**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility to protect the resident's right to be free of sexual abuse by a resident for one (Resident #2) of twelve residents reviewed for abuse. The facility failed to protect Resident #2 from sexual abuse by another resident when Resident #1 led Resident #2 into his room on 09/07/2025 and sexually assaulted her. An IJ was identified on 09/08/2025. The IJ template was provided to the facility on [DATE] at 1:54 PM. While the IJ was removed on 09/10/2025, the facility remained out of compliance at a scope of Isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems. This failure placed residents at risk of subsequent abuse resulting in potential mental anguish, emotional distress, and physical harm. Findings included: Review of Resident #1's admission Record, dated 09/08/25, reflected he was a [AGE] year-old male, admitted on [DATE], with diagnoses of paraplegia (loss of voluntary movement and sensation in the lower half of the body), depression, anxiety, cerebral infarction (stroke), and traumatic brain injury (sudden injury to the brain usually caused by a blow or jolt to the head.) Resident #1 was his own responsible party. Review of Resident #1's MDS, dated [DATE], reflected Resident #1 was able to understand others, and be understood by others, and had a BIMS score of 14, indicating he was cognitively intact. He exhibited no signs of delirium or psychosis, and was not depressed, but did sometimes feel socially isolated. He had no behaviors during the assessment period. Resident #1 used a wheelchair for locomotion, and needed little assistance with his ADLs. Resident #1 required partial to moderate (helper does less than half the effort) assistance with toileting, showering, and lower body dressing. He required only supervision or touching assistance with personal hygiene and upper body dressing. Resident #1 was able to move himself around in bed, and sit and lie down with no assistance. Review of Resident #1's care plans reflected the following care plans:- 07/24/25 for impaired comprehension related to his history of traumatic brain injury- 08/22/25 for potential for disruption of continuity of care related to signing himself out of the facility to gather off the facility property with other residents to smoke and socialize-08/25/25 for a psychosocial well-being problem related to a history of drug and alcohol use- 09/07/25 for sexually inappropriate behavior with another resident. This careplan had a goal of the resident not displaying any sexually inappropriate behavior through the target date of 10/23/25, and had interventions which included trauma assessment, not arguing with resident, monitoring and documenting behavior, notifying psych services when inappropriate behavior is noted, notifying Medical Director when inappropriate sexual behaviors occurred, and speaking in a calm voice when behavior was disruptive. The care plans did not include any other care plan for sexual behavior, or care plan for drug use which had occurred while he was a resident in the facility. Review of Resident #1's psychological services note, dated 09/05/25 reflected he was seen for hallucinations and delusions. The document noted that Resident #1 told the counselor that he had been served with a 30-day discharge notice due to alleged drug use, but denied using drugs. The document also noted that he provided inconsistent information and had difficulty articulating or focusing. Under Risk Factors the note included Sexual Acting Out: None. Review of Resident #1's progress notes reflected the following:- A note on 09/05/25 at 11:30 PM by LVN C reflected Resident was in A hall knocking at a female resident's room (female resident not identified). Resident was informed that the female resident was asleep. This resident was insisting that the female resident needs to come out, but the female resident told this writer with the A hall nurse and a female CNA that she does not want to be disturbed. When this resident was told what the female resident said, he did not want to move away from the hallway to his hall. He then came to the front lobby and sad [sic] he was waiting for a female visitor. Resident was informed that visitation time ends at 8 pm. He then said, I am a [AGE] year-old man, I can go out whenever I want. He then went to the patio. - A note on 09/06/25 at 12:35 PM by LVN B reflected Resident in room door closed, staff member open door togive lunch tray to resident strong drug order [sic] in room. DON and Ad min [sic] notified - A note on 09/06/25 at 2:59 AM by LVN C reflected (.) Resident noncompliant to instructions. Earlier on the shift, resident was knocking at the female residents rooms (identities of female residents unknown) and refused being redirected to his room. - A note on 09/06/25 at 10:26 PM by LVN C reflected, Resident outside (female resident #13's) knocking at the door. Resident redirected back to his room but non-compliant with instructions, refused to go and started talking to a female resident (identity unknown) inquiring her room number. - A note on 09/07/25 at 4:30 AM by RN A reflected This writer and another nurse were at A hall nurses' stationand saw resident trying to get into (male resident's room). We redirected him to go to his room and stop going into other residents' rooms because they are still sleeping. - A note on 09/07/25 at 7:00 AM by LVN B, reflected Resident refused to answer question on how resident (#2) was in the room. Resident refused skin observation - A note on 09/07/25 at 7:07 AM by LVN B reflected Notified DON and ADMIN (Administrator's name) for possible sexual abuse from resident - A note on 09/07/25 at 11:45 AM by the DON reflected This nurse spoke with (name of worker) from (name of group home) which is part of a home community based service for adult mental health, a placement agency; she will come out tomorrow to evaluate him for placement. Resident currently on 1 :1 observation, will continue until placement is found. - A note on 09/07/25 at 12:44 PM by the DON reflected the PCP and Psych Nurse were made aware of the incident. Review of Resident #2's admission Record, dated 09/07/25 reflected she was a [AGE] year-old female, with diagnoses of Alzheimer's disease, dementia in other disease (dementia caused by another health condition), stroke, major depressive disorder, and presence of a cerebrospinal fluid drainage device (stent for draining excess fluid from around the brain). A family member (Resident #2's POA) was her responsible party. Review of Resident #2's MDS, dated [DATE], reflected she was only sometimes able to be understood, and to understand others. She had a BIMS score of three, indicating severely impaired cognition. Resident #2 had fluctuating inattention and disorganized thinking, and the staff mood assessment reflected she had little interest or pleasure in doing things and felt tired from two to six days of a fourteen-day lookback period, and that she had trouble concentrating every day or nearly every day. She exhibited no behavioral symptoms during the assessment period. Review of Resident #2's care plans reflected the following:- 08/19/22 has difficulty making decisions- 03/15/23 Intrudes on other residents' privacy with a goal of not intruding on resident privacy during the quarter, and interventions (all dated 03/15/23) of monitoring and documenting behavior, placing her in an area where frequent observation is possible, and redirecting her when wandering into other resident rooms.- 07/01/23 h/o physically aggressive behavior with staff and other residents, which included 07/01/23 - was physically aggressive with a staff and resident and on 08/17/25 - physically aggressive with another resident, who hit her and caused her to fall- 01/14/24 displays socially inappropriate/ disruptive of taking items not belonging to her, and when confronted curses, calls people names, and refuses to listen, due to her cognitive diagnosis- 07/12/24 refuses to shower or change clothing for 2-3 days and goes home with family member to shower- 08/12/24 has periods of forgetfulness The care plans did not include any care plan for sexual behavior, or drug use. Review of Resident #2's psych services note, dated 08/13/25, reflected the staff reported signs of cognitive impairment (confusion, word-finding difficulties and difficulties with ADLs) but no behavioral concerns. Resident #2 had no history of alcohol or drug use. Resident #2's thought process was impoverished (resident was unable to think well, leading to minimal speech, lack of detail in conversations, and difficulty sustaining topics), flat (unexpressive) affect, poor eye contact, no risk of aggression, poor attention span, fair judgment, and severely impaired long and short term memory. The document reflected the resident had been in several group homes prior to her admission, but wandered away. Review of Resident #2's progress notes reflected the following: - A note on 09/07/25 at 4:40 AM by RN A Resident resting in bed, door open and lights on. No c/o pain and nos/s of acute distress noted. ADLs provided, safety precautions maintained, will continue to