**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 7 residents (Residents #1) reviewed for abuse. The facility failed to ensure residents right to be free from abuse when Resident #1 reported sexual abuse by CNA O to staff in January 2025 and the alleged perpetrator was not suspended, the allegation was not investigated, and the facility did not report the suspected crime to local law enforcement and the State Agency, resulting in failure to protect residents from further potential criminal activity by an alleged perpetrator. An Immediate Jeopardy (IJ) situation was identified on 04/09/25. While the IJ was removed on 04/10/25, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for further abuse, physical harm, psychosocial harm, trauma, unrecognized abuse, and emotional distress. Findings include: Record review of Resident #1's admission Record, dated 04/09/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: vascular dementia (type of dementia caused by conditions that disrupt blood flow to the brain, leading to cognitive and behavioral changes), hypertension (high blood pressure), hemiplegia (total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (lack oxygen to the brain causing damage to brain tissue) affecting left non-dominant side, and lack of coordination. Record review of Resident 1's Quarterly MDS, dated [DATE], revealed a BIMS score of 10, which indicated moderate cognitive impairment. Section GG - Functional Abilities revealed Resident #1 required substantiated/maximal assistance with toileting hygiene and shower/bathing. Record review of Resident #1's Care Plan, dated 04/09/2025, revealed a focus area which reflected Resident #1 had an ADL self-care performance deficit. Part of the interventions reads in part, Bathing requires staff x1 for assistance. During an interview on 04/09/2025 at 10:44 a.m., Resident #1 said back on a day in January 2025, CNA O took him to a shower and while bathing the resident, CNA O stuck his finger inside Resident #1's anus once for about a second. Resident #1 said there were no other witnesses at the time of the incident. Resident #1 said he did not initially report the incident to anyone because he was embarrassed. Resident #1 said he was not injured or in any discomfort after the incident occurred. Resident #1 said he reported it to facility staff a few days later but could not remember who. Resident #1 said the facility did not do anything about what he reported because CNA O was still working at the facility although had not given Resident #1 any more showers. Resident #1 said he did not remember talking to any administrator or anyone else about what he reported. Resident #1 said this made him upset because he would not want another resident to go through what he went through. Resident #1 said CNA O did not work with him anymore after the incident. During an interview on 04/09/2025 at 12:22 p.m., CNA N said about two-three months ago, Resident #1 said he had been sexually abused by CNA O. CNA N said Resident #1 told another staff member during another shift about the allegation and CNA N believed the staff reported it to administration. CNA N said he did not report the allegation to anyone else because he thought it had already been reported. CNA N said he believed it was the Administrator who told staff males could not go into the room, and if they must go into Resident #1's room it needed to be with another staff. CNA N said CNA O was not suspended and stayed working on the floor with other residents. CNA N said no other residents complained about CNA O. CNA N said he did not know if anything was done about the allegation. During an interview on 04/09/2025 at 2:25 p.m., LVN H said Resident #1 refused to have males work with him. LVN H said Resident #1 just said to her he did not like one specific male CNA (CNA O) and was okay with the other male CNAs. LVN H said she did not know why Resident #1 did not want CNA O to work with him. During an interview on 04/09/2025 at 2:33 p.m., CNA P said she heard from other staff that a male was not supposed to take care of Resident #1. CNA P said she did not know why. CNA P said she did not know if the information was documented anywhere. During an interview on 04/09/2025 at 2:49 p.m., LVN F said one day about 3 or 4 months ago, CMA M informed LVN F Resident #1 was complaining about being sexually molested. LVN F said he talked with Resident #1 and the resident told him he felt he was sexually molested by inappropriate touching by a staff member. LVN F said Resident #1 did not say which staff at the time. LVN F said Resident #1 said he did not want any males working with him. LVN F said he reported the allegation to ADON E. LVN F said he believed ADON E reported it to the Administrator. LVN F said ADON E told him to make sure no males went into the room with Resident #1. LVN F said he then informed the staff on the floor about the instructions ADON E told him regarding no males in Resident #1's room. LVN F said the allegation was reported by Resident #1 days after the alleged incident occurred. LVN F said Resident #1 did not complain about any discomfort or injury. LVN F said he did not remember if he documented the incident. During an interview on 04/09/2025 at 3:37 p.m., the ADON E said all allegations reported needed to be reported to the Administrator or the DON right away. The ADON E said she had the DON and Administrator's numbers and they were on-call 24/7. The ADON E said one evening several months back, LVN F said Resident #1 felt he was abused two to three days before when he was getting showered and while staff cleaned his buttocks, Resident #1 felt CNA O touched him inappropriately. The ADON E said he asked LVN F to write him a statement. ADON E learned Resident #1 reported the allegation to CMA M, and she then reported it to LVN F. ADON E said he called the Administrator on the phone and told her there was an allegation of abuse in the building. ADON E could not recall the time he called the Administrator. ADON E said the Administrator told him she was out of the building, but when she came back, she would follow-up on the allegation. ADON E said he did not speak with Resident #1 and figured the Administrator would do what needed to be done such as report and investigate. ADON E said he had been trained to report allegations of abuse/neglect/exploitation to the Administrator immediately. The ADON E said he instructed LVN F no males were allowed in Resident #1's room. ADON E said Resident #1 was informed and he did not have a problem with any other male CNAs, and only CNA O. ADON E said he told LVN F to document the incident on the 24-hour report. ADON E said nothing was brought up in the morning meeting the following day. ADON E said he did not document any of the events anywhere . ADON E said the written statement by LVN F was given to the Administrator and he did not know what the Administrator did then. During an interview on 04/09/2025 at 4:19 p.m., CMA M said she was trained to report allegations of abuse, to include sexual abuse, to the charge nurse and Administrator immediately. CMA M said several months ago, Resident #1 reported to her he did not want CNA O in his room. CMA M said Resident #1 said an incident occurred 2 to 3 days before. CMA M said Resident #1 said while CNA O was assisting him to shower, CNA O touched Resident #1 inappropriately on his backside. CMA M said Resident #1 did not complain of any pain at the time. CMA M said she told Resident #1 she would report it to the nurse, and the nurse would talk with him. CMA M said she told LVN F, but she did not contact the Administrator. CMA M said she knew she should have informed the Administrator but failed to do so since she told LVN F. CMA M said CNA O still worked at the facility but did not provide any patient care to Resident #1. CMA M said she heard no other complaints from any other residents regarding CNA O. During an interview on 04/09/2025 at 4:30 p.m., CNA O said he had been working at the facility for 20 years. CNA O said he had been trained on reporting abuse/neglect allegations immediately to the Administrator. CNA O said no residents complained to him about any abuse or inappropriate touching. CNA O said he had not been suspended for any incidents or allegations. CNA O said no resident had complained about him. CNA O said he was familiar with Resident #1 and the resident did not want any males in the room. CNA O said Resident #1 did not have any problems with him. CNA O said he was told by LVN F not to work with Resident #1 with no other explanation. CNA O denied any knowledge of any sexual abuse. During an interview on 04/09/2025 at 5:05 p.m., the Administrator said her responsibility when it came to allegations of abuse, neglect, or exploitation was to protect the resident, gather information, and proceed with the investigation. The Administrator said she was also responsible to contact the State Survey Agency and if needed law enforcement. The Administrator said all allegations of abuse would be reported to the State Survey Agency within 2 hours. The Administrator said if there were any allegations of sexual abuse, the allegation would be reported to the State Survey Agency, law enforcement, and the physician and responsible parties. The Administrator said she had not received any reports of any type of sexual abuse. The Administrator said she was familiar with Resident #1, and he had not made any complaints with her. The Administrator denied being notified or having any knowledge of any alleged sexual abuse which involved Resident #1. Record review of Resident #1's Progress Notes from January 2025 to April 2025 did not reveal any documentation regarding the allegation of sexual abuse. Record review of Social Service Quarterly Assessment for Resident #1, dated 01/17/2025 at 4:00 p.m., read in part, Resident can have times when he becomes upset at staff but for the most part gets along well with everyone. At this time there are to be no male CNAs in resident's room. Record review of the 24-hour reports for the month of January 2025, did not reveal any information on the allegation of sexual abuse. Record review of TULIP revealed no prior self-reports related to the allegation of abuse which involved Resident #1 from 01/01/2025 to 04/09/2025. Record review of a copy of a statement written by CMA M, dated 1/14/2025, read To whom it may concern, On Wednesday, January 8th, [CMA M] reported to [LVN F] nurse in charge of [Resident #1] reporting an incident of sexual harassment. [Resident #1] stated that he was upset with [CNA O]. [Resident #1] said that [CNA O] inserted his fingers while [CNA O] was showering him. [CMA M] immediately reported to [LVN F]. Record review of the facility provided Abuse/Neglect policy, with revision date 3/29/2018, read in part Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff . Prevention ., The facility will provide the residents, families, and staff an environment free from abuse and neglect. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. Appropriate notification to state and home office will be the responsibility of the administrator and per policy .Reporting, Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect, or exploitation must report this to the DON, administrator, state and/or adult protective services. Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19; a) If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation Investigation .Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist.the employee(s) will immediately be suspended pending an investigation .Protection .The facility will take necessary measures to protect residents This was determined to be an Immediate Jeopardy (IJ) on 04/08/2025 at 8:00 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 04/08/2025 at 8:00 p.m. The following Plan of Removal submitted by the facility was accepted on 4/10/2025 at 1:40 p.m.: Interventions: - Abuse allegation investigations started on 4/9/2025 and are ongoing. Furthermore, as per policy, all new investigations start immediately upon receiving an allegation. - The resident was interviewed at the time of discovery on 4/9/2025 and could not recall exact details of the event due to diagnosis of vascular dementia (type of dementia caused by conditions that disrupt blood flow to the brain, leading to damage and cognitive decline). He does not recall in the same way today, but the general allegation remains the same. A trauma informed care assessment was completed by the DON on 4/9/2025. Results were no negative outcomes. - One on One in-service on Abuse Reporting with the Administrator, DON, by Area Director of Operation (ADO) on 4/9/2025 at 20:08. - One on One in-service on Investigating allegations with the Administrator, DON, by ADO on 4/10/2025 at 10:23am. - Staff working with alleged perpetrators have been interviewed by the Administrator, Director of Nursing, ADO , and Compliance Nurse. Statements revealed the medication aide was the first to learn of the concern, she reported to the charge nurse who reported to the ADON. The ADON reported he phoned the administrator and left copies of the statements with her. All interviews were completed on 4/9/2025. The resident is doing ok; no distress was noted, and the resident was able to voice concerns. - The alleged perpetrator was suspended on 4/9/2025 at 6:00 p.m., pending the outcome of the investigation. - The ADON was suspended on 4/9/2025 at 9:00 p.m., pending the outcome of the investigation. - Notification of Authorities: Law enforcement and HHSC were notified promptly in accordance with state-mandated reporting guidelines on 04/09/2025. - Emotional Support: Social services and/or a mental health provider were contacted to provide counseling and emotional support to the resident; referral was sent as on 04/09/2025. - All residents who were able to be interviewed had safety surveys on 4/9/2025 by the social worker. No abuse incidents were reported. All surveys were completed on 4/9/2025. - All residents who were able to be interviewed were interviewed by DON/Compliance Nurse/Social worker on 4/9/2025. A new skin assessment was completed on all non-verbal residents, by the same group was completed on 4/9/2025 with no abnormal findings (unknown bruises, skin tears, abrasions). -The following in-services were initiated on 4/9/2025 by the Administrator/ADO: Any staff member not present or in-service on 4/9/2025 will not be allowed to assume their duties until in-service. These will be completed by 4/10/2025. - All Staff ? Abuse/Neglect with special focus on sexual abuse ? Abuse/Neglect Reporting ? Who to Report Abuse/Neglect to Administrator and Director of Nursing Previously this was to be reported to only the administrator, but a second layer of reporting was added to prevent oversight of a single individual. - All in-serviced staff will need to be able to articulate back on reporting any abuse allegation and to whom to report by 4/10/2025 -The administrator/designee will assess and monitor understanding by quizzing and providing examples on in-services beginning 4/9/2025. - New staff will be in service during orientation before assuming any duties. - The medical director was notified of the immediate jeopardy situation on 4/9/2025 at 8:23 p.m. - The administrator will report any abuse allegations, investigate, and submit findings to the Area Director and Risk Management for review. 