claimed CNA H had touched in her private parts and when wiping would stick his fingers inside her when he showered her to the Administrator, to other officials, and to State Survey Agency. An IJ Immediate Jeopardy (IJ) was identified on 02/16/24. The IJ template was provided to the facility on [DATE] at 3:01 PM. While the IJ was removed on 02/17/24, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern as the facility was continuing to monitor it's plan for effectiveness. These failures could place residents at risk for abuse, neglect, exploitation, and elopement and decreased quality of life. Findings include: Record review of Resident #2's face sheet dated 02/13/24, revealed, admission on [DATE] to the facility. Record review of Resident #2's most recent facility history and physical in the system dated 12/21/20, revealed, a [AGE] year-old female (present age [AGE] year-old) diagnosed with Osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes), Vascular Dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage, and cachexia (a complicated metabolic syndrome related to underlying illness and characterized by muscle mass loss with or without fat mass loss). Record review of Resident #2's quarterly MDS dated [DATE], revealed, a cognitively intact BIMS (score is used regularly to measure and track a resident's cognitive decline or improvements) score of 11 to be able to make daily decision and recall information. Resident #2 needed partial/moderate (half the help) assistance from nursing staff to help in showering/bathing. Resident #14 was diagnosed with Non-Alzheimer's Dementia, muscle wasting, lack of coordination, and muscle weakness (no muscle strength). Record review of Resident #2's care plan dated 12/19/20, revealed for bathing she required two staff for assistances. Care plan dated 12/19/20 revealed impaired cognitive function or impaired thought processes due to Dementia. Engage the resident in simple, structed activities that avoid overly demanding tasks. Monitor/document/report to medical doctor any changes in cognitive function, specially changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding other, level of consciousness, mental status. Record review of Resident #2's [NAME] (documentation on the facility system that CNAs use to view resident care) dated 02/17/24, revealed bathing: requires staff x2 for assistance. Record review of Resident #2's shower report dated 02/02/24 at 8:16 PM and 02/09/24 at 5:57 PM, revealed CNA H had showered/bathed Resident #2. Record review of CNA H's time sheet dated 02/02/24 and 02/09/24, revealed he had been working on Resident #2's shower days on Friday 02/02/24 and 02/09/24. Resident #2 showers on Mondays, Wednesdays and Fridays of every week. Record review of Resident #2's Weekly Assessments, Event Note Assessments, all other Assessments dated 02/12/24, revealed, from 02/02/24 to 02/13/24 did not indicate any assessments were conducted for the sexual abuse/exploitation allegation of Resident #2. Record review of Resident #2's Progress Notes dated 02/12/24 revealed, from 02/02/24 to 02/13/24, did not indicate any assessments were conducted or any information regarding the sexual abuse/exploitation allegation of Resident #2. Record review and observation of text message provided to surveyor between LVN F, LVN E, and DON 02/02/24 at 5:17 PM read as follows: LVN F when you get a chance can you go talk to Resident #2, she told the Business Office Assistant that when CNA H or CNA O bath her they do something to her. At 5:25 PM - LVN F stated, Yes I will. At 5:28 PM - DON stated, thank you, let me know what she says. At 6:08 PM - LVN F stated, Resident #2 says she feels CNA H touches her inappropriately when he's bathing her. At 6:13 PM - DON stated, OMG (oh my god). LVN F stated, Shouldn't the Social Worker and Administrator have interviewed Resident #2. I feel like that's serious allegations. LVN E stated, Resident #2 says that when CNA H's washing her he washes her Parts and she feels him put his fingers inside of her. DON - stated she would talk to her on Monday (unknown which Monday). LVN F stated, No one came to help out. Nothing else follows in the text message in regard to the sexual abuse/exploitation outcry from Resident #2. During an interview on 02/12/24 at 4:42 PM, with LVN F, he stated, that he had received a message form the DON revealing that Resident #2 was stating CNA H was touching her in her private parts during shower/bathe time. LVN F stated he and LVN E went ot go speak with Resident #2 in which she told them that CNA H was touching her and would stick his fingers inside of her when he showered her and did not want CNA H to shower her anymore. LVN F stated he though it was a serious allegation and though the Administrator and Social Worker would be the ones to go interview Resident #2 regarding her allegation. During an interview on 02/12/24 at 5:12 PM, with LVN E, she stated, the DON had sent LVN F a text message wanting for LVN F to go speak to Resident #2 about her allegation. LVN E stated that she went with LVN F to go talk to Resident #2 in which she stated that CNA H had touched her in her private parts. LVN E stated the DON and Administrator should have been the ones to go and interview Resident #2. LVN E stated Resident #2 claimed that CNA H would penetrate her through the shower chair and would go underneath the bottom of the shower chair. During an interview on 02/13/24 at 1:00 PM, with Resident #2, she stated, she had reported to LVN F that Resident #2 had been touching her down there when CNA H showers her. Resident #2 stated CNA H will put on his music and dance while he showers her. Resident #2 stated she did not have strength and was weak to fight back against CNA H. Resident #2 stated she did not want CNA H around her and did not feel safe around him. Resident #2 stated she had not reported it due to feeling embarrassed. During an interview on 02/13/24 at 1:35 PM, with the DON, she stated that Resident #2 had made an outcry of sexual abuse/exploitation to the Business Office Assistant. The DON stated the Business Office Assistant was told by Resident #2 that CNA H had touched Resident #2 in her private area. The DON stated she had instructed LVN F to go and speak with Resident #2 regarding the sexual abuse/exploitation outcry and report back to her what she had said. The DON stated she was still working on the investigation. The DON stated she had not done any assessments on Resident #2. The DON stated LVN E had done a body assessment for Resident #2 but was not documented. The DON stated if it was not documented it did not happen. The DON stated she could not recall the exact date of Resident #2's sexual abuse/exploitation outcry. The DON stated she had not imputed anything into the computer. The DON stated there was no reason for the delay for not documenting and doing an assessment on Resident #2. The DON stated she would consider an outcry of sexual abuse/exploitation to be very important. The DON stated CNA H was not suspended and was still working at the facility and would not be able to answer why CNA H was not suspended. The DON stated CNA H was still working after the incident and there still existed a risk to the resident(s) of being sexually abuse/exploited. The DON stated it had not been reported to state survey agency and had no reason for the delay to notify state survey agency. The DON stated the Administrator was to report abuse and neglect allegations/incidents. During an interview on 02/13/24 at 2:55 PM, with the Administrator, she stated she was unaware of the alleged allegation from Resident #2 of sexual abuse/exploitation. The Administrator stated she was just notified right now of the sexual abuse/exploitation outcry for Resident #2 from LVN F. The Administrator stated she was told by LVN F that Resident #2 had alleged CNA H had touched her incorrectly. The Administrator stated LVN F told the DON about what Resident #2 had alleged. The Administrator stated she was not told by the DON what Resident #2 had alleged. The Administrator stated once an outcry of an allegation has been made it needed to be reported to the Abuse Coordinator which was her. The Administrator started she would take measures to talk to the resident and see what had happened as well as suspend the staff to ensure the safety of the Resident #2 until the conclusion of the investigation. The Administrator stated there could be a risk if the outcome was proven correct in that CNA H did do the sexual abuse/exploitation. The Administrator stated she had sent CNA H immediately as soon as she found out. The Administrator stated she still needed to go speak to Resident #2. The Administrator stated she did not know if a body assessment was conducted for Resident #2. The Administrator stated she did not report it to state survey agency as she not notified of the sexual abuse/exploitation allegation. The Administrator stated facility staff are trained on abuse, neglect, and exploitation and facility staff did not follow the facility abuse policy protocol for reporting. The Administrator stated it would have been protocol for the nurses to do a body assessment. During an interview on 02/13/24 at 4:35 PM, with the Social Worker, she stated she was just notified of the alleged allegation made of sexual abuse/exploitation from Resident #2 and was conducting interviews with facility residents. The Social Worker stated Resident #2 had told her that she had reported CNA H. Social Worker stated Resident #2 told her that CNA H touches her in her private parts and when he wipes her that he sticks his fingers in her. The Social Worker stated Resident #2 commented that CNA H puts on the music and begins to dance to it while he is showering her. The Social Worker stated Resident #2 had not reported it early because she felt embarrassed to report it and ashamed to tell her family member. The Social Worker stated Resident #2 did not feel safe when CNA H was working at the facility. During an interview on 02/16/24 at 2:08 PM with the Administrator, she stated that law enforcement was not notified on 02/02/24. The Administrator stated during the investigation a head-to-toe assessment of Resident #2 was done by LVN F and LVN E indicating no harm to Resident #2. The Administrator stated the facility only contacts the police if there was harm. The Administrator stated both LVN F and LVN E did the body assessment but was only verbally communicated but there was not documentation of the incident or assessment. During an interview on 02/16/24 at 2:26 PM with LVN F, he stated he was never told to do a body assessment on Resident #2. LVN F stated there was no body assessment done on 02/02/24. LVN F stated he would have to have had a physician order or a directive from his DON to conduct the body assessment which there were none of. LVN F stated he was not trained or certified on assessing residents who claim sexual abuse/exploitation. LVN F stated he did not know what to look for. LVN F stated if he was looking for anything it would be bruises or marks on Resident #2. LVN F stated he recommended for Resident #2 to have been sent out to the hospital to have a rape kit done. LVN F stated on 02/13/24 I was told to go assess Resident #2. During an interview on 02/16/24 at 2:39 PM with LVN E, she stated she was never told to do a head-to-toe body assessment on Resident #2 on 02/02/24. LVN E stated she quickly checked Resident #2's thigh and open up her brief to see if there was any bruises or marks but did not know what to look for as see was not trained or certified to conduct a sexual assessment on a resident. LVN E stated when a resident claims sexual abuse/exploitation that they are sent out to the hospital to go get checked out. LVN F stated on 02/13/24, I was directed to go assess Resident #2. During an interview on 02/17/24 at 5:02 PM with Regional Nurse, she stated the facility nurses were not trained or certified to do sexual assessments but could assess the resident eternally to see if there was any bruises or markings. Record review of the facility Abuse/Neglect policy and procedure manual dated 03/29/18, revealed, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. It was each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Sexual Abuse: Non-consensual sexual contact of any type with a resident. Reporting - Any person having reasonable cause to believe an elderly or incapacitated adult was suffering from abuse, neglect, or exploitation must report this to the DON, Administrator, state and or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of the elderly and incapacitated persons. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriate of resident properly or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet criteria of Provider Letter 19-17 dated 07/10/19. Investigation - Comprehensive investigations will be the responsibility of the administrator and or the Abuse Preventionist. All allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property and injuries of unknown source will be investigated. Record review of the facility Documentation policy and procedure manual dated 2003, revealed, Documentation was the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has a legal requirement regarding accuracy and completeness, legibility, and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessments, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets weekly, daily, monthly, discharge). Goal- The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. The facility will ensure that information was comprehensive and timely and properly signed. Document completed assessments in a timely manner and per policy. Complete documentation in narrative nursing notes as needed in a timely manner. Daily documentation x72 hours will be required for each shift for new admissions, during and following an acute episode, following an incident, and during physiologic, mental, or emotional changes or instability. Record review of the facility Event Reporting: Completion Of (Regional Nurse stated this was the facility's accident policy) policy and procedure not dated revealed, Investigation: The investigation should be completed by the DON/Administrator or designee. The investigation report documents a though investigation of the events of the reported Event including person, equipment, and materials that were involved. The investigation report must include what actions were taken to prevent subsequent Events and signatures of the individuals as indicated on the form. The facility will complete an Event report on variances that occur with the facility. Variances include falls, skin tears, bruises, abrasions, lacerations, fractures, choking, burns, elopement, or behavior that affects others. Record review of the facility Bath, Tub/Shower policy and procedures dated 2003, revealed, The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. The resident will experience improved comfort and cleanliness by bathing. Become familiar with type and pattern of bathing, assistance or aids needed, skin condition, presence of dress or casts. Remain with the resident if he was weak or assistance was needed in washing. The Administrator and DON were informed on 02/16/24 at 3:01 PM, that an Immediate Jeopardy (IJ) had been identified and a copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested. 02/16/24 at 5:19 PM - Area Director of operations submitted 1st Plan of Removal. 02/16/24 at 6:27 PM - Facility was notified of the 1st denied Plan of Removal. 02/16/24 at 7:51 PM - Administrator submitted 2nd Plan of Removal. 02/17/24 at 11:12 AM - Facility notified of 2nd denied Plan of Removal. 02/17/24 at 11:50 AM - Administrator was notified of approved Plan of Removal. The Plan of Removal revealed the facility took the following actions: Interventions: One on One in-service on conduct a thorough investigation when allegations are made and report to State Office to ensure supervision with the Administrator, DON and Social Worker by Area Director of Operation on 2/16/2024 at 4:30 pm Staff working with Alleged perpetrators have been interviewed by ADO. The resident #2 is doing ok; no distress was noted, and the resident was able to voice concerns. The alleged perpetrator was suspended on 2/13/2024 at 4:30 pm, pending the outcome of the investigation. Investigation completed on 2/14/2024. Resident safety surveys were initiated by the social worker on 2/13/2024, and no abuse incidents have been reported. Completion date of 2/13/2024. The following in-services were initiated on 2/13/2024 by Administrator/ADO: Any staff member not present or in-service on 2/13/2024 will not be allowed to assume their duties until in-service. o All Staff Abuse/Neglect Abuse/Neglect Reporting Who to Report Abuse/Neglect to All in-serviced staff will need to be able to articulate back on reporting any abuse allegation and to whom to report. Completion date 2/17/2024 o The administrator/designee will assess and monitor understanding by quizzing and providing examples on in-services. New staff will be in service during orientation. Any employees who are allegedly involved in any abuse will be suspended pending investigation. The medical director was notified of the immediate jeopardy situation on 2/16/2024 at 4:40. Monitoring The administrator will report any abuse allegations, investigate, and submit findings to the Area Director and Risk Management for review. The administrator will submit documentation of the investigation with Resident and Staff interviews, as well as weekly follow-up interviews with staff and residents x 4 weeks to ensure resident safety/satisfaction with the outcome of the investigation. The Area Director will monitor abuse allegations reported and check the real-time system which monitors keywords like abuse x 4 weeks documentation and PCC for any incident and accidents. The QA committee will review findings of any abuse allegations and investigations monthly and make changes as needed to the system. On 02/17/24 at 11:55 AM Verification phase began with the facility approved Plan of Removal. During an interview on 02/17/24 at 11:57 AM, with the Administrator and Area Director of Operations, the Administrator stated the present facility staff were in-serviced regarding, No Residents to be left unsurprised in the patio area. The Area Director of operations stated all facility staff not present were called and in-serviced regarding, No Resident to be left unsurprised in the patio area. The Administrator stated all facility staff were in-serviced by 02/16/24. The Area director of Operations stated on 02/13/24 at 4:30 PM she had already in-serviced the Administrator, DON, and Social Worker regarding Abuse Reporting. The Administrator stated on 02/13/24 at 4:30 PM CNA H was suspended pending the outcome of the investigation for Resident #2. The Area Director of Operations stated on 02/16/24 at 4:30 PM the DON was suspended pending the outcome of the investigation. The Area Director of Operations stated the facility had completed the investigation on 02/14/24, for Resident #2 and was found to be unconfirmed. The Administrator stated on 02/13/24 a Safety Survey of the residents was conducted by the Social Worker and found no abuse incidents had been reported by the residents. The Administrator stated the facility was moving forward with termination of CNA H with unrelated issues to the alleged allegation. The Administrator stated Resident #2 stated she was doing fine, able to voice concerns, and no distress was noted. The Administrator and Area Director of Operations stated on 02/13/24 an in-service was initiated by both Administrator and Area Director of Operations for Abuse/Neglect, Abuse/Neglect Reporting, and Who to report Abuse/Neglect too. The Administrator stated facility staff not present, during the in-service will not be allowed to resume their duties until in-serviced. The Administrator stated on 02/17/24 all in-services provided to facility staff had to be communicate back to the presenter acknowledging they