monitor. - A note on 09/07/25 at 6:45 AM by LVN B Resident not in room, this writer went to check blood sugar, resident not in room. This writer then being [sic] to search the B hall area, outside patio, dining area and was unable to find resident - A note on 09/07/25 at 6:55 AM by LVN B Resident notified by over head page to staff missing resident location, (Resident #2's name and room location). Staff member went room to room. Resident was found by (LVN C) in (Resident #1's room number). - A note on 09/07/25 at 7:01 AM by LVN B Resident was in (Resident #1's room number) wear and [sic] black top with no underwear facing the wall and the back toward the door. her under [sic] and pants in the bed with her. This writer assist with sup. (supervisor ADON) to room gait unsteady she was confused and could not walk. This writer went to get wheelchair and resident was taken to her room - A note on 09/07/25 at 7:01 AM by LVN B Resident in room very unsteady bp 122/76 heart rate 112 temp 96.8.Resident refused head to toe assessment from this writer. No signs of bleeding or bruising to arms or legs andface. - A note on 09/07/25 at 7:01 AM by LVN B This writer stay with resident and staff until EMT arrived. Residentasked several times what's happening to me. This writer told help is on the way. Resident in bed some what alert calm no signs or symptom of pain - A note on 09/07/25 at 7:07 AM by LVN B Notified PCP - A note on 09/07/25 at 7:07 AM by LVN B Notified DON and Admin of situation - A note on 09/07/25 at 7:10 AM by LVN B Notified the police and requested EMT - A note on 09/07/25 at 7:15 AM by LVN B Police on the scene. This writer inform the police that resident wasin another resident room undress and resident has Alzheimer's and Dementia confusion sometime can't make decisionon her on [sic]. - A note on 09/07/25 at 7:17 AM by LVN B EMT on the scene to take resident to hospital for evaluation. Resident refused to go. - A note on 09/07/25 at 7:27 AM by LVN B Notified (Resident #2's family member's name) of the situation and (Resident #2's family member's name) (Resident #2's (Resident #2's family member's name) spoke to resident and resident was sent to (name of hospital). - A note on 09/07/25 at 8:26 AM by LVN B sent to ER - A note on 09/07/25 at 9:00 AM by LVN B (Resident #2's family membe4) and (Resident #2's POA) arrived asking what happened and how did I let this happen. This writer explained the event between 6:45 and 7:00 am. (Resident #2's family member) crying asking why did you let this happen. This writer listen to family member and assured her that Admin (Administrator's name) and DON (DON's name) was working on the situation as we speak - A note on 09/07/25 at 9:30 AM by ADON This nurse was at A-hall nurse's station after huddle (a meeting at shift change, for communication) this morning, when I heard overhead page by B-hall charge nurse that she cannot locate one of her residents and she need help to look for her. Other staff members started looking, while this nurse headstraight [sic] to Shall [sic]. Charge nurse reported to this nurse that (Resident #2) was observed lying in bed in room (Resident #1's room number). This nurse entered room (Resident #1's room number) and saw the male resident in room (Resident #1's room number) sitting across his bed facing the door and (Resident #2) was lying on the bed facing the wall and her back to the door. I asked the male resident what's going on? Why is she lying on your bed? He did not respond. He just looked down. I saw his pants and underwear were down to his thighs, and he tried pulling his pants up to cover his pubic area from being exposed. I turned to (Resident #2) and asked her what are you doing on the male resident's bed?. She replied, nothing. I asked her to get out of bed and let me take her back to her room. She tried to get up but couldn't. I noticed when she moved that she didn't have any underwear or pants on. She had a blouse, and sweater on. She also appeared weak and unstable. I asked the male resident to transfer to his w/c x3 while I try to get the female resident out of the bed, but he didn't move. I pulled the bed away from the wall, with both residents sitting on it, then I assisted the female resident to get out of bed and hold her hand while leading her to her room . She stopped and leaned against the wall outside the door because she was staggering. We finally made it to her room with my assistance. Male resident finally got out of bed to his w/c. Charge nurse had notified the DON, Administrator, and police. DON came into the building to start investigation. Marketing director also notified and came into the building to assist. This nurse took resident's vital signs: BP=122/76, P=112, Resp=28-30. Temp=96.8. She denied pain/discomfort from her vagina. She refused to have this nurse do a complete assessment of virginal [sic] area, stating I'm ok, I don't need that. Ambulance with EMT arrived and took over. Police also arrived and spoke with the male resident, charge nurse, and this nurse. Resident was transferred to [name] hosp for further eval and treatment if indicated. - A note on 09/07/25 at 12:56 PM by LVN B Notified resident [sic] of possible abuse by another resident - A note on 09/07/25 at 7:37 PM by LVN B Resident return from hospital alert bruising to rt eye swollen [sic] to top lip. voiced no to pain, gait unsteady some confusion noted - A note on 09/08/25 at 6:47 AM by LVN C Resident's upper lip remains swollen, denies pain or discomfort. - A note on 09/08/25 at 7:21 AM by LVN I resident awake and alert sitting on side of bed at this time. (.) Resident denies any pain/discomfort at this time. Upper lip remains slightly swollen, no c/o pain or discomfort. No signs ofdifficulty swallowing or chewing. Resident eating snack in room at this time. (.) - A note on 09/08/25 at 9:32 AM by the ADON This nurse saw resident being escorted by cna to smoke patio. CNA was holding her arm to assist her while ambulating from her room on B-hall to smoke patio. CNA reported to this nurse that resident is unstable on her feet on that's why she's holding on [NAME] [sic] arm while walking. Noted upper lip swollen. Resident denied pain at this time. Resident unable to verbalized what happen to her upper lip d/t dx of dementia/alzheimers. Charge nurse notified. DON aware. - A note on 09/08/25 at 10:22 AM by LVN I vitals assessed by this writer at 9:53am. 108/77 p97, 98% RA, 97.1 . Resident c/o pain to upper lip at this time. No order [sic] pain. Requested prn pain med at this time. - A note on 09/08/25 at 11:35 AM by LVN I resident oof to hospital with EMT per (Resident #2's family member) phone call to EMT for resident to get CT Scan. Resident sent with face sheet and med list. (Medical Director's name) and admin staff notified - A note on 09/08/25 at 5:43 PM by Agency LVN K the writer of this note made aware that resident was going to pend [sic] the night at her family home - A note on 09/08/25 at 6:00 PM by Agency LVN K Resident during the AM shift for a hospital appointment at (5:00 PM) family member came to the facility and informed the writer of this note that resident was going to pend [sic] the night at home. Evening and HS meds prepped and given to (Resident #2's family member). - A note on 09/09/25 at 11:35 AM by LVN I resident returned back to facility with (Resident #2's family member) and (Resident #2's family member CC) . (Nurse Practitioner's name) in facility and will assess resident per (Resident #2's family member's) request. Will continue with plan of care. Hospital records for Resident #2 were not reviewed. An observation on 09/07/25 at 12:22 PM revealed that Resident #2 was not in her room but a name plate with her first initial and last name was on the door. An interview and observation on 09/07/25 at 12:24 PM revealed Resident #1 outside his room, wheeling back and forth a short distance, and turning around in a circle and ranting. The ADON was standing next to his door, watching him. Resident #1 agreed to speak privately with the surveyor in his room, and the ADON said she would be right outside the door. Resident #1's speech was hard to understand at times, somewhat slurred, and he jumped from one unfinished sentence to another at times. He was speaking without stopping unless the surveyor interrupted him to ask questions. He said they (the facility staff) were talking this stuff about him, for no reason, and they didn't know anything. He said she (Resident #2) had autism and he didn't know that but they were friends and he talked to her all the time and she made decisions as well as him. He said she thinks good thoughts. When the surveyor asked the name of the lady he was talking about, he gave an incorrect first name starting with the same initial as Resident #2's, and the correct last name. He said They are saying a whole lot of whatever it is. They don't know that me and her have whole, decent conversations. He said he had not talked to her about sex, but he went into her room and told her he was going to his room, and she said she was coming over to get weed. When asked if he normally kept drugs in his room, he