4 weeks and PRN thereafter. -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 by residents and or staff 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 the findings of abuse allegations and investigations monthly and make changes to the system as needed. 4 weeks until substantial compliance is achieved. Monitoring of the facility's plan of removal included the following: During an interview on 04/10/2025 at 1:50 p.m., the ADO stated an investigation into the allegation of sexual abuse was started on 04/09/2025 and continuing. The ADO said she in-serviced the DON and Administrator one-on-one regarding the reporting of abuse and investigating allegations. The ADO said all new investigations would start immediately upon receiving an allegation. The ADO said CNA O and ADON E were suspended pending the investigation. The ADO said a referral for emotional support was sent on 4/9/2025 to provide counseling and emotional support to Resident #1. The ADO said part of the plan included all new staff would be in-serviced during orientation. The ADO said the Administrator would submit documentation of the investigation and have weekly follow-up interviews with staff for 4 weeks to ensure resident safety. The ADO said she would monitor abuse allegations reported by residents and/or staff and check the real-time system for keywords like abuse for 4 weeks. The ADO said the QA committee would review findings of all abuse allegations and investigations monthly and make changes as needed. During an interview on 4/10/2025 at 2:10 p.m., the DON stated an investigation into the allegation of sexual abuse started on 4/9/2025. The DON stated being in-serviced by ADO regarding new investigations would start immediately upon receiving an allegation. The DON said CNA O and ADON E were suspended pending investigation. The DON said residents who were able to be interviewed were interviewed and a skin assessment was completed on all non-verbal residents on 4/9/2025. During an interview on 4/10/2025 at 2:24 p.m., the Administrator stated an investigation into the allegation of sexual abuse started on 4/9/2025 and CNA O and ADON E were suspended pending the investigation. The Administrator stated ADO in-serviced her on new investigations needing to start immediately upon receiving an allegation. The Administrator said staff working with the alleged perpetrator were interviewed on 4/9/2025. The Administrator said law enforcement was contacted on 4/9/2025. The Administrator said all facility staff, before assuming their duties, were in-serviced on abuse/neglect with focus on sexual abuse, abuse/neglect reporting, and who to report allegations of abuse/neglect to, being the Administrator and the DON. During an interview on 04/10/2025 at 2:01 p.m., CNA N who works the 6:00 a.m. to 2:00 p.m. shift, said he said he was in-serviced on abuse/neglect. CNA N said all allegations to include sexual abuse, needed to be reported to the DON and the Administrator immediately after ensuring resident were safe. CNA N was able to point out where to locate the contact number posting. During an interview on 04/10/2025 at 2:03 p.m., LVN J who works the 2:00 p.m. to 10:00 p.m. shift, said he was in-serviced on abuse/neglect reporting. LVN J said all allegations of abuse/neglect to include sexual abuse were to be reported to the Abuse Coordinator/Administrator and DON immediately as soon as verifying the resident was safe. LVN J was able to point out where to locate the posted contact numbers for the Administrator and DON. During an interview on 4/10/2025 at 2:04 p.m., LVN K who works the 6:00 a.m. to 2:00 p.m., shift, said she was in-serviced on abuse/neglect and reporting. LVN K said when it came to abuse/neglect, she must make sure the resident was safe from any abuse and then immediately report the allegation to the DON and Administrator/Abuse Coordinator. LVN K was able to point out where to find the posted contact numbers for the Administrator and DON. During an interview on 4/10/2025 at 2:05 p.m., LVN G who works 6:00 a.m. to 2:00 p.m. shift, said he was in-serviced on abuse/neglect reporting. LVN G said all allegations of abuse/neglect which included sexual abuse must be reported immediately to the Abuse Coordinator and the DON. LVN G was able to point out where to locate contact numbers for the Administrator and the DON. During an interview on 4/10/2025 at 2:06 p.m., CNA S who works 10:00 p.m. to 6:00 a.m. shift, said she was in-serviced on abuse/neglect reporting. CNA S said for all allegations of abuse/neglect which included sexual abuse, it should be reported immediately to Abuse Coordinator and DON after seeing the resident was safe. CNA S was able to point out where to locate the contact numbers for the DON and the Administrator. During an interview on 4/10/2025 at 2:09 p.m., LVN F who works the 2:00 p.m. to 10:00 p.m. shift, said he was in-serviced on abuse/neglect reporting. LVN F said he was responsible to protect residents and make sure they were safe and then report all allegations to the Abuse Coordinator/Administrator and the DON immediately. LVN F was able to point out where to locate the posted contact numbers for the DON and Administrator. During an interview on 4/10/2025 at 2:10 p.m., CNA T who works the 2:00 p.m. to 10:00 p.m. shift, said she was in-serviced on abuse/neglect reporting. CNA T said she needed to make sure residents were safe and then report it right away to the Administrator and the DON. CNA T was able to point out where to locate the posted contact numbers for the DON and Administrator. During an interview on 4/10/2025 at 2:11 p.m., LVN H who works the 2:00 p.m. to 10:00 p.m. shift, said she was in-serviced on abuse/neglect reporting. LVN H said when it came to allegations of abuse/neglect, first make sure the resident was safe, and then call the Administrator/Abuse Coordinator and the DON immediately as soon as possible. LVN H was able to point out where the posted contact numbers for the DON and Administrator were located. During an interview on 4/10/2025 at 2:18 p.m., CNA R said she was in-serviced on reporting abuse/neglect allegations. CNA R said it was the staff responsibility to make sure the resident was safe and then immediately report to the Administrator/Abuse Coordinator and the DON. CNA R was able to point out where to locate contact numbers. During an interview on 4/10/2025 at 2:20 p.m., HK Z said she was in-serviced on reporting abuse/neglect. The HK staff said her responsibility was to report any allegations of abuse/neglect to the Abuse Coordinator and the DON immediately. The HK was able to point out where to locate contact numbers for the Administrator and the DON. During an interview on 4/10/2025 at 2:23 p.m., LVN L who works multiple shift times from 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m., said he was in-serviced on abuse/neglect reporting. LVN L said his responsibility was to keep the residents safe and remove the alleged perpetrator if with the resident. LVN L said he then called the Administrator/Abuse Coordinator and the DON immediately to report the allegation. LVN L was able to point out where to locate contact numbers. During an interview on 4/10/2025 at 2:24 p.m., MA Y said she was in-serviced on reporting abuse/neglect. MA Y said allegations of abuse/neglect which included sexual abuse needed to be reported immediately to the Abuse Coordinator and the DON after making sure the resident was safe. MA Y was able to point out where to locate contact number. During an interview on 4/10/2025 at 2:26 p.m., LVN I who works the 2:00 p.m. to 10:00 p.m. shift, said she received training on abuse/neglect reporting. LVN I said she was responsible to make sure residents were safe and call the Administrator and the DON to report immediately. LVN I was able to point out where the contact numbers of the Administrator and the DON were posted. During an interview on 4/10/2025 at 2:31 p.m., CNA U said she was in-serviced on reporting abuse/neglect. CNA U said she was trained to make sure residents were safe and report allegations of abuse/neglect, to include sexual abuse, to the Abuse Coordinator and the DON immediately. During an interview on 4/10/2025 at 2:35 p.m., the Activity Director said she was trained on reporting abuse/neglect. The Activity Director said for allegations of abuse/neglect, she would report immediately to the Abuse Coordinator/Administrator and the DON. The Activity Director pointed out where the contact numbers were for the DON and Administrator were located. During an interview on 4/10/2025 at 2:38 p.m., Dietary Staff W said she was trained on reporting abuse/neglect. Dietary Staff W said if she suspected or witnessed any abuse/neglect, she would make sure the resident was safe and then report it to the Abuse Coordinator/Administrator and the DON immediately. Record review of the Facility's In-Service training records titled Self-Reporting Protocol/Ad Hoc QAPI dated 4/9/2025, revealed allegation reported to the State; alleged perpetrator suspended; resident interviewed; interview of resident roommate; interviews with interviewable residents regarding staff treatment; skin assessment for residents who are unable to be interviewed; interview of staff regarding if they observed any potential abuse; performed a Trauma Informed PRN Assessment; notification to law enforcement; notification of medical director; were conducted and signed by the Administrator and the DON. Record review of the facility's document titled In-Service Training Attendance Roster, dated 4/9/2025, reflected that ADO conducted one-on-one in-services with the Administrator and the DON on training topic of allegation reporting guidelines. Record review of the facility's documentation regarding investigating allegations, revealed witness statements were taken on 04/09/2025 related to the allegation of sexual abuse, from Resident #1, the DON, ADON E and the Administrator. Record review of the Facility's In-Service Training records revealed training was conducted on 4/10/2025. The in-services were, dated 4/9/2025 and 4/10/2025, and included the topics of abuse/neglect/exploitation, abuse/neglect reporting, and who to report allegations of abuse/neglect to. Seventy-eight (78) out of (81) staff had signed the in-service training forms. Record review of Employee Disciplinary Reports, dated 04/09/2025, revealed CNA O and ADON E were placed on suspension pending investigation. Record review of the Police Department Incident Information Card, dated 4/9/2025, revealed a police report was made . Record review of Order, dated 4/10/2025, revealed an order for Resident #1 for counseling and emotional support services. Record review of Trauma Informed PRN Assessment, dated 04/09/2025, revealed the assessment was completed for Resident #1 by the DON. Record review of Resident Safe Surveys, dated 4/9/2025, reflected 45 resident surveys were conducted. The document covered the areas of 1) had anyone physically harmed the resident, if yes provide details; 2) has staff yelled or cursed at you; 3) does the resident feel comfortable asking staff for assistance; and 4) does staff treat you with respect. No potential abuse was noted. Record review of Resident Skin Assessments, dated 4/9/2025, reflected 17 assessments were performed for non-verbal residents with no abnormal findings. The ADO and Administrator were informed that the IJ was removed on 04/10/2025 at 4:46 a.