understood what was being in-serviced on. The Administrator stated quizzes were given and examples had to be provided by the in-service-e confirming understanding of the material. The Administrator stated new employee would be in-serviced on during orientation. The Administrator stated all alleged employees involved in an allegation will be suspended pending the outcome of the investigation. The Area Director of Operation stated on 02/16/24 at 4:40 PM the Medical Director was notified of the Immediate Jeopardy, commenting that the facility will have to get better. The Area Director of Operation stated the Administrator was to report any and all allegations of abuse and submit all documentation for investigations conduct which would be reviewed by Area Director of Operations and Risk Management. The Area Director of Operations stated the Administrator was also to submit interviews with staff and residents related to investigations four times a week to ensure safety/satisfaction outcomes. The Area Director of Operations stated the facility system will be checked for key words like abuse four times a week for incidents or accidents that might have happened or been documented. The Administrator stated an off-cycle Quality Assurance meeting was held on 02/16/24 at 5:00 PM, regarding the Immediate Jeopardy and follow ups will be held monthly to see if adjustments were needed to abuse allegations and investigations. During an interview on 02/17/24 at 12:42 PM, with LVN P, he stated, he had received an in-service on abuse. LVN P stated that any kind of abuse had to be reported to the Administrator immediately. LVN P stated during the in-service it was talked about the 5 different types of abuses such as emotional, verbal, physical, sexual, and financial abuse to include injuries of unknown origin. LVN P stated that the in-servicer did test his knowledge on the material by asking him questions and giving him a quiz on it. During an interview on 02/17/24 at 12:48 PM, with LVN Q, he stated, he received an in-service on abuse and neglect. LVN Q stated as soon as an alleged allegation was made or suspected, must be reported immediately to the Administrator. LVN Q stated he was asked questions about the in-service he had received and had to answer them. During an interview on 02/17/24 at 12:42 PM, with LVN I, she stated, she had received several in-services such as abuse. LVN I stated she was told of the different types of abuses and if she saw or suspected abuse happening who to report it to. LVN I stated she had to report abuse to the Administrator who was the Abuse Coordinator. LVN I stated she was questioned on the in-service like it was a test. During an interview on 02/17/24 at 1:15 PM, with MA R, she stated, she was in-serviced on abuse and neglect. MA R stated any suspected or seen abuse had to be reported to the Abuse Coordinator which was the Administrator. MA R stated she was questioned on what was in-serviced. During an interview on 02/17/24 at 1:23 PM, with ADON G, she stated, she had received an in-service regarding abuse and neglect. ADON G stated they told her what constitutes abuse and neglect and who to report it to. ADON G stated abuse was reported to the Administrator immediately. ADON G stated she was questioned over the in-service(s) of abuse to check her knowledge. During an interview on 02/17/24 at 1:31 PM, with CNA T, she stated, an in-service of abuse was given to her. CNA T stated it entailed what abuse was like the five different types. CNA T stated she was questioned over the material being presented. CNA T stated any kind of abuse had to be reported immediately to the Administrator. During an interview on 02/17/24 at 1:43 PM, with CNA U, she stated, she was in-serviced on abuse regarding the different types of abuse. CNA U stated staff are to do report if someone talks bad or physically hits a resident. bad or physically hits them. CNA U stated it had to be reported to the Administrator. CNA U stated she had received a quiz on the in-service. During an interview on 02/17/24 at 1:52 PM, with LVN V, she stated, she had received an in-service on abuse and neglect on 02/16/24. LVN V stated to report anything the facility staff felt was abuse and who to report it too. LVN V stated it was to be reported to the Abuse Coordinator which was the Administrator. LVN V stated she was asked questions about they felt it was reportable and why. After the Plan or Removal and Monitoring: The Administrator was informed the Immediate Jeopardy was removed on 02/17/24 at 3:35 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern as the facility was continuing to monitor it's plan for effectiveness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure residents were provided supervision and assistive devices to prevent accidents for 2 of 10 (Resident #1 and Resident #12) residents reviewed for accidents. The facility failed to provide supervision to prevent the elopement of Resident #1. Staff failed to respond to the door alarm when the resident exited the facility. Resident #1 was outside, unsupervised by staff for approximately 1 hours, and suffered lacerations and abrasions. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/19/24. The IJ template was provided to the Administrator. The IJ was removed on 01/20/24, but the facility remained out of compliance at a scope of actual harm and severity level of isolated because the facility failed to have a system in place to ensure residents are monitored when facility door alarms sound off. The facility failed to conduct safe transfers for Resident #12, CNA F did a one-person transfer with Hoyer lift. These failure could place residents at risk of harm and injuries due to lack of supervision and failure to follow protocols. Findings include: Resident #1 Record review of Resident #1 ' s face sheet dated 01/19/24 revealed admission on [DATE] to the facility. Record review of Resident #1 ' s facility history and physical dated 11/20/23 revealed a [AGE] year-old male diagnosed with anoxic brain injury (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation), mental illness (disorders that affect your mood, thinking and behavior), and cardiomyopathy (a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body). Record review of Resident #1 ' s admission MDS dated [DATE] revealed a moderately cognitive impairment to be able to recall and make daily decisions BIMS (a brief cognitive screening measure that focuses on orientation and short-term word recall) score of 7. Resident #1 had a behavior of wandering. Activities of daily living revealed Resident #1 to be independent with eating, oral hygiene, toileting, dressing, toilet transfers, sit