said no but when the surveyor asked about Resident #2 saying she was coming over to get marijuana, he said that he just kept a little weed in his room. He said that when they were in his room she I'm ready and he said no because them people are going to come in here but she pulled her clothes off. He said the door to his room just opened, he could not lock it, and people came in all the time. He said they both fit in his (twin) bed, and they watched TV first, then she wanted to have sex. He repeated that she was his friend, and just a friend, and that they (facility staff) know better than I am fixin' to rape. He said it was just like 10 minutes and he didn't even finish and he repeated this, and that the staff were makin' a big deal about it, and that they did not understand, repeatedly throughout this conversation. He said Resident #2's shoe was on the floor, and his money fell in her shoe. When the surveyor tried to talk about the allegation again, he continued to talk about the money, which was over $300, but when asked what kind of decisions he had ever seen Resident #2 make, he denied that she had any problem making her mind up about anything including sex or anything else. He said she was able to say yes or no and that she was happy while they were together, not upset. He said someone came in and saw them sitting there, and looked all over and got upset. He said a nurse came in and he was sitting upright in the bed. He then backtracked to how Resident #2 was his friend, and said she said naw then she said yes. When the surveyor asked if she said no to sex before she said yes, he said no, she never said no and that she wanted to get together with him. He said that when they were looking at the TV she told him to put on this song she liked, and he started looking for a song on his phone, and humming. He said when she said that he wasn't even thinkin' like that but he did it because she wanted to. He talked more about his money, the amount, and that she (pointed at the door) took the money and counted it and he wanted his money back. Several times during this interview the surveyor had to ask him to re-state things, and when he did, his speech was noticeably more clear and easy to understand. In his demeanor he seemed to be more emotional about his money and did not express any concern for Resident #2. Constantly throughout the interview he put his hands on his head and shook his head, while he denied there was any problem with his actions toward Resident #2. An interview on 09/07/25 at 12:36 PM with the ADON revealed she was the person designated to watch Resident #2 at this time. She said there was some question about who the money belonged to, because it was found in another resident's room, and it was being held until they were certain of who it belonged to. The resident was inside his room and loudly said they knew it was his money and he wanted it back. A telephone interview on 09/07/25 at 12:44 PM with Resident #2's Family Member said the facility called at about 7:30 that morning (09/07/25) to tell her they needed the resident to go to the hospital, and she would not go, because she did not understand why. She talked to Resident #2 so she would go, and when she was at the facility she saw the man who did it. She said there was nothing wrong with him, except his was in a wheelchair, and he said the night nurse knew they had been doing it (he and Resident #2 having sexual contact) for a while, and told them it was OK. During the conversation, Resident #2's family member was crying and said that earlier another man had jumped on Resident #2 and hit her on the head. She said the resident had a stent in her head and they sent her to the hospital because she was worried that the man might have done something to her stent. She said Resident #2 had dementia and she was very concerned, because she thought the staff were supposed to protect Resident #2, and check her at least every two hours, and she wanted to know how nobody noticed she was in a man's room. She said her dementia was getting worse, and she was not able to decide to go to a man's bed. She said she did not believe there was any way Resident #2 would be thinking to look for that (sex) and she would not be looking for drugs. She was worried the facility would lie about it and say Resident #2 meant to be in the man's room. She did not know how the resident was doing, because she was still at the hospital. Once she was released her family meant to take her home for a while. A telephone interview on 09/07/25 at 12:59 PM with Resident #2's POA said he had been told that Resident #2 had been found in a man's room with no clothes on, around 6:50-7:00AM that morning, and she appeared to have no recollection that anything happened. He said she did not seem agitated or upset because she was completely unaware of what happened. He said he was at the hospital during this conversation and they were waiting for them to do a rape kit on the resident. He said she had never talked about being involved with a man at the facility and no staff had ever told them she showed any interest in that, and he would not expect her to, because she could not remember anything from one minute to the next. Resident #2's POA said they were feeling very bad about the facility after another man assaulted her by hitting her, twice, for no reason and he wanted to find a better place for her because of that. He said the other assaults had been in the last couple of months, he thought. He said that on top of that, now this has happened and they (her family) were very, very upset. An interview on 09/07/25 at 2:10 PM with LVN B revealed the staff were having huddle at about 6:30 or 6:40 and she noticed Resident #2's door was open and she was not in there. She said she made a round to look for her, and she was not in any of her normal places. She said she went from room to room on her hall and checked the rooms again, in case they had missed each other in passing. When she was not able to find Resident #2 she asked another nurse if they had seen her, and did a page overhead to call for help. RN A and LVN C found Resident #2 in Resident #1's room and told her. The ADON was also searching and she went into Resident #2's room with her. She said Resident #2 was in the bed, facing the wall, and her underwear and pants were off, and her shirt was pulled part-way up her back. She said the ADON asked Resident #1 to pull his clothes up and get in the wheelchair so they could get Resident #2 off the bed. LVN B said she called the Administrator and the DON because this was abuse, and she called 911 for police and EMTs. She said Resident #2 seemed loopy and could not get out of the bed, so they helped her to a chair. She said normally Resident #2 was able to walk very well, and she walked all the time, but she was having trouble walking. She said Resident #2 was hugging herself and shaking when the ADON got her back into her own bed, and the ADON stayed with her. She said the DON stayed on her cell phone with her while she called the police, and that Resident #1 would not allow them into his room or talk to them. The police came and spoke with Resident #1, then with her, and she gave them her version of what happened. LVN B said Resident #2 was not able to make decisions about things like that for herself, but she was very passive, and easily influenced, and if she needed her to be somewhere she just said Come on (Resident #2's name), let's go and she would go right along with her. She did not believe Resident #2 would ever be seeking out drugs or sex, and she had never shown any idea of those things, in the time she had known her. She had never had any sort of sexually related behaviors. She said Resident #1 had a history of going on pass and doing drugs and Resident #2 never left the building except with her family, and never went out to the tree to be with other residents. She mostly just kept to herself. She said that Resident #1 was a sick person and on the night of 09/06/25 he was hanging his entire torso out his window, and smoking something that made his room and the hall smell terrible. When she told him to stop, he swore at her. She said he did that a lot, and was very threatening. She reported it to the Administrator and the night staff. The Administrator told her to call the police. She had been told that Resident #1 had earlier gone into a men's room, looking for a female friend and when RN A and LVN C told him no, it was a men's room, he said it was her (identity of her unknown) room. RN A and LVN C redirected him back to his room after that, and they watched him go all the way to his room. She reiterated that she felt Resident #1 was a sick person and that something was very wrong with him, and he was very perverted. She said when she notified Resident #2's family member, because she was able to get her to do things, she talked to her and got her to go to the hospital. Later Resident #2's family member and Resident #2's POA came to the facility and they had Resident #1's phone with them, and wanted to know where Resident #2's phone and wallet was. Resident #1 was there and told