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials including the State Survey Agency in accordance with State law through established procedures for 1 of 7 residents (Resident #2) reviewed for abuse. -The Facility Administrator failed to report a suspected crime to local law enforcement and the State Survey Agency, resulting in failure to protect residents from further potential criminal activity by an alleged perpetrator when Resident #1 reported sexual abuse by CNA O to staff in January 2025. An Immediate Jeopardy (IJ) situation was identified on 04/09/25. While the IJ was removed on 04/10/25, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for abuse, physical harm, psychosocial harm, trauma, unrecognized abuse, and emotional distress. Findings include: Record review of Resident #1's admission Record, dated 04/09/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: vascular dementia (type of dementia caused by conditions that disrupt blood flow to the brain, leading to cognitive and behavioral changes), hypertension (high blood pressure), hemiplegia (total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (lack oxygen to the brain causing damage to brain tissue) affecting left non-dominant side, and lack of coordination. Record review of Resident 1's Quarterly MDS, dated [DATE], revealed a BIMS score of 10, which indicated moderate cognitive impairment. Section GG - Functional Abilities revealed Resident #1 required substantiated/maximal assistance with toileting hygiene and shower/bathing. Record review of Resident #1's Care Plan, dated 04/09/2025, revealed a focus area which reflected Resident #1 had an ADL self-care performance deficit. Part of the interventions reads in part, Bathing requires staff x1 for assistance. During an interview on 04/09/2025 at 10:44 a.m., Resident #1 said back on a day in January 2025, CNA O took him to a shower and while bathing the resident, CNA O stuck his finger inside Resident #1's anus once for about a second. Resident #1 said there were no other witnesses at the time of the incident. Resident #1 said he did not initially report the incident to anyone because he was embarrassed. Resident #1 said he was not injured or in any discomfort after the incident occurred. Resident #1 said he reported it to facility staff a few days later but could not remember who. Resident #1 said the facility did not do anything about what he reported because CNA O was still working at the facility although had not given Resident #1 any more showers. Resident #1 said he did not remember talking to any administrator or anyone else about what he reported. Resident #1 said this made him upset because he would not want another resident to go through what he went through. Resident #1 said CNA O did not work with him anymore after the incident. During an interview on 04/09/2025 at 12:22 p.m., CNA N said about two-three months ago, Resident #1 said he had been sexually abused by CNA O. CNA N said Resident #1 told another staff member during another shift about the allegation and CNA N believed the staff reported it to administration. CNA N said he did not report the allegation to anyone else because he thought it had already been reported. CNA N said he believed it was the Administrator who told staff males could not go into the room, and if they must go into Resident #1's room it needed to be with another staff. CNA N said CNA O was not suspended and stayed working on the floor with other residents. CNA N said no other residents complained about CNA O. CNA N said he did not know if anything was done about the allegation. During an interview on 04/09/2025 at 2:25 p.m., LVN H said Resident #1 refused to have males work with him. LVN H said Resident #1 just said to her he did not like one specific male CNA (CNA O) and was okay with the other male CNAs. LVN H said she did not know why Resident #1 did not want CNA O to work with him. During an interview on 04/09/2025 at 2:33 p.m., CNA P said she heard from other staff that a male was not supposed to take care of Resident #1. CNA P said she did not know why. CNA P said she did not know if the information was documented anywhere. During an interview on 04/09/2025 at 2:49 p.m., LVN F said one day about 3 or 4 months ago, CMA M informed LVN F Resident #1 was complaining about being sexually molested. LVN F said he talked with Resident #1 and the resident told him he felt he was sexually molested by inappropriate touching by a staff member. LVN F said he reported the allegation to ADON E. LVN F said he believed ADON E reported it to the Administrator. LVN F said the allegation was reported by Resident #1 days after the alleged incident occurred. LVN F said he did not remember if he documented the incident. During an interview on 04/09/2025 at 3:37 p.m., the ADON E said all allegations reported needed to be reported to the Administrator or the DON right away. The ADON E said she had the DON and Administrator's numbers, and they were on-call 24/7. The ADON E said one evening several months back, LVN F said Resident #1 felt he was abused two to three days before when he was getting showered and while staff cleaned his buttocks, Resident #1 felt CNA O touched him inappropriately. The ADON E said he asked LVN F to write him a statement. ADON E learned Resident #1 reported the allegation to CMA M, and she then reported it to LVN F. ADON E said he called the Administrator on the phone and told her there was an allegation of abuse in the building. ADON E could not recall the time he called the Administrator. ADON E said the Administrator told him she was out of the building, but when she came back, she would follow-up on the allegation. ADON E said he had been trained to report allegations of abuse/neglect/exploitation to the Administrator immediately. ADON E said he told LVN F to document the incident on the 24-hour report. ADON E said the written statement by LVN F was given to the Administrator and he did not know what the Administrator did then. During an interview on 04/09/2025 at 4:19 p.m., CMA M said she was trained to report allegations of abuse, to include sexual abuse, to the charge nurse and Administrator immediately. CMA M said several months ago, Resident #1 reported to her he did not want CNA O in his room. CMA M said Resident #1 said an incident occurred 2 to 3 days before. CMA M said Resident #1 said while CNA O was assisting him to shower, CNA O touched Resident #1 inappropriately on his backside. CMA M said Resident #1 did not complain of any pain at the time. CMA M said she told Resident #1 she would report it to the nurse, and the nurse would talk with him. CMA M said she told LVN F, but she did not contact the Administrator. CMA M said she knew she should have informed the Administrator but failed to do so since she told LVN F. CMA M said CNA O still worked at the facility but did not provide any patient care to Resident #1. CMA M said she heard no other complaints from any other residents regarding CNA O. During an interview on 04/09/2025 at 4:30 p.m., CNA O said he had been working at the facility for 20 years. CNA O said he had been trained on reporting abuse/neglect allegations immediately to the Administrator. CNA O said no residents complained to him about any abuse or inappropriate touching. CNA O said he had not been suspended for any incidents or allegations. CNA O said no resident had complained about him. CNA O said he was familiar with Resident #1 and the resident did not want any males in the room. CNA O said Resident #1 did not have any problems with him. CNA O said he was told by LVN F not to work with Resident #1 with no other explanation. CNA O denied any knowledge of any sexual abuse. During an interview on 04/09/2025 at 5:05 p.m., the Administrator said her responsibility when it came to allegations of abuse, neglect, or exploitation was to protect the resident, gather information, and proceed with the investigation. The Administrator said she was also responsible to contact the State Survey Agency and if needed law enforcement. The Administrator said all allegations of abuse would be reported to the State Survey Agency within 2 hours. The Administrator said if there were any allegations of sexual abuse, the allegation would be reported to the State Survey Agency, law enforcement, and the physician and responsible parties. The Administrator said she had not received any reports of any type of sexual abuse. The Administrator said she was familiar with Resident #1, and he had not made any complaints with her. The Administrator denied being notified or having any knowledge of any alleged sexual abuse which involved Resident #1. Record review of Resident #1's Progress Notes from January 2025 to April 2025 did not reveal any documentation regarding the allegation of sexual abuse. Record review of Social Service Quarterly Assessment for Resident #1, dated 01/17/2025 at 4:00 p.m., read in part, Resident can have times when he becomes upset at staff but for the most part gets along well with everyone. At this time there are to be no male CNAs in resident's room. Record review of the 24-hour reports for the month of January 2025, did not reveal any information on the allegation of sexual abuse. Record review of TULIP revealed no prior self-reports related to the allegation of abuse which involved Resident #1 from 01/01/2025 to 04/09/2025. Record review of a copy of a statement written by CMA M, dated 1/14/2025, read To whom it may concern, On Wednesday, January 8th, [CMA M] reported to [LVN F] nurse in charge of [Resident #1] reporting an incident of sexual harassment. [Resident #1] stated that he was upset with [CNA O]. [Resident #1] said that [CNA O] inserted his fingers while [CNA O] was showering him. [CMA M] immediately reported to [LVN F]. Record review of the facility provided Abuse/Neglect policy, with revision date 3/29/2018, read in part All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Appropriate notification to state and home office will be the responsibility of the administrator and per policy .Reporting: Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect, or exploitation must report this to the DON, administrator, state and/or adult protective services. Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19; a) If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation Investigation .Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. This was determined to be an Immediate Jeopardy (IJ) on 04/08/2025 at 8:00 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 04/08/2025 at 8:00 p.m. The following Plan of Removal submitted by the facility was accepted on 4/10/2025 at 1:40 p.m.: Interventions: - Abuse allegation investigations started on 4/9/2025 and are ongoing. Furthermore, as per policy, all new investigations start immediately upon receiving an allegation. - The resident was interviewed at the time of discovery on 4/9/2025 and could not recall exact details of the event due to diagnosis of vascular dementia (type of dementia caused by conditions that disrupt blood flow to the brain, leading to damage and cognitive decline). He does not recall in the same way today, but the general allegation remains the same. A trauma informed care assessment was completed by the DON on 4/9/2025. Results were no negative outcomes. - One on One in-service on Abuse Reporting with the Administrator, DON, by Area Director of Operation (ADO) on 4/9/2025 at 20:08. - One on One in-service on Investigating allegations with the Administrator, DON, by ADO on 4/10/2025 at 10:23am. - Staff working with alleged perpetrators have been interviewed by the Administrator, Director of Nursing, ADO, and Compliance Nurse. Statements revealed the medication aide was the first to learn of the concern, she reported to the charge nurse who reported to the ADON. The ADON reported he phoned the administrator and left copies of the statements with her. All interviews were completed on 4/9/2025. The resident is doing ok; no distress was noted, and the resident was able to voice concerns. - The alleged perpetrator was suspended on 4/9/2025 at 6:00 p.m., pending the outcome of the investigation. - The ADON was suspended on 4/9/2025 at 9:00 p.m., pending the outcome of the investigation. - Notification of Authorities: Law enforcement and HHSC were notified promptly in accordance with state-mandated reporting guidelines on 04/09/2025. - Emotional Support: Social services and/or a mental health provider were contacted to provide counseling and emotional support to the resident; referral was sent as on 04/09/2025. - All residents who were able to be interviewed had safety surveys on 4/9/2025 by the social worker. No abuse incidents were reported. All surveys were completed on 4/9/2025. - All residents who were able to be interviewed were interviewed by DON/Compliance Nurse/Social worker on 4/9/2025. A new skin assessment was completed on all non-verbal residents, by the same group was completed on 4/9/2025 with no abnormal findings (unknown bruises, skin tears, abrasions). -The following in-services were initiated on 4/9/2025 by the Administrator/ADO: Any staff member not present or in-service on 4/9/2025 will not be allowed to assume their duties until in-service. These will be completed by 4/10/2025. - All Staff ? Abuse/Neglect with special focus on sexual abuse ? Abuse/Neglect Reporting ? Who to Report Abuse/Neglect to Administrator and Director of Nursing Previously this was to be reported to only the administrator, but a second layer of reporting was added to prevent oversight of a single individual. - All in-serviced staff will need to be able to articulate back on reporting any abuse allegation and to whom to report by 4/10/2025 -The administrator/designee will assess and monitor understanding by quizzing and providing examples on in-services beginning 4/9/2025. - New staff will be in service during orientation before assuming any duties. - The medical director was notified of the immediate jeopardy situation on 4/9/2025 at 8:23 p.m. - The administrator will report any abuse allegations, investigate, and submit findings to the Area Director and Risk Management for review. 4 weeks and PRN thereafter. -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 by residents and or staff 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 the findings of abuse allegations and investigations monthly and make changes to the system as needed. 