to stand, lying to sitting on side of bed, and be able to walk 150 feet but only 10 feet on uneven surfaces. Resident #1 was diagnosed with Coronary Artery Disease (caused by plaque buildup in the wall of the arteries that supply blood to the heart), Seizure Disorder (abnormal electrical brain activity), anoxic brain damage, cardiomyopathy, and lack of coordination (Uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), muscle weakness (no muscle strength), and cognitive communication deficit (difficulty with thinking and how someone uses language). Record review of Resident #1 ' s care plan dated 12/06/23 [sic] revealed at risk for elopement as evidenced by anoxic brain damage. Assess/record/report to medical doctor risk factors for potential elopement such as - wandering. Repeated request to leave facility, statements such as, I ' m leaving (no date was indicated for this comment), I ' m going home (no date was indicated for this comment), attempts to leave facility, elopement attempts from previous facility. Supervise closely and make regular compliance rounds whenever resident was in room. Determine the reason the resident was attempting to elope. Is the resident looking for something or someone? Does it indicate the need for more exercise? Intervene as appropriate. Resident #1 was at risk for wandering. Impaired safety awareness. Assess for fall risk. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? If a resident was exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. Resident #1 was on anticoagulant therapy. Avoid activities that could result injury. Take precautious to avoid falls. Record review of Resident #1 ' s Elopement Risk assessment dated [DATE] revealed high risk for elopement score of 12. Moderately impaired - decision poor, cues/supervision required. Elopement was signed and locked on 11/30/23 instead of being locked on 11/20/23 when Resident #1 was admitted to facility. Record review of Resident #1 ' s Elopement Risk assessment dated [DATE] revealed high risk for elopement score of 11. Moderately impaired - decision poor, cues/supervision required. It was unknown why an elopement assessment was conduct as Resident #1 was no longer returned to the facility. Record review of Resident #1 ' s Fall Risk assessment dated [DATE] revealed a moderate score of 8. Resident #1 had intermittent confusion. Record review of Resident #1 ' s Order Recap dated 11/20/23 revealed on anticoagulant - monitor for bruising, nosebleeds, for prolonged bleeding from wound. Review of weather records for 11/30/23 between 6:15 am to 7:45 am, the temperature was 51-53 degrees Fahrenheit, there was light rain, and wind gusts from 30 to 37 miles per hour. [https://www.wunderground.com/history/daily/us/tx/el-paso/KELP/date/2023-11-30 accessed 2/2/24]. Record review of Resident #1 ' s progress notes written by LVN A dated 11/30/23 revealed, at 8:30 am - As per nursing 06:00 am staff CNA (unidentified) noticed resident was not in his room. Checked on dining room and receptionist where resident always stays. Code orange elopement) was activated. Family, DON, Administrator, police department, medical doctor notified. 10:04 am - As per 6am CNA staff started doing rounds and got into patient room later around 7:00 am. Record review of sister facility ' s progress notes dated 11/30/23, where Resident #1 transferred, following the elopement, revealed Resident arrived via car accompanied by family member at 10:00 AM. According to family member he eloped from previous facility and was found wandering streets in the Westside of the city until he was picked up by the police. Police then transported Resident #1 to a family member residential address that he remembered. Family member was then contact and picked up Resident #1 and bought him here. Resident #1 looked disheveled (things other than hair that have a messy or untidy appearance) in appearance. Walking in socks because his shoes were still wet from the rain. Head to toe assessment - laceration and abrasion noted to facial area/upper right brow/forehead. Large dark discoloration to left side of ribs. Record review of Resident #1 ' s skin assessment from sister facility dated 11/30/23 revealed Resident #1 with the following: a dark painful bruise to left side of ribs 14cm by 9cm. Right pinky finger with a skin tear 0.3cm by 0.3cm. Right side abrasion above upper brow 6cm by 5.5cm. Right cheek abrasion 2cm by 2cm. Left palm abrasion 5cm by 4cm. Right palm abrasion 7cm by 4cm. Left knee abrasion 3.5cm by 3.5cm. Right knee abrasion 6cm by 3.5 cm. Left top of foot abrasion 4.5cm by 2cm. Right elbow abrasion 2cm by 2cm. Right side laceration above upper brow 0.5cm by 0.5cm Left side laceration near orbital 1cm linear laceration. Right side of sacral area laceration, crescent shaped 0.5cm. Skin findings - redness to neck and chest Record review of the x-ray conducted, by the sister facility, after the resident transferred from this facility, of Resident #1 dated 11/30/23 revealed X-Ray to right rib status post fall, pain, bruising. Findings: Multiple radiographs of ribs were obtained. They show no fracture or other focal bony abnormality. There was no evidence for pneumothorax (a collapsed lung), pleural effusion (an unusual amount of fluid around the lung), pleural thickening (develops when scar tissue thickens the delicate lining around the lungs (the pleura) or pulmonary contusion (an injury to the lung parenchyma in the absence of laceration to lung tissue or any vascular structures). The view of the chest shows no abnormality area. Record review of the Resident #1 ' s Event Note dated 11/30/23 revealed, As per nursing, 06:00AM - staff CNA noticed resident was not in his room. Checked on dining room and receptionist area where resident likes to stay. Code Orange was activated. Family, DON, Administrator, police department, medical doctor was notified. Note What door exited - Unknown Note How long missing - Unknown Record review of city streets on google maps dated 01/19/24 revealed near the facility was a busy two-way intersection (265.24 ft away) with a speed limit of 35 miles per hour. Further up the street near the facility was another four-way busy intersection (1,222.46 ft away) with a speed limit of 45 miles per hour. Record review of facility 3613-A that was submitted to state agency dated 12/07/23 revealed - Timeline - · 5AM resident was seen in his bed asleep · 5:30 AM resident was given his morning medications · 5:40 AM CNA observed resident walking around his room · 6:15 AM LVN heard back door alarm going off, she run to check and did not see anyone. · 6:25 AM Construction workers saw an old man walking around the parking lot, did