Resident #2's POA Give me my phone and the POA asked Resident #1 how Resident #2 even had his phone. Resident #1's response when Resident #2's POA asked him if he did that (sex) to Resident #1 was it lasted maybe 10 minutes and it's not a big deal and everyone is making a big deal about it. LVN B said Resident #1 said they (he and Resident #2) went in the room and it didn't last long and that everyone was acting like they didn't know what a man and woman being together was. She said Resident #2's POA called the police and her family member was in tears. She said she explained to Resident #1 that Resident #2 was not mentally equal to him, and he responded that she was older than him, and she explained it was not about age, it was about her mind. She said she did not know why someone did not go watch Resident #1 after he tried to go into rooms in the middle of the night. She said she had been so stressed over Resident #1's behavior that she had to take some time off. She said Resident #1 had talked about a lot of things that made her uncomfortable, and been very threatening toward her. She had asked him to turn his loud music down once, and close his door, because it was night, and people were sleeping, and he said he was going to get somebody's cousin to fuck her up. She said she talked to the Administrator about it, but he just said they could call the police but they probably would not do anything. She told the DON she did not feel safe there, and took some time off. She said they moved her to a different nurses station, but it did not help. She said Resident #2's only real behavior problem was that she was a little bit of a klepto and would go into rooms and pick up other people's things, and she collected the water pitchers, and things like that. The only time she ever heard of her going into a man's room was because she wanted to take something she saw, not because it was a man's room. She said the resident probably had no idea whose room it even was. She said Resident #2 probably did not even know Resident #1's name. She said she felt like Resident #1 was really bad, and the Administrative staff should have taken him more seriously before this. An interview on 09/07/25 at 4:58 PM with the Hospital SANE revealed she had just seen Resident #2, and examined her for possible sexual assault. She said the resident could not remember what happened or answer any questions about it, so the information she got came mostly from her family. She said she did a full head-to-toe assessment, taking pictures of anything she found, and swabbed her for DNA. She said the only injury she found was some redness on her face , which her family said was not normal for her, but that lack of injury did not necessarily mean lack of assault. She said Resident #2 did not remember at all what happened, and did not seem particularly upset. An interview on 09/07/25 at 6:38 PM with RN A revealed Resident #1 was trying to go into a man's room on the night of 09/06/25, and he and the other nurse (LVN C) told him to stop trying to go into rooms because it was late and people wanted to rest. He said he was aware of Resident #1 and another resident who had recently been discharged having a consensual sexual relationship, and he had reported it to the DON and Administrator. He said both residents were fully alert and oriented and able to consent. He said he was not aware of Resident #1 trying to have sex with any other resident. He said they were near the nurses station at the front door (at the opposite of a hall from Resident #1 and Resident #2's rooms) at the time, and watched Resident #1 go all the way down the hall, and into his room. He said it was about 4:00 AM on 09/07/25 when that happened. He said around 4:45 AM Resident #2 was in bed, with the light on, which was normal for her. He said at that time, Resident #1 was in his room, sitting in his wheelchair, watching TV. He said Resident #2 had never had any sexual behaviors, or shown any interest in drugs, that he was aware of. He said they had done training on abuse and neglect, including sexual abuse, and what consent meant, and he did not know if Resident #2 would be able to give consent, but Resident #1 was able to consent. He said Resident #2 could remember bits and pieces of things that happened years ago, but was not able to remember recent things because her short-term memory was very poor. He said he did not think someone with poor short-term memory would be able to give informed consent, which meant a person was able to understand the implications of their decisions. An interview on 09/07/25 at 7:03 PM with LVN C revealed he was working at the station by the front door, on admitting a resident, when he heard the call on the intercom that there was a missing resident, so he went to the other nurses station. He said he checked in Resident #2's room, and she was not there so he went room to room and found Res[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observations and record review, the facility failed to ensure 1 (Resident#1) out of 4 received adequate supervision when reviewed for accidents. The facility failed to provide Resident#1 with adequate supervision on 08/01/25 when Resident#1 left the unsupervised for 3 day's The facility was not made aware until 08/04/25 that Resident#1 had been admitted the hospital. An IJ was identified on 08/21/15. The IJ template was provided to the facility on [DATE] at 4:45 pm. While the IJ was removed on 08/22/25, the facility remained out of compliance at a scope of potential for more than minimal harm that is not Immediate Jeopardy and a severity level of isolated because all staff had not been trained on 08/22/25. Thia failure could affect all resident's health, safety and possible death. Findings included:Record review of Resident#1's face sheet, dated 08/30/25 reflected, he was a [AGE] year old male who was originally admitted on [DATE] and readmitted on [DATE] and diagnosed with Paraplegia (symptom of paralysis that mainly affects your legs (though it can sometimes affect your lower body and some of your arm abilities, too), Anemia ( a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), Hyperlipidemia (have high lipid levels), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Anxiety disorder (frequently have intense, excessive and persistent worry and fear about everyday situations), Cerebral infarction ( an ischemic stroke, it is the most common form of stroke) personal history of traumatic brain injury (a brain injury that is caused by an outside force), chronic pain( lasts months or years and can affect any part of your body), essential hypertension (abnormally high blood pressure), pressure ulcer (forms on an area of the skin with prolonged pressure due to immobility) of right buttock, stage 4 (Full-thickness tissue loss with exposed bone, tendon, ligament, fascia, cartilage, or muscle)-onset 07/23/25, and Sepsis (potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) -unspecified organism-08/08/25 onset. Record review of Resident#1's MDS, dated [DATE] reflected his BIMS score was 14 which indicated cognitive intact. Record review reflected no behaviors noted on the MDS. Record review of Resident#1 care plan, dated 07/14/25 reflected, no documentation of resident leaving the facility unsupervised. Record review of Resident#1's progress notes dated, 07/25/25 to 08/20/25 reflected in part:On 08/01/25 Nurse noted reflected. Resident signed out on pass at 2145. Still out of the facility. Completed by LVN A. On 08/02/25 Nurse notes reflected, Resident still out on pass. Completed by LVN G On 08/03/25 Nurse note reflected, out on pass. Completed by LVN I On 08/04/25 Administration notes reflected, Resident on leave. Completed by LVN G On 08/07/25 communication with physician noted reflected, Spoke with nurse he is doing fine. Vitals are fine he is still on IV antibiotics for an infection once he has completed his antibiotics, he should be ready to discharge. Completed by nursing. Record review on 08/20/25 of sign out/in sheet from sign out/in booklet from the receptionist desk reflected, Resident#1 did not sign out on 08/01/25.Record review of hospital records dated 08/21/25 reflected Resident#1 arrived at the hospital on [DATE] at 12:35 pm. Resident#1 chief complaint reflected Resident#1 checked himself out, been sitting out in the rain and heat for 3 days. Record review of hospital record did not detail how Resident#1 arrived at the hospital.Diagnosed reflected:*Sepsis (serious condition in which the body responds improperly to an infection) due to Pseudomonas aeruginosa (severe infections, particularly in immunocompromised individuals) and Beta hemolytic streptococci group C infected decubitus ulcer (Bedsores are injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time)* Fever 101.2 (fever is defined as a temperature above 100.4 F )*Tachycardia (heart rate over 100 beats a minute)*Leukocytosis (high white blood cell count, can indicate a range of conditions, including infections, inflammation, injury and immune system disorders.)