4 weeks until substantial compliance is achieved. Monitoring of the facility's plan of removal included the following: During an interview on 04/10/2025 at 1:50 p.m., the ADO stated an investigation into the allegation of sexual abuse was started on 04/09/2025 and continuing. The ADO said she in-serviced the DON and Administrator one-on-one regarding the reporting of abuse and investigating allegations. The ADO said all new investigations would start immediately upon receiving an allegation. The ADO said CNA O and ADON E were suspended pending the investigation. The ADO said a referral for emotional support was sent on 4/9/2025 to provide counseling and emotional support to Resident #1. The ADO said part of the plan included all new staff would be in-serviced during orientation. The ADO said the Administrator would submit documentation of the investigation and have weekly follow-up interviews with staff for 4 weeks to ensure resident safety. The ADO said she would monitor abuse allegations reported by residents and/or staff and check the real-time system for keywords like abuse for 4 weeks. The ADO said the QA committee would review findings of all abuse allegations and investigations monthly and make changes as needed. During an interview on 4/10/2025 at 2:10 p.m., the DON stated an investigation into the allegation of sexual abuse started on 4/9/2025. The DON stated being in-serviced by ADO regarding new investigations would start immediately upon receiving an allegation. The DON said CNA O and ADON E were suspended pending investigation. The DON said residents who were able to be interviewed were interviewed and a skin assessment was completed on all non-verbal residents on 4/9/2025. During an interview on 4/10/2025 at 2:24 p.m., the Administrator stated an investigation into the allegation of sexual abuse started on 4/9/2025 and CNA O and ADON E were suspended pending the investigation. The Administrator stated ADO in-serviced her on new investigations needing to start immediately upon receiving an allegation. The Administrator said staff working with the alleged perpetrator were interviewed on 4/9/2025. The Administrator said law enforcement was contacted on 4/9/2025. The Administrator said all facility staff, before assuming their duties, were in-serviced on abuse/neglect with focus on sexual abuse, abuse/neglect reporting, and who to report allegations of abuse/neglect to, being the Administrator and the DON. During an interview on 04/10/2025 at 2:01 p.m., CNA N who works the 6:00 a.m. to 2:00 p.m. shift, said he said he was in-serviced on abuse/neglect. CNA N said all allegations to include sexual abuse, needed to be reported to the DON and the Administrator immediately after ensuring resident were safe. CNA N was able to point out where to locate the contact number posting. During an interview on 04/10/2025 at 2:03 p.m., LVN J who works the 2:00 p.m. to 10:00 p.m. shift, said he was in-serviced on abuse/neglect reporting. LVN J said all allegations of abuse/neglect to include sexual abuse were to be reported to the Abuse Coordinator/Administrator and DON immediately as soon as verifying the resident was safe. LVN J was able to point out where to locate the posted contact numbers for the Administrator and DON. During an interview on 4/10/2025 at 2:04 p.m., LVN K who works the 6:00 a.m. to 2:00 p.m., shift, said she was in-serviced on abuse/neglect and reporting. LVN K said when it came to abuse/neglect, she must make sure the resident was safe from any abuse and then immediately report the allegation to the DON and Administrator/Abuse Coordinator. LVN K was able to point out where to find the posted contact numbers for the Administrator and DON. During an interview on 4/10/2025 at 2:05 p.m., LVN G who works 6:00 a.m. to 2:00 p.m. shift, said he was in-serviced on abuse/neglect reporting. LVN G said all allegations of abuse/neglect which included sexual abuse must be reported immediately to the Abuse Coordinator and the DON. LVN G was able to point out where to locate contact numbers for the Administrator and the DON. During an interview on 4/10/2025 at 2:06 p.m., CNA S who works 10:00 p.m. to 6:00 a.m. shift, said she was in-serviced on abuse/neglect reporting. CNA S said for all allegations of abuse/neglect which included sexual abuse, it should be reported immediately to Abuse Coordinator and DON after seeing the resident was safe. CNA S was able to point out where to locate the contact numbers for the DON and the Administrator. During an interview on 4/10/2025 at 2:09 p.m., LVN F who works the 2:00 p.m. to 10:00 p.m. shift, said he was in-serviced on abuse/neglect reporting. LVN F said he was responsible to protect residents and make sure they were safe and then report all allegations to the Abuse Coordinator/Administrator and the DON immediately. LVN F was able to point out where to locate the posted contact number s for the DON and Administrator. During an interview on 4/10/2025 at 2:10 p.m., CNA T who works the 2:00 p.m. to 10:00 p.m. shift, said she was in-serviced on abuse/neglect reporting. CNA T said she needed to make sure residents were safe and then report it right away to the Administrator and the DON. CNA T was able to point out where to locate the posted contact numbers for the DON and Administrator. During an interview on 4/10/2025 at 2:11 p.m., LVN H who works the 2:00 p.m. to 10:00 p.m. shift, said she was in-serviced on abuse/neglect reporting. LVN H said when it came to allegations of abuse/neglect, first make sure the resident was safe, and then call the Administrator/Abuse Coordinator and the DON immediately as soon as possible. LVN H was able to point out where the posted contact numbers for the DON and Administrator were located. During an interview on 4/10/2025 at 2:18 p.m., CNA R said she was in-serviced on reporting abuse/neglect allegations. CNA R said it was the staff responsibility to make sure the resident was safe and then immediately report to the Administrator/Abuse Coordinator and the DON. CNA R was able to point out where to locate contact numbers. During an interview on 4/10/2025 at 2:20 p.m., HK Z said she was in-serviced on reporting abuse/neglect. The HK staff said her responsibility was to report any allegations of abuse/neglect to the Abuse Coordinator and the DON immediately. The HK was able to point out where to locate contact numbers for the Administrator and the DON. During an interview on 4/10/2025 at 2:23 p.m., LVN L who works multiple shift times from 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m., said he was in-serviced on abuse/neglect reporting. LVN L said his responsibility was to keep the residents safe and remove the alleged perpetrator if with the resident. LVN L said he then called the Administrator/Abuse Coordinator and the DON immediately to report the allegation. LVN L was able to point out where to locate contact numbers. During an interview on 4/10/2025 at 2:24 p.m., MA Y said she was in-serviced on reporting abuse/neglect. MA Y said allegations of abuse/neglect which included sexual abuse needed to be reported immediately to the Abuse Coordinator and the DON after making sure the resident was safe. MA Y was able to point out where to locate contact number. During an interview on 4/10/2025 at 2:26 p.m., LVN I who works the 2:00 p.m. to 10:00 p.m. shift, said she received training on abuse/neglect reporting. LVN I said she was responsible to make sure residents were safe and call the Administrator and the DON to report immediately. LVN I was able to point out where the contact numbers of the Administrator and the DON were posted. During an interview on 4/10/2025 at 2:31 p.m., CNA U said she was in-serviced on reporting abuse/neglect. CNA U said she was trained to make sure residents were safe and report allegations of abuse/neglect, to include sexual abuse, to the Abuse Coordinator and the DON immediately. During an interview on 4/10/2025 at 2:35 p.m., the Activity Director said she was trained on reporting abuse/neglect. The Activity Director said for allegations of abuse/neglect, she would report immediately to the Abuse Coordinator/Administrator and the DON. The Activity Director pointed out where the contact numbers were for the DON and Administrator were located. During an interview on 4/10/2025 at 2:38 p.m., Dietary Staff W said she was trained on reporting abuse/neglect. Dietary Staff W said if she suspected or witnessed any abuse/neglect, she would make sure the resident was safe and then report it to the Abuse Coordinator/Administrator and the DON immediately. Record review of the Facility's In-Service training records titled Self-Reporting Protocol/Ad Hoc QAPI dated 4/9/2025, revealed allegation reported to the State; alleged perpetrator suspended; resident interviewed; interview of resident roommate; interviews with interviewable residents regarding staff treatment; skin assessment for residents who are unable to be interviewed; interview of staff regarding if they observed any potential abuse; performed a Trauma Informed PRN Assessment; notification to law enforcement; notification of medical director; were conducted and signed by the Administrator and the DON. Record review of the facility's document titled In-Service Training Attendance Roster, dated 4/9/2025, reflected that ADO conducted one-on-one in-services with the Administrator and the DON on training topic of allegation reporting guidelines. Record review of the facility's documentation regarding investigating allegations, revealed witness statements were taken on 04/09/2025 related to the allegation of sexual abuse, from Resident #1, the DON, ADON E and the Administrator. Record review of the Facility's In-Service Training records revealed training was conducted on 4/10/2025. The in-services were, dated 4/9/2025 and 4/10/2025, and included the topics of abuse/neglect/exploitation, abuse/neglect reporting, and who to report allegations of abuse/neglect to. Seventy-eight (78) out of (81) staff had signed the in-service training forms. Record review of Employee Disciplinary Reports, dated 04/09/2025, revealed CNA O and ADON E were placed on suspension pending investigation. Record review of the Police Department Incident Information Card, dated 4/9/2025, revealed a police report was made. Record review of Order, dated 4/10/2025, revealed an order for Resident #1 for counseling and emotional support services. Record review of Trauma Informed PRN Assessment, dated 04/09/2025, revealed the assessment was completed for Resident #1 by the DON. Record review of Resident Safe Surveys, dated 4/9/2025, reflected 45 resident surveys were conducted. The document covered the areas of 1) had anyone physically harmed the resident, if yes provide details; 2) has staff yelled or cursed at you; 3) does the resident feel comfortable asking staff for assistance; and 4) does staff treat you with respect. No potential abuse was noted. Record review of Resident Skin Assessments, dated 4/9/2025, reflected 17 assessments were performed for non-verbal residents with no abnormal findings. The ADO and Administrator were informed that the IJ was removed on 04/10/2025 at 4:46 a.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment the facility had evidence that all alleged violations were thoroughly investigated and prevent further abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 1 of 7 residents (Residents #1) reviewed for abuse/neglect. 1. The facility failed to investigate an allegation of sexual abuse of Resident #1. 2. The facility failed to prevent further potential abuse and mistreatment by allowing the alleged perpetrator to remain in the facility and to have direct contact with the residents. An Immediate Jeopardy (IJ) situation was identified 04/09/25. While the IJ was removed on 04/10/25, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for abuse, physical harm, psychosocial harm, trauma, unrecognized abuse and emotional distress. The findings include: Record review of Resident #1's admission Record, dated 04/09/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: vascular dementia (type of dementia caused by conditions that disrupt blood flow to the brain, leading to cognitive and behavioral changes), hypertension (high blood pressure), hemiplegia (total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (lack oxygen to the brain causing damage to brain tissue) affecting left non-dominant side, and lack of coordination. Record review of Resident 1's Quarterly MDS, dated [DATE], revealed a BIMS score of 10, which indicated moderate cognitive impairment. Section GG - Functional Abilities revealed Resident #1 required substantiated/maximal assistance with toileting hygiene and shower/bathing. Record review of Resident #1's Care Plan, dated 04/09/2025, revealed a focus area which reflected Resident #1 had an ADL self-care performance deficit. Part of the interventions reads in part, Bathing requires staff x1 for assistance. During an interview on 04/09/2025 at 10:44 a.m., Resident #1 said back on a day in January 2025, CNA O took him to a shower and while bathing the resident, CNA O stuck his finger inside Resident #1's anus once for about a second. Resident #1 said there were no other witnesses at the time of the incident. Resident #1 said he did not initially report the incident to anyone because he was embarrassed. Resident #1 said he was not injured or in any discomfort after the incident occurred. Resident #1 said he reported it to facility staff a few days later but could not remember who. Resident #1 said the facility did not do anything about what he reported because CNA O was still working at the facility although had not given Resident #1 any more showers. Resident #1 said he did not remember talking to any administrator or anyone else about what he reported. Resident #1 said this made him upset because he would not want another resident to go through what he went through. Resident #1 said CNA O did not work with him anymore after the incident. During an interview on 04/09/2025 at 12:22 p.m., CNA N said about two-three months ago, Resident #1 said he had been sexually abused by CNA O. CNA N said Resident #1 told another staff member during another shift about the allegation and CNA N believed the staff reported it to administration. CNA N said he did not report the allegation to anyone else because he thought it had already been reported. CNA N said he believed it was the Administrator who told staff males could not go into the room, and if they must go into Resident #1's room it needed to be with another staff. CNA N said CNA O was not suspended and stayed working on the floor with other residents. CNA N said no other residents complained about CNA O. CNA N said he did not know if anything was done about the allegation. During an interview on 04/09/2025 at 2:25 p.m., LVN H said Resident #1 refused to have males work with him. LVN H said Resident #1 just said to her he did not like one specific male CNA (CNA O) and was okay with the other male CNAs. LVN H said she did not know why Resident #1 did not want CNA O to work with him. During an interview on 04/09/2025 at 2:33 p.m., CNA P said she heard from other staff that a male was not supposed to take care of Resident #1. CNA P said she did not know why. CNA P said she did not know if the information was documented anywhere. During an interview on 04/09/2025 at 2:49 p.m., LVN F said one day about 3 or 4 months ago, CMA M informed LVN F Resident #1 was complaining about being sexually molested. LVN F said he talked with Resident #1 and the resident told him he felt he was sexually molested by inappropriate touching by a staff member. LVN