not mention anything since they did not know he was a resident of the facility. · 6:35 AM Code Orange was initiated. Staff searched the premises and nearby stores and gas stations. · 7:12 AM EPPD notified of a missing person · 7:45 AM EPPD took resident to mothers · 8:45 AM resident arrived at sister facility and rehab · Transferred to sister facility as per family Record review of Detective e-mail dated 01/22/24 revealed Resident #1 was found at 7:50 AM on local retailer 1.29 miles (2.08 km). Resident #1 was alert and the weather was unknown at that time. During an observation and interview on 01/19/24 at 10:36 am, Surveyor A and Administrator opened hallway 1 exit door for alarm to ring. LVN K and CNA L responded to door alarm. No administrative staff were observed responding to the door alarm. LVN K stated when exit door alarm rings she was to open the door and check the outside premises to ensure no residents were observed outside. LVN K stated she would then do a head count and ensure all her residents were accounted for and notify DON. During an interview on 01/19/2024 at 10:43 am, LVN K stated when exit door alarms ring all staff were expected to respond to the exit door and assist to include housekeeping, CNAs, nurses, and administration staff. LVN K stated the lack of response from staff when door alarm rang was concerning. LVN K stated only her and CNA L responded to the door alarm. LVN K stated she had 5 CNAs on that side of the building. LVN K stated she knew 2 CNAs were busy with changing residents, CNA K responded, was not aware of CNA S whereabouts and CNA R was out on break. During an observation and interview on 01/19/24 at 11:13 am, SW office was the closest office to hallway 1. The SW denied hearing a door alarm ring. During an interview on 01/19/23 at 11:00 AM with the Administrator, she stated she was notified of Resident #1 missing from ADON E at 6:50 AM, in which the nursing staff could not find him. The Administrator stated she had instructed ADON E to check all the rooms in the facility. The Administrator stated a CNA went in Resident #1 ' s room to get him up for the day and could not find him. The Administrator stated she had informed the ADON E that she would start looking outside when she got to the facility. The Administrator stated Resident #1 did not have a history of elopement in their facility and the past facility he came from. The Administrator stated Resident #1 did not have a wander guard as the facility was a wander guard free facility. The Administrator stated the local police department did not give the facility the police report of Resident #1 and did not know why. The Administrator stated the back door leading to the back patio was going off in the morning around 6 AM. The Administrator stated LVN A responded to the door and turned off the alarm. The Administrator stated LVN A looked outside and saw no one and other staff members responded but once seeing LVN A had responded turned around and went back to their work areas. The Administrator stated the facility staff did not do a perimeter check around the facility. The Administrator stated it was not documented that a head count was conducted to make sure no other residents were missing. The Administrator stated it was expected for facility staff to respond immediately to door alarms and check to see what was going on or if anybody needed assistance. The Administrator stated she in-serviced the facility staff in regard to whenever a door alarm goes off that facility staff have to respond and not go back to what they are doing. The Administrator stated Resident #1 exited through the back door. The Administrator stated the facility implemented other interventions such as shortening the front door lock from 30 seconds to 15 seconds, changing the code on the doors, and conducting audits on residents with elopement. The Administrator stated the facility made every effort to prevent elopement. The Administrator stated as per their facility Elopement Prevention policy the facility did not think about placing all their wandering residents in the same hallway. During an observation and interview on 01/19/24 at 11:17 am, Surveyor B opened exit door on hallway 2 (furthest away from receptionist/ dining room area) for alarm to ring. Administrative staff offices were by the receptionist and dining room area. Surveyor A could faintly hear the door alarm ringing. No Administrative staff responded to door alarm. The Receptionist denied hearing a door alarm ringing. During an interview on 01/19/24 at 1:33 PM with Sister Facility Administrator, he stated Resident #1 was readmitted to his facility. Sister Facility Administrator stated the family bought Resident #1 to the facility. Sister Facility Administrator stated the facility had photos of Resident #1 having bruises to the right side of face and bruises to hands/knees and ribs. Sister Facility Administrator stated a skin assessment was conducted. Sister Facility Administrator state the local police found Resident #1 and took him to his family member place. Sister Facility Administrator stated Resident #1 was soaking wet due to it raining outside. Sister Facility Administrator stated the facility had x-rays and results were negative for fractures. During an interview on 01/19/24 at 2:23 PM with Police Officer, he stated a call was placed by the facility on 11/30/23 at 7:43 AM reporting a missing person. Police Officer stated Resident #1 was found at 7:50 AM. Police Office stated when missing persons are reported the officer responding was to create a report if they had sustained any injuries even if it was weather related. Police Officer stated there was not one made for this case. Police Officer stated could be possible he could be okay. Police Officer stated it did not indicate where the resident was found and he appeared okay. Police Officer stated Resident #1 was taken home. During an interview on 01/19/24 at 3:08 PM with LVN A, she stated the day of the incident with Resident #1 the back door alarm was going off. LVN A stated she came in at 6:00 AM and it was going off. LVN A stated the back patio fence doors were not open. LVN A stated she turned off the back door alarm and did not see a Receptionist posted near the front entrance door, which was opposite of the back. LVN A stated she checked that no one was outside. LVN A stated LVN Q looked in the front entrance and did not see anyone. LVN A stated as soon as the missing person was announced the nursing staff all jumped in to help and search. LVN A stated she did not let the other nurses know that they needed to do a head count, but all of her residents were accounted for. LVN A stated the alarm went