*Foul drainage from woundPolysubstance use disorder reflected, a history of methamphetamine ( a potent central nervous system (CNS) stimulant that is mainly used as a recreational), cannabis (which can also be called marijuana, weed, pot, or bud, refers to the dried flowers, leaves, stems, and seeds of the cannabis plant) and opiate (are natural or synthetic chemicals that bind to receptors in your brain or body to reduce the intensity of pain signals reaching the brain) abuse.*Repeated drug toxic screened positive for amphetamines, benzodiazepines (benzos, are a class of central nervous system (CNS) depressant drugs), cannabinoids and cocaine (Central nervous system stimulant and tropane alkaloid derived primarily from the leaves of two coca species.Requested EMS report online from city on 08/22/25 and have not received at this time. Record review of progress notes dated 08/01/25 to 08/04/25 reflected no documentation of emergency contact was called before 08/04/25. No documentation of active search for Resident#1 before 08/04/25. Record review of Resident#1 sign out and in sheet reflected, sign out and sign in sheet not completed. Review reflected dates, times, signatures and destination information missing. In an interview on 08/20/25 at 10:00 am the Admin and the DON stated the incident with Resident#1 would not be considered an elopement because Resident#1 signed out before he left the facility. The Admin stated the Representative adds a new sheet to the sign out sheet when the page was full and he kept the completed sign in/out sheets in his office in a separate binder. Admin stated Resident#1 signed out on his own and would sign himself back in. In an interview on 08/20/25 at 10:45 am Resident#1 stated he did not want to talk about why he left the facility, where he went, who he was with and about his hospital stay. Resident#1 stated he was ok and did not have any concerns. Resident#1 stated that he signs himself in and out when he left the facility. In an interview on 08/20/25 at 11:00 am the Front desk Representative stated she was told to encourage the residents to sign in/ sign out but do not complete the sign out sheet for them. Front desk Representative stated Resident#1 was one of the residents did not sign out every time he left and would get upset when staff asked him to sign out. In an interview on 08/20/25 at 11:45 am the admission Director stated Resident#1 called her on 08/02 cussing her out and saying he saw her having sex with another man and that she stole his money. The admission Director stated she knew he had to be on an unknown substance because he was not acting that way the day before. The admission Director stated Resident#1 was found down [name of street] Street and transported to the hospital. In an interview on 08/21/25 at 4:30 am over the phone with LVN A who stated Resident#1 was already gone when he arrived at the facility at 10pm. LVN A stated he was told that Resident#1 had signed out and went to [NAME] and the box. LVN A did not recall who told him about Resident# 1 leaving. In an interview on 08/21/25 at 12:30 pm with the Marketer stated he started calling around to the local hospitals for Resident#1 after he was gone for 24 hours. The marketer stated he was not able to find Resident#1. The Marketer stated a discharge planner informed him that Resident#1 was in the hospital. The Marketer stated the discharge planner stated Resident #1 was denied admission to other facilities. The Marketer stated the facility did not want to get in trouble for dumping Resident#1 and he returned to the facility on [DATE]. In an interview on 08/21/25 at 1:50 pm LVN G stated she was Resident#1 day nurse, and the resident leaves the facility throughout the day. Resident#1 knows that he needs to sign in and out in the front before he leaves. In an interview on 08/21/25 at 2:20 pm LVN H stated she was Resident#1's night nurse and he left the facility often out on pass and returns the same day. LVN H stated he goes out by the tree with the other residents for 30 minutes or so and returned. In an interview on 08/22/25 at 8:00am with Resident#1 emergency contact stated she was notified on Monday 08/04/25 that Resident#1 had signed himself out and was in the hospital. Resident#1 emergency contact stated he was not able to stay with her and the facility had asked her about Resident#1 being discharged to her home and she said no. Resident#1 emergency contact stated she could not remember who called her. On 08/21/25 at 4:45PM the IJ was called. The template was provided to the Admin and DON, POR was approved on 08/22/25. Identification of Residents Affected or Likely to be Affected:The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: ____8/22/2025__________) The Administrator and DON were in-serviced at 6:45pm on 8/22/25 by the Corporate Consulting Nurse on residents signing out and what to do if they do not return within the expected timeframe. The Administrator/DON provided education to staff on resident's signing out of facility on 8/21/2025. Resident # 1 returned to facility on 8/8/2025. Nurse assessed head to toe. Medical director and family notified of resident return on 8/8/25 Census checks to be completed on 8/21/2025 by DON/designee The Care Plan Coordinator/designee ensured all residents who sign out of facility have their care plan updated to reflect the education provided on returning to the facility, the dangers of using illegal substances, and providing an estimated return time. The DON/designee checked for any residents that have signed out at the current time to determine if any have been out on pass for over 24 hours, no other residents were identified as being out of the facility without the staff aware. 1. The facility took the following actions to prevent an adverse outcome from reoccurring.(Completion Date: 8/22/2025) The charge nurses will conduct census checks twice a shift for two weeks and then they system will be re-evaluated. A resident council meeting was held on 8/22/25 to discuss drug usage, signing in and out of facility. Each resident was notified they will be provided to give an anticipated return time. The residents will be notified that if they do not return within the anticipated return timeframe the police will be notified, and the facility will start an investigation of their whereabouts. The DON or designee educated all staff that any resident that does not return within 2 hours of time frame we will notify MD and family and start to look for residents, The Corporate Nurse/Consultant Nurse In-serviced the administrator/don on the updated policy for residents signing out on 8/21/2025. All new staff and agency staff will be in-serviced upon hire or before working the shift. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. Record review of the facility's policy titled Wandering and Elopements revised 03/2019 reflected: 3. If a resident is missing, initiate the elopement/missing resident emergency procedure:b. If the resident was not authorized to leave, initiate a search of the building(s) and premises.c. If the resident is not located, notify the Administrator and the Director of Nursing, the resident's legal representative, the attending physician, law enforcement officials.4. When the resident returns to the facility, the Director of Nursing services or charge Nurse shall:A. Examine the resident for injuries.E. Complete and file an incident reportF. Document relevant information in the resident's medical records. Record review of the facility policy titled signing Residents out revised 08/2006 reflected: Policy statement: All residents leaving the premises must be signed out.1. Each resident leaving the premises (excluding transfers/discharges) must be signed out 9. Resident must be signed in upon return to the facility. Record review of sign in and sign out sheet provided by the admin after the IJ was identified reflected, different handwriting, printed signature, missing dates, times and no destination information. Review of the sign out and in sheet reflected, Resident#1 signed out at 9:45pm on 08/01/25 and showed Resident#1 signed back in on 08/08/25 at 3:55 pm. Review of dates from 07/24 to 08/01/25 reflected Resident#1 did not stay gone more then then 3 hours at a time on the slots that were filled out. Review of sign out sheet reflected cted the sheet was not completely full. In an interview on 08/22/25 at 2:53 pm with the corporate consulting nurse at 11:00 am she was able to verbalize everything that the facility had implemented. In an interview on 08/22/25 between 1:00 pm to 3:30 pm, the ADON, DON, Admin, LVN B, CNA C, CNA D, CNA E, CNA F, LVN G, LVN H, LVN I, RN J, Front desk representative, over the phone interviews RN A, stated they had been in-serviced on when a resident refused to sign out let the charge nurse know, and residents need to document the approximate time they plan on being back. If a resident stays out longer than 2 hours of the approximate time they will be back the facility will start calling around for the resident and then report to the police. If a resident returns to the facility and they appear to be under a substance the police will be called. The facility will complete census check twice a shift