F said Resident #1 did not say which staff at the time. LVN F said Resident #1 said he did not want any males working with him. LVN F said he reported the allegation to ADON E. LVN F said he believed ADON E reported it to the Administrator. LVN F said ADON E told him to make sure no males went into the room with Resident #1. LVN F said he then informed the staff on the floor about the instructions ADON E told him regarding no males in Resident #1's room. LVN F said the allegation was reported by Resident #1 days after the alleged incident occurred. LVN F said Resident #1 did not complain about any discomfort or injury. LVN F said he did not remember if he documented the incident. During an interview on 04/09/2025 at 3:37 p.m., the ADON E said all allegations reported needed to be reported to the Administrator or the DON right away. The ADON E said she had the DON and Administrator's numbers, and they were on-call 24/7. The ADON E said one evening several months back, LVN F said Resident #1 felt he was abused two to three days before when he was getting showered and while staff cleaned his buttocks, Resident #1 felt CNA O touched him inappropriately. The ADON E said he asked LVN F to write him a statement. ADON E said he called the Administrator on the phone and told her there was an allegation of abuse in the building. ADON E could not recall the time he called the Administrator. The ADON E said he instructed LVN F no males were allowed in Resident #1's room. ADON E said Resident #1 was informed and he did not have a problem with any other male CNAs, and only CNA O. ADON E said he told LVN F to document the incident on the 24-hour report. ADON E said the written statement by LVN F was given to the Administrator and he did not know what the Administrator did then. During an interview on 04/09/2025 at 4:19 p.m., CMA M said she was trained to report allegations of abuse, to include sexual abuse, to the charge nurse and Administrator immediately. CMA M said several months ago, Resident #1 reported to her he did not want CNA O in his room. CMA M said Resident #1 said CNA O touched him inappropriately on his backside. CMA M said she told LVN F, but she did not contact the Administrator. CMA M said she knew she should have informed the Administrator but failed to do so since she told LVN F. CMA M said CNA O still worked at the facility but did not provide any patient care to Resident #1. During an interview on 04/09/2025 at 4:30 p.m., CNA O said he had been working at the facility for 20 years. CNA O said he had been trained on reporting abuse/neglect allegations immediately to the Administrator. CNA O said no residents complained to him about any abuse or inappropriate touching. CNA O said he had not been suspended for any incidents or allegations. CNA O said no resident had complained about him. CNA O said he was familiar with Resident #1 and the resident did not want any males in the room. CNA O said Resident #1 did not have any problems with him. CNA O said he was told by LVN F not to work with Resident #1 with no other explanation. CNA O denied any knowledge of any sexual abuse. During an interview on 04/09/2025 at 5:05 p.m., the Administrator said her responsibility when it came to allegations of abuse, neglect, or exploitation was to protect the resident, gather information, and proceed with the investigation. The Administrator said she was also responsible to contact the State Survey Agency and if needed law enforcement. The Administrator said all allegations of abuse would be reported to the State Survey Agency within 2 hours. The Administrator said if there were any allegations of sexual abuse, the allegation would be reported to the State Survey Agency, law enforcement, and the physician and responsible parties. The Administrator said she had not received any reports of any type of sexual abuse. The Administrator said she was familiar with Resident #1, and he had not made any complaints with her. The Administrator denied being notified or having any knowledge of any alleged sexual abuse which involved Resident #1. Record review of Resident #1's Progress Notes from January 2025 to April 2025 did not reveal any documentation regarding the allegation of sexual abuse. Record review of Social Service Quarterly Assessment for Resident #1, dated 01/17/2025 at 4:00 p.m., read in part, Resident can have times when he becomes upset at staff but for the most part gets along well with everyone. At this time there are to be no male CNAs in resident's room. Record review of the 24-hour reports for the month of January 2025, did not reveal any information on the allegation of sexual abuse. Record review of TULIP revealed no prior self-reports related to the allegation of abuse which involved Resident #1 from 01/01/2025 to 04/09/2025. Record review of a copy of a statement written by CMA M, dated 1/14/2025, read To whom it may concern, On Wednesday, January 8th, [CMA M] reported to [LVN F] nurse in charge of [Resident #1] reporting an incident of sexual harassment. [Resident #1] stated that he was upset with [CNA O]. [Resident #1] said that [CNA O] inserted his fingers while [CNA O] was showering him. [CMA M] immediately reported to [LVN F]. Record review of the facility provided Abuse/Neglect policy, with revision date 3/29/2018, read in part All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility protocol. Investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint. Investigation .Comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist. This was determined to be an Immediate Jeopardy (IJ) on 04/08/2025 at 8:00 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 04/08/2025 at 8:00 p.m. The following Plan of Removal submitted by the facility was accepted on 4/10/2025 at 1:40 p.m.: Interventions: - Abuse allegation investigations started on 4/9/2025 and are ongoing. Furthermore, as per policy, all new investigations start immediately upon receiving an allegation. - The resident was interviewed at the time of discovery on 4/9/2025 and could not recall exact details of the event due to diagnosis of vascular dementia (type of dementia caused by conditions that disrupt blood flow to the brain, leading to damage and cognitive decline). He does not recall in the same way today, but the general allegation remains the same. A trauma informed care assessment was completed by the DON on 4/9/2025. Results were no negative outcomes. - One on One in-service on Abuse Reporting with the Administrator, DON, by Area Director of Operation (ADO) on 4/9/2025 at 20:08. - One on One in-service on Investigating allegations with the Administrator, DON, by ADO on 4/10/2025 at 10:23am. - Staff working with alleged perpetrators have been interviewed by the Administrator, Director of Nursing, ADO, and Compliance Nurse. Statements revealed the medication aide was the first to learn of the concern, she reported to the charge nurse who reported to the ADON. The ADON reported he phoned the administrator and left copies of the statements with her. All interviews were completed on 4/9/2025. The resident is doing ok; no distress was noted, and the resident was able to voice concerns. - The alleged perpetrator was suspended on 4/9/2025 at 6:00 p.m., pending the outcome of the investigation. - The ADON was suspended on 4/9/2025 at 9:00 p.m., pending the outcome of the investigation. - Notification of Authorities: Law enforcement and HHSC were notified promptly in accordance with state-mandated reporting guidelines on 04/09/2025. - Emotional Support: Social services and/or a mental health provider were contacted to provide counseling and emotional support to the resident; referral was sent as on 04/09/2025. - All residents who were able to be interviewed had safety surveys on 4/9/2025 by the social worker. No abuse incidents were reported. All surveys were completed on 4/9/2025. - All residents who were able to be interviewed were interviewed by DON/Compliance Nurse/Social worker on 4/9/2025. A new skin assessment was completed on all non-verbal residents, by the same group was completed on 4/9/2025 with no abnormal findings (unknown bruises, skin tears, abrasions). -The following in-services were initiated on 4/9/2025 by the Administrator/ADO: Any staff member not present or in-service on 4/9/2025 will not be allowed to assume their duties until in-service. These will be completed by 4/10/2025. - All Staff ? Abuse/Neglect with special focus on sexual abuse ? Abuse/Neglect Reporting ? Who to Report Abuse/Neglect to Administrator and Director of Nursing Previously this was to be reported to only the administrator, but a second layer of reporting was added to prevent oversight of a single individual. - All in-serviced staff will need to be able to articulate back on reporting any abuse allegation and to whom to report by 4/10/2025 -The administrator/designee will assess and monitor understanding by quizzing and providing examples on in-services beginning 4/9/2025. - New staff will be in service during orientation before assuming any duties. - The medical director was notified of the immediate jeopardy situation on 4/9/2025 at 8:23 p.m. - The administrator will report any abuse allegations, investigate, and submit findings to the Area Director and Risk Management for review. 4 weeks and PRN thereafter. -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 by residents and or staff 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 the findings of abuse allegations and investigations monthly and make changes to the system as needed. 4 weeks until substantial compliance is achieved. Monitoring of the facility's plan of removal included the following: During an interview on 04/10/2025 at 1:50 p.m., the ADO stated an investigation into the allegation of sexual abuse was started on 04/09/2025 and continuing. The ADO said she in-serviced the DON and Administrator one-on-one regarding the reporting of abuse and investigating allegations. The ADO said all new investigations would start immediately upon receiving an allegation. The ADO said CNA O and ADON E were suspended pending the investigation. The ADO said a referral for emotional support was sent on 4/9/2025 to provide counseling and emotional support to Resident #1. The ADO said part of the plan included all new staff would be in-serviced during orientation. The ADO said the Administrator would submit documentation of the investigation and have weekly follow-up interviews with staff for 4 weeks to ensure resident safety. The ADO said she would monitor abuse allegations reported by residents and/or staff and check the real-time system for keywords like abuse for 4 weeks. The ADO said the QA committee would review findings of all abuse allegations and investigations monthly and make changes as needed. During an interview on 4/10/2025 at 2:10 p.m., the DON stated an investigation into the allegation of sexual abuse started on 4/9/2025. The DON stated being in-serviced by ADO regarding new investigations would start immediately upon receiving an allegation. The DON said CNA O and ADON E were suspended pending investigation. The DON said residents who were able to be interviewed were interviewed and a skin assessment was completed on all non-verbal residents on 4/9/2025. During an interview on 4/10/2025 at 2:24 p.m., the Administrator stated an investigation into the allegation of sexual abuse started on 4/9/2025 and CNA O and ADON E were suspended pending the investigation. The Administrator stated ADO in-serviced her on new investigations needing to start immediately upon receiving an allegation. The Administrator said staff working with the alleged perpetrator were interviewed on 4/9/2025. The Administrator said law enforcement was contacted on 4/9/2025. The Administrator said all facility staff, before assuming their duties, were in-serviced on abuse/neglect with focus on sexual abuse, abuse/neglect reporting, and who to report allegations of abuse/neglect to, being the Administrator and the DON. During an interview on 04/10/2025 at 2:01 p.m., CNA N who works the 6:00 a.m. to 2:00 p.m. shift, said he said he was in-serviced on abuse/neglect. CNA N said all allegations to include sexual abuse, needed to be reported to the DON and the Administrator immediately after ensuring resident were safe. CNA N was able to point out where to locate the contact number posting. During an interview on 04/10/2025 at 2:03 p.m., LVN J who works the 2:00 p.m. to 10:00 p.m. shift, said he was in-serviced on abuse/neglect reporting. LVN J said all allegations of abuse/neglect to include sexual abuse were to be reported to the Abuse Coordinator/Administrator and DON immediately as soon as verifying the resident was safe. LVN J was able to point out where to locate the posted contact numbers for the Administrator and DON. During an interview on 4/10/2025 at 2:04 p.m., LVN K who works the 6:00 a.m. to 2:00 p.m., shift, said she was in-serviced on abuse/neglect and reporting. LVN K said when it came to abuse/neglect, she must make sure the resident was safe from any abuse and then immediately report the allegation to the DON and Administrator/Abuse Coordinator. LVN K was able to point out where to find the posted contact numbers for the Administrator and DON. During an interview on 4/10/2025 at 2:05 p.m., LVN G who works 6:00 a.m. to 2:00 p.m. shift, said he was in-serviced on abuse/neglect reporting. LVN G said all allegations of abuse/neglect which included sexual abuse must be reported immediately to the Abuse Coordinator and the DON. LVN G was able to point out where to locate contact numbers for the Administrator and the DON. During an interview on 4/10/2025 at 2:06 p.m., CNA S who works 10:00 p.m. to 6:00 a.m. shift, said she was in-serviced on abuse/neglect reporting. CNA S said for all allegations of abuse/neglect which included sexual abuse, it should be reported immediately to Abuse Coordinator and DON after seeing the resident was safe. CNA S was able to point out where to locate the contact numbers for the DON and the Administrator. During an interview on 4/10/2025 at 2:09 p.m., LVN F who works the 2:00 p.m. to 10:00 p.m. shift, said he was in-serviced on abuse/neglect reporting. LVN F said he was responsible to protect