off and after the alarm went off she did her head count. Record review of Family Members photos of Resident #1 dated 01/24/24, taken when Resident #1 was brought to their house, by police, revealed bleeding abrasion(s) to Resident #1 ' s right upper brow and right cheek, scrapes or scratches to both left and right knees, red marks. Record review of facility training dated 01/19/24 When exiting be aware of surroundings, wait until door was locked to step away in-service not dated revealed it was given and signed by facility staff. Record review of facility training Do not share door code with residents/family members not dated revealed it was given and signed by facility staff. Record review of facility training Changing door code every 2 weeks not dated revealed it was given and signed by facility staff. Record review of facility Remodel area Window door check for Hall 1, 2, 3, 4, 5, 6 dated September, October, November with no year revealed dates and times. Record review of facility Assessment Scoring Report sheet dated 01/01/20-01/01/19/24 revealed 30 facility residents at risk of elopment. Record review of the facility Elopement Prevention policy dated 01/2023 revealed, Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for resident who are at risk elopement. If a resident was discovered to be missing, a search shall begin immediately. (See policy entitled Elopement Response.) Use door locks that are out of reach/sight to prevent wanders from opening doors. Use door alarms or monitoring devices to notify staff when residents try to leave the facility. Consider putting wandering residents on the same unit with a single exit near the nursing station. If applicable, consider the resident for a secured unit. Physical Plant: All facility exits that residents have access to will have a device in place to alert staff of elopement attempts. Wander guard System Keypad exit magnetic locks Keyed Alarms Secured Unit Staff Training: Staff will receive training during their orientation process and then annually regarding - Elopement prevention, Operation of all exit devices, and Actions to take if elopement occurs. Record review of the facility Elopement Response policy dated 10/27/10 revealed, Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or was suspected, our elopement response plan will be immediately implemented. Should an employee discover the resident was missing from the facility, he/she should: Make a thorough search of the building(s) and premises. Make an extensive search of the surrounding area. If unable to locate resident in the building, proceed as follows: After 30-minutes, if the resident has not been found, the following calls must be made: Report missing resident to the police. Post return resident evaluation and care: The facility will evaluate its elopement prevention program and all residents will be reassessed for elopement risk. Record review of the facility elopement Drill or Actual Elopement Guide and in-service dated 04/10/23, 06/29/23, and 10/31/23 revealed, Instruction: elopement drills should be conducted monthly on different shifts at random times. The facility Administrator only provided these 3 in-services and failed to produce the other months as indicated to be done monthly. Time how long it takes staff to begin looking and realize the resident/mascot cannot be found and initiate the elopement plan. Evaluate the actions of the staff and the efficiency of the elopement plan. Report the findings to the QAPI committee. Record review of the facility Preventive Strategies to Reduce Fall Risk policy dated 10/05/16 revealed, Policy: The goal of fall prevention strategies was to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident ' s mobility. Record review of the facility Assessment Scoring Report dated 01/01/20-01/19/24 revealed 30 resiudents with elopement risk. Incident Reporting - Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s). The Administrator and DON were informed on 01/19/24 at 4:40 PM that Immediate jeopardy (IJ) had been identified and copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested within the hour. The following Plan of Removal submitted by the facility was accepted on 1/20/2024 at 10:16 am. The Plan of Removal revealed the facility took the following actions: Starting 1/19/24, facility staff were in-serviced by the DON/ADON on the following: All active employee during shift where alarm is heard should Immediately respond to alarm and check the surrounding external areas when alarm goes off. Charge nurses are responsible to do a head count when the door alarm goes off. The head count will be completed within 15min. If resident is not accounted for, charge nurse will initiate code orange. The nurse will complete the head count and document on facility system, 24-hour report, and will report to the administrator. If all residents are accounted for charge nurse will page overhead speaker, code orange all clear. Installation of stop alarms will be completed by 1/19/24 by 8:00pm and alarms will be on, ON mode, at all times. Stop alarms were tested upon installation by Maintenance director to ensure that it is audible throughout the facility including dining room and offices. New staff/Agency staff will be educated during orientation. All staff not in-service on 1/19/2024 in person or on the phone will be in-serviced before the start of their shift. On 1/19/24, the maintenance director of the facility did the following: Stop alarms are being installed by 1/19/24 by 8:00pm in all exit doors to ensure the alarm sound is loud enough to reach offices and dining rooms. The medical director was notified of this plan on January 19, 2024, and an off-cycle QAPI plan was initiated regarding this event, completion date 1/20/24 9:00 am This affected Resident #1 and had the potential to affect 30 other residents with wandering/exit seeking behaviors, Residents are identified by the Elopement risk assessment in facility system. Monitoring: The DON and/or designee will monitor that headcount, outdoor checks, and sign-out sheets are used properly and completed at least five times per week. The administrator, DON, and/or designee will do elopement drills weekly to ensure staff are responding immediately to door alarms. Maintenance director/designee will be responsible for testing alarms 2 times a week to ensure alarms are working properly. Interviews, observations and Record Review to confirm implementation of the Plan of Removal were conducted as follows: Observations on 01/20/2024: 10:16 am, admin opened door to hallway 3. CNA U, 2 staff from down the hallway in hallway 1 respond. CNA W and CNA G, 2 maintenance personnel in the hallway looked over to door. 10:20 am, admin opened hallway 6 alarm. CNA I, Housekeeping Aide, HR, LVN X, Transportation Aide, LVN Y, and CNA F responded. 