to ensure residents are accounted for. In an interview on 08/22/25 at 3:30 pm the DON and Admin verbalized everything the facility had implemented. Record review of Resident#1 revised, care plan initiated on 08/21/25 reflected, Potential for disrupting continuity of care due to the resident will sign himself out of the facility and sits outside with a group of other residents and socializes . Goal reflected, The resident will understand the risk associated with signing out of the facility.The resident was educated to provide an expected time of return upon signing out of the facility. If the resident does not return within 2 hours of the expected timeframe,Attempt to contact the resident, the family members, the police, the MD, the DON and Administrator. The resident was educated on the risk of being outside during extreme heat and heat related illnesses and the potential for harm. The resident was educated on the risk of using illegal substances while out on pass. The resident will be encouraged to sign out each time they leave the facility and to give the expected time of return. During an observation on 08/22/25 at 3:45pm, residents were gathered for a special resident council meeting. The DON talking to residents about signing in and out of the facility log. The DON stated residents must put an approximate time they will return to the facility and if they did not return in 2 hours, the facility would start a search for them. Record review of revised sign in/out sheet reflected, a return time was added to the sign out section and the destination/phone number information was deleted. An IJ was identified on 08/21/15. The IT template was provided to the facility on [DATE] at 4:45 pm. While the IT was removed on 08/22/25, the facility remained out of compliance at a scope of potential for more than minimal harm that is not Immediate Threat and a severity level of isolated because all staff had not been trained on 08/22/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for4 (Res#1, Res#2, Res#3 and Res#4) of 5 residents reviewed for updated care plans. The facility failed to provide Resident#1,2,3,4 with updated care plans to reflected concerns for health and safety when leaving the facility unsupervised. An IJ was identified on 08/21/25. The IJ template was provided to the facility on [DATE] at 5:53 pm While the IJ was removed on 08/22/25, the facility remained out of compliance at a scope of potential for more than minimal harm that is not Immediate Jeopardy and a severity level of pattern because all staff had not been trained on 08/22/25. This failure can affect residents health, safety and possible death.Findings included:Record review of Resident#1's face sheet dated 08/20/25 reflected, he was a [AGE] year old male who was originally admitted on [DATE] and readmitted on [DATE] and diagnosed with Paraplegia (symptom of paralysis that mainly affects your legs (though it can sometimes affect your lower body and some of your arm abilities, too), Anemia ( a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), Hyperlipidemia (have high lipid levels), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), Anxiety disorder (frequently have intense, excessive and persistent worry and fear about everyday situations), Cerebral infarction ( an ischemic stroke, it is the most common form of stroke) personal history of traumatic brain injury (a brain injury that is caused by an outside force), chronic pain( lasts months or years and can affect any part of your body), essential hypertension (abnormally high blood pressure), pressure ulcer (forms on an area of the skin with prolonged pressure due to immobility) of right buttock, stage 4 (Full-thickness tissue loss with exposed bone, tendon, ligament, fascia, cartilage, or muscle)-onset 07/23/25, and Sepsis (potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) -unspecified organism-08/08/25 onset. Record review of Resident#1's MDS, dated [DATE] reflected his BIMS score was 14 which indicated cognitive intact. Record review of Resident#1 care plan, dated 07/14/25 reflected, no documentation of resident health and safety being addressed when leaving the facility unsupervised. Record review of Resident#2's face sheet, dated 08/22/25 reflected, he was a [AGE] year-old male who or was originally admitted on [DATE] and readmitted on [DATE] and diagnosed with Epilepsy (neurological disorder characterized by recurrent, unprovoked seizures), depression, mid cognitive impairment of uncertain unknown etiology (cognitive issues like memory and thinking problems are present but the specific underlying cause hasn't been identified), depression, unspecified convulsions, hyperlipidemia (a condition characterized by high levels of lipids (fats) in the blood, including cholesterol and triglycerides), hypothyroidism (happens when your thyroid gland doesn't make enough thyroid hormones to meet your body's needs), and tracheostomy (a surgical procedure that creates an opening in the trachea (windpipe) to provide an airway and facilitate breathing.) Record review of Resident#2's MDS, dated [DATE] reflected his BIMS score was 14 which indicated cognitive intact. Record review of Resident#2 care plan, dated 08/18/25 reflected, no documentation of resident health and safety being addressed when leaving the facility unsupervised. Record review of Resident#3 s face sheet, 08/21/25 reflected, she was a [AGE] year-old female who was originally admitted on [DATE] and diagnosed with unspecified Dementia (a condition where cognitive decline is present, but the specific underlying cause cannot be identified), bipolar disorder, anxiety disorder and cerebral infraction (occurs when blood flow to the brain is interrupted, leading to cell death and brain damage), unspecified. Record review of Resident#3's MDS, date reflected her BIMS score was 13 which indicated cognitive intact. Record review of Resident#3 care plan, dated 07/14/25 reflected, no documentation of resident health and safety being addressed when leaving the facility unsupervised. Record review of Resident#4 face sheet, dated 08/22/25 reflected, he was a [AGE] year-old male who was originally admitted [DATE] and readmitted [DATE] and diagnosed with major depressive disorder, diffuse traumatic brain injury (a type of brain injury that occurs when the brain experiences rapid acceleration or deceleration forces, causing widespread damage to the white matter tracts) with loss of consciousness of unspecified, conversion disorders with seizures or convulsions (involves real physical symptoms that resemble epileptic seizures but result from psychological factors),Epileptic seizures related to external causes not intractable (seizures triggered by an external factor that are not the chronic, difficult-to-manage form of epilepsy). Record review of Resident#4's MDS, date reflected his BIMS score was 14 which indicated cognitive intact. Record review of Resident#4 care plan, dated 08/01/25 reflected, no documentation of resident health and safety being addressed when leaving the facility unsupervised. In an interview on 08/20/25 at 10:45 am Resident#1 stated he did not want to talk about why he left the facility, where he went, who he was with and about his hospital stay. Resident#1 stated he was ok and did not have any concerns. Resident#1 stated that he signs himself in and out when he left the facility. In an interview on 08/20/25 at 10:52 am Resident# 4 stated he signed himself in and out. Resident#4 stated that he comes back to the facility every day. Resident#4 stated he did not have any concerns. In an interview on 08/21/24 at 12:48 pm resident#3 stated he signed himself in and out. Resident#3 stated he came back the same day that he left. Resident#3 stated he did not have any concerns. In an interview on 08/22/25 at 11:30 am the DON stated she was responsible for updating the care plans. The DON stated she was not sure why those residents care plans were not updated to reflect that they did not follow the facility policy on signing in and out. Those residents care plans do not mention they can leave unsupervised. The DON stated she has been working the floor a lot. The DON stated not updating the care plan could leave residents needs not being met. Record review od facility policy dated, revised 12/2016, titled Care plans, comprehensive person centered reflected in part: C. Describe services that would otherwise be provided for the above, but are not provided due to residents exercising his or her right, including the right to refuse treatment.G, incorporate identified problem areas.13. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents condition changes. On 08/21/25 at 5:53 PM the IJ was called. The template was provided to the Admin and DON, POR was approved on 08/22/25. 