residents and make sure they were safe and then report all allegations to the Abuse Coordinator/Administrator and the DON immediately. LVN F was able to point out where to locate the posted contact numbers for the DON and Administrator. During an interview on 4/10/2025 at 2:10 p.m., CNA T who works the 2:00 p.m. to 10:00 p.m. shift, said she was in-serviced on abuse/neglect reporting. CNA T said she needed to make sure residents were safe and then report it right away to the Administrator and the DON. CNA T was able to point out where to locate the posted contact numbers for the DON and Administrator. During an interview on 4/10/2025 at 2:11 p.m., LVN H who works the 2:00 p.m. to 10:00 p.m. shift, said she was in-serviced on abuse/neglect reporting. LVN H said when it came to allegations of abuse/neglect, first make sure the resident was safe, and then call the Administrator/Abuse Coordinator and the DON immediately as soon as possible. LVN H was able to point out where the posted contact numbers for the DON and Administrator were located. During an interview on 4/10/2025 at 2:18 p.m., CNA R said she was in-serviced on reporting abuse/neglect allegations. CNA R said it was the staff responsibility to make sure the resident was safe and then immediately report to the Administrator/Abuse Coordinator and the DON. CNA R was able to point out where to locate contact numbers. During an interview on 4/10/2025 at 2:20 p.m., HK Z said she was in-serviced on reporting abuse/neglect. The HK staff said her responsibility was to report any allegations of abuse/neglect to the Abuse Coordinator and the DON immediately. The HK was able to point out where to locate contact numbers for the Administrator and the DON. During an interview on 4/10/2025 at 2:23 p.m., LVN L who works multiple shift times from 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m., said he was in-serviced on abuse/neglect reporting. LVN L said his responsibility was to keep the residents safe and remove the alleged perpetrator if with the resident. LVN L said he then called the Administrator/Abuse Coordinator and the DON immediately to report the allegation. LVN L was able to point out where to locate contact numbers. During an interview on 4/10/2025 at 2:24 p.m., MA Y said she was in-serviced on reporting abuse/neglect. MA Y said allegations of abuse/neglect which included sexual abuse needed to be reported immediately to the Abuse Coordinator and the DON after making sure the resident was safe. MA Y was able to point out where to locate contact number. During an interview on 4/10/2025 at 2:26 p.m., LVN I who works the 2:00 p.m. to 10:00 p.m. shift, said she received training on abuse/neglect reporting. LVN I said she was responsible to make sure residents were safe and call the Administrator and the DON to report immediately. LVN I was able to point out where the contact numbers of the Administrator and the DON were posted. During an interview on 4/10/2025 at 2:31 p.m., CNA U said she was in-serviced on reporting abuse/neglect. CNA U said she was trained to make sure residents were safe and report allegations of abuse/neglect, to include sexual abuse, to the Abuse Coordinator and the DON immediately. During an interview on 4/10/2025 at 2:35 p.m., the Activity Director said she was trained on reporting abuse/neglect. The Activity Director said for allegations of abuse/neglect, she would report immediately to the Abuse Coordinator/Administrator and the DON. The Activity Director pointed out where the contact numbers were for the DON and Administrator were located. During an interview on 4/10/2025 at 2:38 p.m., Dietary Staff W said she was trained on reporting abuse/neglect. Dietary Staff W said if she suspected or witnessed any abuse/neglect, she would make sure the resident was safe and then report it to the Abuse Coordinator/Administrator and the DON immediately. Record review of the Facility's In-Service training records titled Self-Reporting Protocol/Ad Hoc QAPI dated 4/9/2025, revealed allegation reported to the State; alleged perpetrator suspended; resident interviewed; interview of resident roommate; interviews with interviewable residents regarding staff treatment; skin assessment for residents who are unable to be interviewed; interview of staff regarding if they observed any potential abuse; performed a Trauma Informed PRN Assessment; notification to law enforcement; notification of medical director; were conducted and signed by the Administrator and the DON. Record review of the facility's document titled In-Service Training Attendance Roster, dated 4/9/2025, reflected that ADO conducted one-on-one in-services with the Administrator and the DON on training topic of allegation reporting guidelines. Record review of the facility's documentation regarding investigating allegations, revealed witness statements were taken on 04/09/2025 related to the allegation of sexual abuse, from Resident #1, the DON, ADON E and the Administrator. Record review of the Facility's In-Service Training records revealed training was conducted on 4/10/2025. The in-services were, dated 4/9/2025 and 4/10/2025, and included the topics of abuse/neglect/exploitation, abuse/neglect reporting, and who to report allegations of abuse/neglect to. Seventy-eight (78) out of (81) staff had signed the in-service training forms. Record review of Employee Disciplinary Reports, dated 04/09/2025, revealed CNA O and ADON E were placed on suspension pending investigation. Record review of the Police Department Incident Information Card, dated 4/9/2025, revealed a police report was made. Record review of Order, dated 4/10/2025, revealed an order for Resident #1 for counseling and emotional support services. Record review of Trauma Informed PRN Assessment, dated 04/09/2025, revealed the assessment was completed for Resident #1 by the DON. Record review of Resident Safe Surveys, dated 4/9/2025, reflected 45 resident surveys were conducted. The document covered the areas of 1) had anyone physically harmed the resident, if yes provide details; 2) has staff yelled or cursed at you; 3) does the resident feel comfortable asking staff for assistance; and 4) does staff treat you with respect. No potential abuse was noted. Record review of Resident Skin Assessments, dated 4/9/2025, reflected 17 assessments were performed for non-verbal residents with no abnormal findings. The ADO and Administrator were informed that the IJ was removed on 04/10/2025 at 4:46 a.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately notify and consult with the resident's physician when a significant change in a resident physical, mental, or psychosocial status (that was, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 5 (Resident #1) residents reviewed for change in condition. The facility failed to immediately inform NP/MD of Resident #1's change in condition addressing cyanotic episode (change of body tissue color to a bluish-purple hue, as a result of decrease in the amount of oxygen) to fingertips and lips. Resident #1's MD/NP was not notified of change in condition from approximately 8:00 a.m. to 10:36 p.m. on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. The IJ template was provided to the Administrator and DON on [DATE] at 2:51 p.m. The IJ was removed on [DATE], but the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to monitor their corrective actions. This failure placed Residents at risk of serious decrease in health related to delayed treatment. Findings included: Record review of Resident #1's face sheet dated [DATE] revealed an [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses of dementia and COPD (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 03, her cognitive was severely impaired. Record review of Resident #1's SBAR note dated [DATE] revealed a respiratory change with oxygen saturations of 88-90% on room air. Respiratory change was shortness of breath on exertion only and upper lung fields with wheezing when auscultated, diminished to bilateral bases. Chest x-ray results on [DATE] were right lower lobe infiltrate seen with possible right pleural effusion, bilateral pulmonary vascular congestion with mild cardiomegaly. Medication history of Lasix daily by mouth. Primary diagnoses were COPD and dementia. NP was notified at [DATE] at 4:50 pm. New orders provided by NP were to increase Lasix to 60 mg by mouth for 5 days then resume current dosing, ipratropium nebulizer 0.5 mg inhaler as needed every 4 hours, and robitussin mucus and chest as needed by mouth for cough. Record review of Resident #1's chest x-ray results dated [DATE] revealed findings of right lower lobe infiltrate (substance denser than air, such as pus, blood, or protein, which lingers within the parenchyma of the lungs) with possible right pleural effusion (accumulation of fluid in between the parietal and visceral pleura, called the pleural cavity). Bilateral pulmonary vascular congestion (accumulation of fluid in the lungs, resulting in impaired gas exchange and arterial hypoxemia) is seen with mild cardiomegaly. Record review of Resident #1's progress note dated [DATE] written by LVN C revealed resident coughing, congestion noted. oxygen 86-88% at room air. History of COPD. NP order for chest x-ray. Results received NP notified. New order as needed ipatroprium-albulteral 1 vial inhale orally every 4 hours. Lasix 60 mg by mouth for 5 days, and as needed robitussin mucus and chest congestion 10 ml by mouth every 6 hours for pain and temperature . Placed in bed, bed in lowest position, call light in reach. Will continue to monitor. Record review of Resident #1's progress notes for [DATE] for morning shift (6am-2pm), no documentation on record. Record review of Resident #1's progress notes dated [DATE] at 9:41 pm written by LVN D revealed resident noted to be breathing through mouth when breathing so oxygen not being absorbed. Simple mask applied and oxygen saturation remain stable with simple mask. Nebulizer treatments administered, resident continues with audible congestion in both lungs, able to cough up phlegm. Record review of Resident #1's progress notes dated [DATE] at 12:50 am written by LVN E revealed NP notified at 10:36 pm ([DATE]) 911 activated . Altered mental status, hypoxia (oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis), tachycardia(heart rate over 100 beats a minute), resident noted to be lethargic (general state of fatigue that involves a lack of energy and motivation for physical and mental tasks), only wakes to answer simple questions. Respirations 25, oxygen saturation at 8 3% on 6 liters simple mask, sitting up at 90 degrees. Tachycardic pulse at 122, cyanosis to fingertips noted . At 10:43 pm EMS arrived; resident transferred out at 10:49 pm ([DATE]) to local hospital. Record review of local hospital record dated [DATE] revealed Resident #1 presented to emergency room with respiratory distress, hypoxia, and altered mental status. Chief complaint: altered mental status, respiratory distress, hypoxia, and fever. Chest x-ray revealed bilateral multifocal pulmonary infiltrates. Critical Care: Patient was critically ill due to hypoxia, bilateral pneumonia, sepsis, lactic acidosis, hypokalemia, elevated troponin levels. Resident #1 expired at the hospital on [DATE]. During an interview on [DATE] at 10:38 am, LVN A stated she worked on [DATE] the morning shift (6am-2 pm) and was the charge nurse for Resident #1. LVN A stated she had received report on [DATE] morning that Resident #1 had chest x-ray completed on [DATE] with new orders of nebulizers treatments to be administered. LVN A stated on the morning of 01/15 /2024 at around 7:30 am or 8:00 am she had been notified by CNA B that Resident #1's lips and fingertips were purple. LVN A stated she went to assess Resident #1 and her oxygen saturation were in the 70's at room air. LVN A stated placed Resident #1 on oxygen and her oxygen saturations were in the 90's. LVN A stated she had notified treating NP but could no provide evidence to support (no texts or call log). LVN A stated she had documented, when referred to Resident #1 electronic records, LVN A stated she had not completed a progress note and/or SBAR assessment. LVN A stated she could not remember why she failed to document the cyanosis incident. During an interview on [DATE] at 10:52 am, CNA B stated she had worked the morning shift (6am to 2pm) on 01/15 /2024 and was the assigned to Resident #1. CNA B stated she had assisted Resident #1 to her wheelchair to start getting her ready for breakfast at around 7:30 am or 8:00 am. CNA B stated when she was getting Resident #1 ready, she noticed her fingertips were purple and then noticed her lips were purple too. CNA B stated she called LVN A to report and assess Resident #1 and saw LVN A place Resident #1 on oxygen. CNA B stated Resident #1 was ok the rest of the shift . During an interview on [DATE] at 11:05 am, the DON stated she was not notified of Resident #1's cyanotic episode on the morning of [DATE] by LVN A. The DON stated she had reviewed the 24-hour report on the morning of [DATE] and did not see any documentation of the incident. The DON stated charge nurses were expected to document all incidents on electronic records on either progress notes or SBAR assessment. The DON stated the cyanotic episode should had been reported to NP/MD, DON, and RP. The DON stated the NP could answer risks for not reporting the cyanotic episode. The DON stated failure to document Resident #1's cyanotic episode on the morning of [DATE] could have affected the continuity of care and monitoring of respiratory status to identify change in condition. During an interview on [DATE] at 3:54 pm, NP stated she was out of town and did not have her notes available for reference. The NP stated she did not recall being notified of Resident #1's cyanotic episode on the morning of [DATE]. The NP stated if she had been notified, she would have given orders for ER transfer for further treatment. The NP stated she expected for staff to send residents to ER right away and not wait for condition to worsen. The NP stated risk of not being notified of cyanotic episode on the morning of [DATE] could had delayed care in treatment resulting in altered mental status due to hypoxia worsening. During an interview on [DATE] at 6:07 pm via text message, the NP sent Investigator screenshots of her phone and stated she had not received report of change in condition on the morning of [DATE]. The NP stated she would have given orders for immediate transfer to hospital. The NP stated if Resident #1 was having cyanotic changes that was a very delicate and important change to have been reported. The NP stated it did place Resident #1 at risk of decompensation and/or worsening status. Record review of Notifying the Physician of Change in Status policy dated [DATE] read in part the nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. The Administrator and DON were informed on [DATE] at 2:51 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 plan or removal was accepted on [DATE] at 1:53 pm. The Plan of Removal revealed the facility took the following actions: 1. Immediate Actions Taken for Those Residents Identified: Resident #1: Documented that Resident #1 no longer resides at the facility. Conducted a thorough review of Resident #1's records to ensure that all care needs were appropriately managed until their departure. A summary report of the care provided and any incidents leading to the change in residence status was compiled for internal review and learning. Notification: Implemented an immediate review process for all residents experiencing a change in condition to ensure that the NP and relevant healthcare professionals are immediately notified according to the facility's policy. Medical director was notified of immediate jeopardy on [DATE]. 