10:25 am, hallway 1 door was pushed alarm went off. LVN M, CNA U, CNA W, CNA Z, Housekeeping Aide, SCNA BB, and Maintenance Assistant all responded immediately within 5 seconds of pushing the exit door. 10:27 am, hallway 1 door was pushed alarm went off. Could hear in reception SW responded and receptionist was with family but notified Administrator. 10:38 AM - Maintenance Director turn on the alarm system and the doors in the hallway closed and exit doors opened. Facility staff were seen responding from all over the facility. Charge nurses were seen taken head count of the residents. An all clear was given after the head count was taken. Interviews on 01/20/24: CNA I, Housekeeping Aide, HR, LVN N, LVN X, Transportation Aide, LVN Y, CAN F confirmed in-services provided regarding code orange, response to exit door alarms, assist with head count, search outside premises/perimeter to ensure no residents were found outside, police notification, stated they could identify elopement risk residents in PCC and/or elopement binders that were located in nurses station and receptionist area. During an interview on 01/20/24 beginning at 10:30 AM with CNA I, Housekeeping Aide, HR, LVN N, LVN X, Transportation Aide, LVN Y, CAN F confirmed in-services provided regarding code orange, response to exit door alarms, assist with head count, search outside premises/perimeter to ensure no residents were found outside, police notification, stated they could identify elopement risk residents in PCC and/or elopement binders that were located in nurses station and receptionist area. During an interview on 01/20/24 at 11:30 AM with ADON E, she stated she had worked the night shift on 01/19/24 and was in-serviced with the door alarm response. ADON E stated it was procedures to responding to the door alarm soundings. ADON E stated when the door alarms sounds then everyone had to respond to the door that was alarming. ADON E stated facility staff where to also go outside and check the perimeter of the facility to see of there were any residents outside. ADON E stated the nurses were to conduct a head count of all the residents to ensure they were all in the facility. ADON E stated if all residents were accounted for then an all clear could be call, if not then a Code Orange (Indicating Elopement) would have to be initiated. ADON E stated if the resident was not found within 30 minutes, then the local police would have to be notified. During an interview on 01/20/24 at 11:58 AM with CNA T, she stated she was in-serviced on when the door alarm goes off the facility staff have to rush to the door that ' s sounding. CNA T stated two or three staff have to go outside and search the surrounding areas of the facility. CNA T stated if the resident was not found then they call a Code Orange (Indicating Elopement) and the Administrator gets notified. CNA T stated a head count was to be done by the nurses. CNA T stated after 30-minutes of looking for the missing resident then the facility staff call the police. CNA T stated if the resident was found then the nurse gets notified and an all clear gets called. During an interview on 01/20/24 at 11:58 AM with the DON, she stated when a door alarm goes off the nurses need to conduct a head count of all the residents to ensure they are all accounted for. The DON stated when a door alarm goes off all staff are to respond to the door alarm that was going off. The DON stated staff are to search the perimeter for any residents. The DON stated the managers will be responsible for ensuring the nurses are doing the head count of the residents. The DON stated the nurses will also review the sign in/out sheets to make sure the residents are accounted for and the DON and ADONs will oversee that the nurses are doing the checks. The DON stated Maintenance Director will check the outdoor combination locks. The DON stated there was a check sheet for maintenance checking the outdoor combination locks. The DON stated the Administrator, and the DON will be in charge of conducting the Elopement Drill every week with the assistance of an alert resident or a stuff animal. The DON stated the focus of the elopement drill was to check for staff response and timing. During an interview on 01/20/24 at 12:28 PM with the Administrator, she stated the DON will ensure that nurses are doing a head count when a door alarm goes off. The Administrator stated there was a spread sheet that was created to document the headcounts. The Administrator stated the outdoor checks are when the facility staff go outside and check the perimeter of the facility to see if there are any residents. The Administrator stated her, and the DON were responsible for checking the headcount and outdoor checks on the spread sheet to ensure the staff are doing the headcount and outdoor checks. The Administrator stated the elopement drill were to be conducted weekly on different times and days. The Administration stated they were looking to see the response time and how staff work together with deflating task with the elopement drill. The Administrator stated these drills will be record on the Elopement Drill Form. The Administrator stated the Maintenance Director will checking the door alarms to make sure they are working properly (making sure they are ringing) and will be recorded on a sign on/off sheet. The Administrator stated the sheets will be turned in at the end of each week for her to review. Record review of facility in-service dated 01/19/24 revealed it was given and signed by facility staff The in-service indicated when a door alarm goes off, charge nurse are responsible to do a head count within 15 minutes if resident not accounted for. Charge nurse will initiate Code Orange Record review of facility in-service dated 01/19/24 revealed it was given and signed by facility staff. The in-service indicate the nurse will complete the head count and document on facility system, 24-hours report, and will be reported to the administrator. Record review of facility in-service dated 01/19/24 revealed it was given and signed by facility staff. The in-service indicate If all residents are accounted for change nurse with page overhead speaker, code orange all clear Record review of facility Call police after 30-mintues of resident missing in-service dated 01/19/24 revealed it was given and signed by facility staff. Record review of facility Check and walk the perimeter when a door alarm goes off in-service dated 01/19/24 revealed it was given and signed by facility staff. Record review of fac[TRUNCATED]