1. Identification of Residents Affected or Likely to be Affected:The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 8/21/2025 [Residnet#1] returned to the facility on 8/8/2025 [Resident#1] care plan was updated by don/designee on 8/21/2025 2. Actions to Prevent Occurrence/Recurrence:The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 8/21/2025) Care plans will be reviewed for all residents that sign themselves out. The IDT team will be in-serviced on revising the care plans for each resident that signs out by the corporate nurse/DON by 8/22/2025. The administrator/director of nursing were in-serviced by corporate team on 8/21/2025 at 6:54 on updating care plans A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until the pattern of compliance is maintained. QAPI will be completed by corporate nurse by 8/21/25. New staff will be educated and trained on resident signing in and out, with timely returning Agency staff will be educated and trained on residents signing in and out, with timely returning prior to starting shift. Care plan, drugs, and signing out policies always made available for review.Record review of Resident#1 revised 08/22/25, care plan initiated on 08/21/25 reflected Potential for disrupting continuity of care due to the resident will sign himself out of the facility and sits outside with a group of other residents and socializes . Goal reflected, The resident will understand the risk associated with signing out of the facility.The resident was educated to provide an expected time of return upon signing out of the facility. If the resident does not return within 2 hours of the expected timeframe, Attempt to contact the resident, the family members, the police, the MD, the DON and Administrator. The resident was educated on the risk of being outside during extreme heat and heat related illnesses and the potential for harm. The resident was educated on the risk of using illegal substances while out on pass The resident will be encouraged to sign out each time they leave the facility and to give the expected time of return. Record review of Resident#2 revised care plan initiated on 08/21/25 reflected, Potential for disrupting continuity of care due to the resident will sign himself out of the facility and sits outside with a group of other residents and socializes . Goal reflected, Referral to psyche services as needed. The resident will understand the risk associated with signing out of the facility.The resident was educated to provide an expected time of return upon signing out of the facility. If the resident does not return within 2 hours of the expected timeframe, attempt to contact the resident, the family members, the police, the MD, the DON and Administrator. The resident was educated on the risk of being outside during extreme heat and heat related illnesses and the potential for harm. The resident was educated on the risk of using illegal substances while out on pass The resident will be encouraged to sign out each time they leave the facility and to give the expected time of return. Record review of Resident#3 revised care plan initiated on 08/21/25 reflected, Potential for disrupting continuity of care due to the resident will sign herself out of the facility and sits outside with a group of other s . Goal reflected, The resident will understand the risk associated with signing out of the facility.The resident was educated to provide an expected time of return upon signing out of the facility. If the resident does not return within 2 hours of the expected timeframe, attempt to contact the resident, the family members, the police, the MD, the DON and Administrator. The resident was educated on the risk of being outside during extreme heat and heat related illnesses and the potential for harm. The resident was educated on the risk of using illegal substances while out on pass The resident will be encouraged to sign out each time they leave the facility and to give the expected time of return. In an interview on 08/22/25 at 2:53 pm with the corporate consulting nurse at 11:00 am she was able to verbalize everything that the facility had implemented. In an interview on 08/23/25 between 1:00 pm to 3:30 pm, the ADON, DON, RN J, LVN G, LVN H, LVN I stated the care plans needed to be updated as needed and acute changes . The DON stated after QAPI meetings and morning minutes Residents care plans needed to be updated so that concerns or issues that need to have interventions could be addressed. RN J stated the care plans needed to reflect the Residents current conditions and concerns. RN J stated measurable interventions and goals need to be put in place to address corns for residents' health and safety. All residents care plans were audit who signed themselves out. The DON was responsible for updating care plans daily after IDT meetings if needed and monthly after QAA meetings and as needed. In an interview on 08/22/25 at 3:30 pm the DON and Admin verbalized everything the facility had implemented. An IJ was identified on 08/21/25. The IJ template was provided to the facility on [DATE] at 5:53 pm While the IJ was removed on 08/22/25, the facility remained out of compliance at a scope of potential for more than minimal harm that is not Immediate Jeopardy and a severity level of pattern because all staff had not been trained on 08/22/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of eleven residents (Resident #1) reviewed for abuse, neglect, and exploitation. -The facility failed to ensure Resident #1 was free from deprivation of services and goods abuse when the facility failed to have effective interventions and services in place to address the resident's inappropriate sexual behaviors and prevent him from sexually abusing others, which could lead to harm to himself and others. An Immediate Jeopardy (IJ) situation was identified on 5/19/25. While the IJ was removed on 5/20/25, the facility remained out of compliance at a scope of pattern with a potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems . This failure could place residents at risk for abuse or neglect that could lead to serious harm. Findings include: Record review of Resident #1's face sheet, dated 5/20/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: dementia (brain disorder that affects memory, thinking, and behavior), metabolic encephalopathy (brain disorder that causes confusion) COPD (lung disease), type II diabetes (inability to regulate blood sugar levels), chronic respiratory failure (lack of oxygen), end-stage renal failure (kidney disease), and hypertension (high blood pressure). Record review of Resident #1's admission MDS assessment, dated 4/08/25, reflected his BIMS score was 10, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required partial to moderate assistance with most ADLs, used a walker, and was independent with most mobility tasks. The MDS Assessment under Section E-Behaviors, reflected Resident #1 did not have any physical or verbal behaviors. Record review of Resident #1's care plan, revised 4/23/25, reflected the resident had a history of socially inappropriate behaviors: sexually inappropriate behavior. Interventions included: administering medication as ordered, eliciting family input for best approaches, praising the resident for demonstrating desired behavior, providing all care with another staff member, and removing the resident from public area when behavior was disruptive and/or unacceptable. Further review of this document reflected Resident #1 was not care planned for sexually inappropriate behaviors upon admission. Record review of Resident #1's clinical notes, dated 3/21/25 and signed by the MD, from previous nursing facility reflected in part the following: HPI: LTC on therapy Today: . [Resident #1] has had multiple complaints and issues regarding inappropriate sexual behavior with staff and residents, He currently has a sitter, Psychiatry also following, Vitals stable. I believe patient is no longer safe to remain at the facility given sexual aggression towards other residents. I believe patient would be more appropriate to reside in a male only locked unit given behaviors Record review of Resident #1's progress note, dated 4/23/25 at 9:34 AM by the SSD, reflected the following: [SSD] contacted [RP] to make her aware of [Resident #1's] behavior and what all took place during the activity with the high school students. [RP] shared that [Resident #1] had already told her he spanked a high [NAME] on the butt. Record review of Resident #1's progress note, dated 4/23/25 at 9:53 AM by the DON, reflected the following: [DON] was notified by [Activity Director] that [Resident #1] has 'inappropriately touched' a student that was in facility for a activity. [Activity Director] stated that another student told him but didn't say who the student was. [DON] asked if police was made aware, was told that they have already gone, [DON] told director to notify abuse coordinator. Nursing placed [Resident #1] on Q15 min monitoring, until alternate placement can be made, immediate discharge to be given, MD made aware. Record review of Resident #1's progress note, dated 4/23/25 at 10:12 AM by the SSD, reflected the following: [Resident #1's] [RP] reached out and shared that she won't be able to properly care for [Resident #1]so she is not able to pick him up. [SSD] informed [RP] that she will be sending over clinical information to several nursing homes and facilities. Record review of documents provided by the DON titled Resident 