2. How the Facility Identified Other Residents: Review Process: The Director of Nursing (DON) conducted a comprehensive review of the 24-hour reports for all residents over the past month to identify any documented changes in conditions. The results of findings were documented in the change of condition audit tool. Review was conducted on [DATE]. Documentation Audit: An audit was performed on resident files to ensure that all changes in condition were properly documented and that necessary notifications were made to the NP or responsible healthcare provider. The results of findings were documented in the change of condition audit tool. Review was conducted on [DATE]. Staff training for recognizing change of condition was initiated on [DATE]. Licensed staff will not work until they are serviced on change of conditions. Date of Completion [DATE]. Staff Interviews: Conducted interviews with nursing staff to gather additional insights into any undocumented or reported changes in resident conditions, aiming to identify gaps in communication or documentation. Interviews were conducted by DON and designee on [DATE] resulted in no negative findings. Results were reported on Change of Condition Audit Tool. 3. Measures Put into Place/System Changes: Staff Training: Director of Nursing and designee(s) implemented mandatory training sessions for all nursing and caregiving staff on the Notifying the Physician of Change in Status policy, emphasizing the importance of timely communication with healthcare providers regarding changes in resident conditions. Date of completion [DATE]. Communication Channels: Established a dedicated communication line / in-service utilizing the SBAR assessment for staff to use when reporting changes in resident conditions to the NP or other healthcare providers, ensuring immediate attention. SBAR assessments can be documented in the resident(s) clinical record. In-service was provided to licensed nurses and was completed by Director of Nursing and designee(s) as of [DATE]. DON and or Designee will review SBAR reports charted daily. The facility has implemented mandatory training sessions for licensed and non-licensed personnel on the policy relating to changes in resident conditions. Completion of this training is required before staff are permitted to work, ensuring they are well-versed in recognizing and reporting changes in resident conditions. This training will be completed by the Director of Nursing (DON) and or designee. Staff will be required to provide a return demonstration of education provided to them. Completion date [DATE]. 4. How the Corrective Actions Will be Monitored: LVN A will not return to work until she receives a comprehensive in-service regarding change of condition monitoring and documentation. LVN A will also need to complete a full clinical competency assessment performed by the Director of Nursing prior to returning to her scheduled shifts starting on [DATE]. Newly hired staff will be required to undergo comprehensive in-service training regarding change of condition monitoring and documentation, in addition to completing a full clinical competency assessment conducted by the DON and or designee before they can begin their scheduled shifts. This ensures that all staff, regardless of their employment status, are adequately prepared to care for residents; staff will be required to provide a return demonstration of the education provided to them. Daily audits of SBAR assessments, Weekly nursing summaries, and 24-hour report reviews will be conducted for the next 4 weeks. The audits on the documentation and notification process for changes in resident conditions, to be conducted by the DON and or designee; findings will be discussed in the morning clinical meeting. Date of completion [DATE]. Licensed nurses will complete a nursing summary assessment documented in the electronic medical record for each resident on a weekly basis. If a change of condition is noted with a resident by a licensed or non-licensed personnel an SBAR will be completed by the Licensed Nurse and change will be reported to the MD. The DON or designee will verbally follow up with each shift to ensure that any reported change in resident condition has been reported to the appropriate health care provider and documented in the patient's clinical record for the next 4 weeks or until assured compliance is met. The results of findings will be documented in the change of condition audit tool each shift. Date of completion [DATE]. SBAR assessment and 24-hour report audits will continue until assured compliance was met. Audit findings will be reviewed during the monthly QAPI meetings. Interviews and Record Review to confirm implementation of the Plan of Removal were conducted as follows: Per interview with MD on [DATE] he was not working on the weekend and would return my call on Monday [DATE]. Obtained screen shot from DON for time of notification on [DATE] at 5:01 pm. Interviews on [DATE]: 2:00 pm, LVN F (weekend shift) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:04 pm, LVN G (weekend shift) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:14 pm, LVN H (weekend shift and PRN weekday) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:42 pm, LVN I (weekday 6-2 shift/ telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:53 pm, LVN J (weekday 2-10 shift/ telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:57 pm, LVN D (weekday 2-10 pm/telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 3:00 pm, LVN K wound care nurse (Monday Friday/ telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 3:07 pm, called LVN A there was no answer and could not leave VM due to VM box full. 3:15 pm, called LVN A there was no answer and could not leave VM due to VM box full. Reviewed staff schedule for [DATE]-[DATE]- LVN A works 6-2 shift Monday thru Friday. Returns to work [DATE]. 2:22 pm, the DON stated expectations remained the same, charge nurses were to notify NP of any change in condition and document all interventions provided. The DON sated she notified MD of IJ on [DATE] via text. The DON sated the mandatory trainings were the in services, change in condition policy review with staff and obtain staff signatures on the policy, and post quizzes would be provided. The DON sated new staff would be trained the same way, the facility would go over the change in condition policy and have them signed and complete quiz. The DON sated she would be doing weekly audits of summary assessment documentation. The DON sated she would verify documentation was accurate and follow up with verbal report throughout the change in condition monitoring. The DON stated ADON will be the designee to assist with the change in condition monitoring. The DON stated staff would follow up on changes in condition reported during morning daily meetings. The DON stated LVN A was to return to work until Monday [DATE] but had already spoken to her and would be in-serviced in person before her shift on [DATE]. 3:11 pm, ADON confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. ADON stated he would be assisting the DON with SBAR audits daily and would review during daily morning meetings. ADON stated he would be assisting with completing the SBAR audit tool and will be placed in the SBAR binder located in DON office. The ADON stated LVN A would return to work on Monday [DATE]. The ADON stated DON and ADON would be conducting in person training with LVN A, they would review change in condition policy, obtain signature on the policy and provide quiz before she was allowed to work the floor. Record reviews: Reviewed 72-hour summary pulled by DON and handwritten comments to follow up on and/or solidify dated [DATE]. Reviewed change in condition tool dated [DATE] to cross reference handwritten notes on 72-hour summary reports with no concerns identified. Reviewed change in condition nursing quiz dated [DATE]-[DATE] by charge nurses, administrative department, CNAs, and no licensed staff. Total of 60. Reviewed in-service dated [DATE]: change of condition notification with policy attached. Reviewed in-service dated [DATE]: change in residents' condition and reporting that change to the nurse (LVN or RN) at the facility immediately. Reviewed in-service dated [DATE]: observing a change in a resident's condition and reporting that change to the nurse immediately. Reviewed change in condition policies dated [DATE]-[DATE] by charge nurses (16 total). Reviewed in-service dated [DATE]: SBAR communication tool. The IJ was lowered on [DATE] at 3:35 pm, but the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to monitor their corrective actions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 5 (Resident #1) residents reviewed for quality of care. The facility failed to immediately inform NP/MD of Resident #1's change in condition addressing cyanotic episode (change of body tissue color to a bluish-purple hue, as a result of decrease in the amount of oxygen) to fingertips and lips. Resident #1's MD/NP was not notified of change in condition from approximately 8:00 a.m. to 10:36 p.m. on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. The IJ template was provided to the Administrator and DON on [DATE] at 2:51 p.m. The IJ was removed on [DATE], but the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to monitor their corrective actions. This failure could place residents at risk for diminished quality of care, untreated medical issues, and death. Findings included: Record review of Resident #1's face sheet dated [DATE] revealed an [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses of dementia and COPD (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 03, her cognitive was severely impaired. Record review of Resident #1's SBAR note dated [DATE] revealed a respiratory change with oxygen saturations of 88-90% on room air. Respiratory change was shortness of breath on exertion only and upper lung fields with wheezing when auscultated, diminished to bilateral bases. Chest x-ray results on [DATE] were right lower lobe infiltrate seen with possible right pleural effusion, bilateral pulmonary vascular congestion with mild cardiomegaly. Medication history of Lasix daily by mouth. Primary diagnoses were COPD and dementia. NP was notified at [DATE] at 4:50 pm. New orders provided by NP were to increase Lasix to 60 mg by mouth for 5 days then resume current dosing, ipratropium nebulizer 0.5 mg inhaler as needed every 4 hours, and robitussin mucus and chest as needed by mouth for cough. Record review of Resident #1's chest x-ray results dated [DATE] revealed findings of right lower lobe infiltrate (substance denser than air, such as pus, blood, or protein, which lingers within the parenchyma of the lungs) with possible right pleural effusion (accumulation of fluid in between the parietal and visceral pleura, called the pleural cavity). Bilateral pulmonary vascular congestion (accumulation of fluid in the lungs, resulting in impaired gas exchange and arterial hypoxemia) is seen with mild cardiomegaly. Record review of Resident #1's progress note dated [DATE] written by LVN C revealed resident coughing, congestion noted. oxygen 86-88% at room air. History of COPD. NP order for chest x-ray. Results received NP notified. New order as needed ipatroprium-albulteral 1 vial inhale orally every 4 hours. Lasix 60 mg by mouth for 5 days, and as needed robitussin mucus and chest congestion 10 ml by mouth every 6 hours for pain and temperature . Placed in bed, bed in lowest position, call light in reach. Will continue to monitor. Record review of Resident #1's progress notes for [DATE] for morning shift (6am-2pm), no documentation on record. Record review of Resident #1's progress notes dated [DATE] at 9:41 pm written by LVN D revealed resident noted to be breathing through mouth when breathing so oxygen not being absorbed. Simple mask applied and oxygen saturation remain stable with simple mask. Nebulizer treatments administered, resident continues with audible congestion in both lungs, able to cough up phlegm. Record review of Resident #1's progress notes dated [DATE] at 12:50 am written by LVN E revealed NP notified at 10:36 pm ([DATE]) 911 activated . Altered mental status, hypoxia (oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis), tachycardia(heart rate over 100 beats a minute), resident noted to be lethargic (general state of fatigue that involves a lack of energy and motivation for physical and mental tasks), only wakes to answer simple questions. Respirations 25, oxygen saturation at 8 3% on 6 liters simple mask, sitting up at 90 degrees. Tachycardic pulse at 122, cyanosis to fingertips noted . At 10:43 pm EMS arrived; resident transferred out at 10:49 pm ([DATE]) to local hospital. Record review of local hospital record dated [DATE] revealed Resident #1 presented to emergency room with respiratory distress, hypoxia, and altered mental status. Chief complaint: altered mental status, respiratory distress, hypoxia, and fever. Chest x-ray revealed bilateral multifocal pulmonary infiltrates. Critical Care: Patient was critically ill due to hypoxia, bilateral pneumonia, sepsis, lactic acidosis, hypokalemia, elevated troponin levels. Resident #1 expired at the hospital on [DATE]. During an interview on [DATE] at 10:38 am, LVN A stated she worked on [DATE] the morning shift (6am-2 pm) and was the charge nurse for Resident #1. LVN A stated she had received report on [DATE] morning that Resident #1 had chest x-ray completed on [DATE] with new orders of nebulizers treatments to be administered. LVN A stated on the morning of 01/15 /2024 at around 7:30 am or 8:00 am she had been notified by CNA B that Resident #1's lips and fingertips were purple. LVN A stated she went to assess Resident #1 and her oxygen saturation were in the 70's at room air. LVN A stated placed Resident #1 on oxygen and her oxygen saturations were in the 90's. LVN A stated she had notified treating NP but could no provide evidence to support (no texts or call log). LVN A stated she had documented, when referred to Resident #1 electronic records, LVN A stated she had not completed a progress note and/or SBAR assessment. LVN A stated she could not remember why she failed to document the cyanosis incident. During an interview on [DATE] at 10:52 am, CNA B stated she had worked the morning shift (6am to 2pm) on 01/15 /2024 and was the assigned to Resident #1. CNA B stated she had assisted Resident #1 to her wheelchair to start getting her ready for breakfast at around 7:30 am or 8:00 am. CNA B stated when she was getting Resident #1 ready, she noticed her fingertips were purple and then noticed her lips were purple too. CNA B stated she called LVN A to report and assess Resident #1 and saw LVN A place Resident #1 on oxygen. CNA B stated Resident #1 was ok the rest of the shift . During an interview on [DATE] at 11:05 am, the DON stated she was not notified of Resident #1's cyanotic episode on the morning of [DATE] by LVN A. The DON stated she had reviewed the 24-hour report on the morning of [DATE] and did not see any documentation of the incident. The DON stated charge nurses were expected to document all incidents on electronic records on either progress notes or SBAR assessment. The DON stated the cyanotic episode should had been reported to NP/MD, DON, and RP. The DON stated the NP could answer risks for not reporting the cyanotic episode. The DON stated failure to document Resident #1's cyanotic episode on the morning of [DATE] could have affected the continuity of care and monitoring of respiratory status to identify change in condition. During an interview on [DATE] at 3:54 pm, NP stated she was out of town and did not have her notes available for reference. The NP stated she did not recall being notified of Resident #1's cyanotic episode on the morning of [DATE]. The NP stated if she had been notified, she would have given orders for ER transfer for further treatment. The NP stated she expected for staff to send residents to ER right away and not wait for condition to worsen. The NP stated risk of not being notified of cyanotic episode on the morning of [DATE] could had delayed care in treatment resulting in altered mental status due to hypoxia worsening. During an interview on [DATE] at 6:07 pm via text message, the NP sent Investigator screenshots of her phone and stated she had not received report of change in condition on the morning of [DATE]. The NP stated she would have given orders for immediate transfer to hospital. The NP stated if Resident #1 was having cyanotic changes that was a very delicate and important change to have been reported. The NP stated it did place Resident #1 at risk of decompensation and/or worsening status. Record review of Notifying the Physician of Change in Status policy dated [DATE] read in part the nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. The Administrator and DON were informed on [DATE] at 2:51 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 plan or removal was accepted on [DATE] at 1:53 pm. The Plan of Removal revealed the facility took the following actions: 1. Immediate Actions Taken for Those Residents Identified: Resident #1: Documented that Resident #1 no longer resides at the facility. Conducted a thorough review of Resident #1's records to ensure that all care needs were appropriately managed until their departure. A summary report of the care provided and any incidents leading to the change in residence status was compiled for internal review and learning. Notification: Implemented an immediate review process for all residents experiencing a change in condition to ensure that the NP and relevant healthcare professionals are immediately notified according to the facility's policy. Medical director was notified of immediate jeopardy on [DATE]. 2. How the Facility Identified Other Residents: Review Process: The Director of Nursing (DON) conducted a comprehensive review of the 24-hour reports for all residents over the past month to identify any documented changes in conditions. The results of findings were documented in the change of condition audit tool. Review was conducted on [DATE]. Documentation Audit: An audit was performed on resident files to ensure that all changes in condition were properly documented and that necessary notifications were made to the NP or responsible healthcare provider. The results of findings were documented in the change of condition audit tool. Review was conducted on [DATE]. Staff training for recognizing change of condition was initiated on [DATE]. Licensed staff will not work until they are serviced on change of conditions. Date of Completion [DATE]. Staff Interviews: Conducted interviews with nursing staff to gather additional insights into any undocumented or reported changes in resident conditions, aiming to identify gaps in communication or documentation. Interviews were conducted by DON and designee on [DATE] resulted in no negative findings. Results were reported on Change of Condition Audit Tool. 3. Measures Put into Place/System Changes: Staff Training: Director of Nursing and designee(s) implemented mandatory training sessions for all nursing and caregiving staff on the Notifying the Physician of Change in Status policy, emphasizing the importance of timely communication with healthcare providers regarding changes in resident conditions. Date of completion [DATE]. Communication Channels: Established a dedicated communication line / in-service utilizing the SBAR assessment for staff to use when reporting changes in resident conditions to the NP or other healthcare providers, ensuring immediate attention. SBAR assessments can be documented in the resident(s) clinical record. In-service was provided to licensed nurses and was completed by Director of Nursing and designee(s) as of [DATE]. DON and or Designee will review SBAR reports charted daily. The facility has implemented mandatory training sessions for licensed and non-licensed personnel on the policy relating to changes in resident conditions. Completion of this training is required before staff are permitted to work, ensuring they are well-versed in recognizing and reporting changes in resident conditions. This training will be completed by the Director of Nursing (DON) and or designee. Staff will be required to provide a return demonstration of education provided to them. Completion date [DATE]. 4. How the Corrective Actions Will be Monitored: LVN A will not return to work until she receives a comprehensive in-service regarding change of condition monitoring and documentation. LVN A will also need to complete a full clinical competency assessment performed by the Director of Nursing prior to returning to her scheduled shifts starting on [DATE]. Newly hired staff will be required to undergo comprehensive in-service training regarding change of condition monitoring and documentation, in addition to completing a full clinical competency assessment conducted by the DON and or designee before they can begin their scheduled shifts. This ensures that all staff, regardless of their employment status, are adequately prepared to care for residents; staff will be required to provide a return demonstration of the education provided to them. Daily audits of SBAR assessments, Weekly nursing summaries, and 24-hour report reviews will be conducted for the next 4 weeks. The audits on the documentation and notification process for changes in resident conditions, to be conducted by the DON and or designee; findings will be discussed in the morning clinical meeting. Date of completion [DATE]. Licensed nurses will complete a nursing summary assessment documented in the electronic medical record for each resident on a weekly basis. If a change of condition is noted with a resident by a licensed or non-licensed personnel an SBAR will be completed by the Licensed Nurse and change will be reported to the MD. The DON or designee will verbally follow up with each shift to ensure that any reported change in resident condition has been reported to the appropriate health care provider and documented in the patient's clinical record for the next 4 weeks or until assured compliance is met. The results of findings will be documented in the change of condition audit tool each shift. Date of completion [DATE]. SBAR assessment and 24-hour report audits will continue until assured compliance was met. Audit findings will be reviewed during the monthly QAPI meetings. Interviews and Record Review to confirm implementation of the Plan of Removal were conducted as follows: Per interview with MD on [DATE] he was not working on the weekend and would return my call on Monday [DATE]. Obtained screen shot from DON for time of notification on [DATE] at 5:01 pm. Interviews on [DATE]: 2:00 pm, LVN F (weekend shift) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:04 pm, LVN G (weekend shift) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:14 pm, LVN H (weekend shift and PRN weekday) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:42 pm, LVN I (weekday 6-2 shift/ telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:53 pm, LVN J (weekday 2-10 shift/ telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 2:57 pm, LVN D (weekday 2-10 pm/telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 3:00 pm, LVN K wound care nurse (Monday Friday/ telephone) confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. 3:07 pm, called LVN A there was no answer and could not leave VM due to VM box full. 3:15 pm, called LVN A there was no answer and could not leave VM due to VM box full. Reviewed staff schedule for [DATE]-[DATE]- LVN A works 6-2 shift Monday thru Friday. Returns to work [DATE]. 2:22 pm, the DON stated expectations remained the same, charge nurses were to notify NP of any change in condition and document all interventions provided. The DON sated she notified MD of IJ on [DATE] via text. The DON sated the mandatory trainings were the in services, change in condition policy review with staff and obtain staff signatures on the policy, and post quizzes would be provided. The DON sated new staff would be trained the same way, the facility would go over the change in condition policy and have them signed and complete quiz. The DON sated she would be doing weekly audits of summary assessment documentation. The DON sated she would verify documentation was accurate and follow up with verbal report throughout the change in condition monitoring. The DON stated ADON will be the designee to assist with the change in condition monitoring. The DON stated staff would follow up on changes in condition reported during morning daily meetings. The DON stated LVN A was to return to work until Monday [DATE] but had already spoken to her and would be in-serviced in person before her shift on [DATE]. 3:11 pm, ADON confirmed training in SBAR completion, report change in condition and interventions in place to DON, NP/MD, RP. Do all interventions required and document in progress note, paper 24 hour note, and SBAR. SBAR is the new line of communication. Report changes right away after gathering all important information first before notifying. Signed policy and took quiz. ADON stated he would be assisting the DON with SBAR audits daily and would review during daily morning meetings. ADON stated he would be assisting with completing the SBAR audit tool and will be placed in the SBAR binder located in DON office. The ADON stated LVN A would return to work on Monday [DATE]. The ADON stated DON and ADON would be conducting in person training with LVN A, they would review change in condition policy, obtain signature on the policy and provide quiz before she was allowed to work the floor. Record reviews: Reviewed 72-hour summary pulled by DON and handwritten comments to follow up on and/or solidify dated [DATE]. Reviewed change in condition tool dated [DATE] to cross reference handwritten notes on 72-hour summary reports with no concerns identified. Reviewed change in condition nursing quiz dated [DATE]-[DATE] by charge nurses, administrative department, CNAs, and no licensed staff. Total of 60. Reviewed in-service dated [DATE]: change of condition notification with policy attached. Reviewed in-service dated [DATE]: change in residents' condition and reporting that change to the nurse (LVN or RN) at the facility immediately. Reviewed in-service dated [DATE]: observing a change in a resident's condition and reporting that change to the nurse immediately. Reviewed change in condition policies dated [DATE]-[DATE] by charge nurses (16 total). Reviewed in-service dated [DATE]: SBAR communication tool. The IJ was lowered on [DATE] at 3:35 pm, but the facility remained out of compliance at a scope of isolated and a severity of potential for more than minimal harm due to the facility's need to monitor their corrective actions.