15 Minute Checks, dated 4/23/25-5/04/25, reflected Resident #1 remained on Q15 monitoring during this time. Record review of documents provided by the DON titled [Nursing Facility] Resident Safe Survey Questionnaire for Staff, dated 4/23/25, reflected 30 residents were surveyed regarding abuse and neglected from staff with no concerns. Further review of this document reflected there were no questions directly regarding concerns for sexual abuse by staff or other residents. Attempted interview on 5/16/25 at 10:30 AM with Resident #1 was unsuccessful due to the resident being away from the facility at the dialysis clinic. In an interview on 5/16/25 at 12:35 PM with the DON and Administrator, the DON denied knowing Resident #1 had a history of exhibiting sexually inappropriate behaviors. The Administrator stated the facility did not have a policy that required the facility to check a resident's background or the sex offender registry prior to admission. The DON stated per regional managers, the facility did not discriminate against residents regarding criminal background. The Administrator and DON failed to mention Resident #1 was involved in an incident on 4/23/25 where he exhibited sexually inappropriate behavior by touching a student visitor during this interview. In an interview on 5/16/25 at 1:35 PM, Resident #3 stated she felt uncomfortable around Resident #1, who she called a sex offender, because he always stared at her while making sexual gestures. Resident #3 stated a lot of female residents were uncomfortable around Resident #1 and it was reported to the Administrator and the DON, and they never did anything about it. Resident #3 stated students from the local high school used to visit and paint the female residents' fingernails; however, they stopped after Resident #1 touched one of the students inappropriately last month. She denied ever being touched by Resident #1. In an interview on 5/16/25 at 2:15 PM, Resident #11 stated Resident #1 was creepy because he would come up to her room door and stick his tongue out, wink, and blow kisses at her. Resident #11 stated Resident #1 did that to a lot of other female residents, and they were all uncomfortable around him. Resident #11 stated she reported this to her nurse ; however, Resident #1's behavior did not stop. Resident #11 denied ever being touched by Resident #1 but stated he touched a student while they were visiting the facility to participate in activities with the residents. Resident #11 stated after the incident Resident #1 had 1 to 1 supervision and that stopped the behaviors, but he was not on it long. Record review of Resident #1's active consolidated physician orders, dated 5/20/25, reflected in part the following: -Estradiol Oral Tablet 2 mg; give 1 tablet by mouth one time a day for hypersexuality. Start Date: 5/15/25. Further review of this document reflected Resident #1 did not have an order for psychological/psychiatric services. In an interview on 5/16/25 at 4:20 PM with the Administrator and DON, the DON stated she was aware of Resident #1 touching a student visitor inappropriately. The DON stated she did not know the state surveyor was referring to that incident during the earlier interview. The DON stated the Activity Director reported to her the students were in the dining room areas doing an activity with the residents when one of the students ran out upset and another student reported she was touched inappropriately by Resident #1. The DON stated Resident #1 was placed on Q 15-minute supervision and issued an immediate discharge notice; however, they were unable to find placement and Resident #1's RP stated she could not care for the resident. The DON stated she was responsible for reviewing clinical notes before admitting a resident; however, she did not remember seeing in Resident #1's clinical notes that he had a history of exhibiting sexually inappropriate behaviors or that it was recommended he be placed on an all-male secured unit. The DON stated if she saw the recommendation, she probably would not have admitted Resident #1, or she would have put appropriate interventions in place. The DON stated the MD recently placed Resident #1 on medication for his hypersexual behaviors and he was care planned to have 2 staff when care was being provided. The Administrator stated he was aware of the incident and after reviewing the camera footage he was unable to determine exactly what happened due to a pole blocking the view. He stated he only saw the student jump back then get up and run from the area. The Administrator stated since he could not determine what happened from the footage, he did not proceed with a full investigation, report it to the state agency, or notify law enforcement. The Administrator stated it was the facility's policy to investigate and report abuse and neglect; however, he did not think he needed to investigate or report the incident based on the information he had. He stated the risk of not investigating and reporting incidents of alleged abuse or neglect could place the residents at risk of being harmed. In an interview on 5/16/25 at 4:40 PM, the Ombudsman stated she had an open case for Resident #1 regarding the resident being sexually inappropriate with a student who was visiting the facility. The Ombudsman stated Resident #1's RP called her because the facility was trying to discharge the resident to a group home which was inappropriate for his level of care. The Ombudsman stated the RP informed that Resident #1 was unaware of his actions and the consequences of it due to his dementia and did not feel it was right for him to be punished. The Ombudsman stated she never received a discharge notice Resident #1. She stated she visited the facility to investigate and felt the facility should have reported the incident to the state agency. The Ombudsman stated she reviewed Resident #1's clinical notes from the previous facility and found that it was recommended the resident be placed on a male secured unit. The Ombudsman stated Resident #1 should not have been admitted to the current nursing facility if they could not accommodate his care needs as they did not have a male secured unit. The Ombudsman expressed deep concerns that the incident was not reported, and the facility had considered discharging the resident to a group home. In an interview on 5/19/25 at 9:26 AM, the Activity Director stated students from the local high school would come to the facility twice a month to do activities with the residents. The Activity Director stated on 4/23/25, the students were at the facility doing an activity with the residents in the dining area. He stated a student came up to him visibly upset then pointed at Resident #1 and stated he grabbed one of the student's thighs. The Activity Director stated he saw the student run out of the area but did not know her name and the other students refused to identify her. The Activity Director stated he immediately removed Resident #1 from the area until the students left the facility. He stated he reported the incident to the Administrator and the DON. The Activity Director stated Resident #1 was placed on 1 to 1 supervision for some time, but he was not sure what else was done. He stated the Administrator did not ban the students from the facility because he was still expecting them to show up; however, they never returned. The Activity Director stated he heard Resident #1 was sexually inappropriate with the aides, but he never heard of Resident #1 doing anything to other residents. Further interview on 5/19/25 at 3:00 PM with the Administrator and DON, the DON stated after the incident she did not in-service the staff on abuse/neglect and sexually inappropriate behaviors. The DON stated the staff received routine trainings and in-services as needed on abuse and neglect, but she did not know if they received trainings specifically regarding sexual behaviors other than upon hire. The DON stated staff knew to document daily on Resident #1 and the staff who were assigned to do Q 15-miute checks were informed about the incident and knew what to monitor for; however, this was not documented as an in-service. The Administrator stated he had a meeting with management regarding the incident, but it was not documented. The Administrator stated he had a memo typed up that had not been sent out yet because he was waiting to see if the students would return to the facility. He did not state what information was included in the memo . The DON stated not having effective interventions in place, placed residents and visitors at risk of being sexually abused. She stated this also placed Resident #1 at risk of being harmed because he could be sexually inappropriate towards someone who could hurt him. In an interview on 5/19/25 at 4:36 PM, Resident #1's RP stated the facility notified her sometime last month to inform her the resident was being discharged to a group home for being sexually inappropriate with a student that was visiting the facility. The RP stated she was aware Resident #1 exhibited sexually inappropriate behaviors from his previous facility; however, he could not help it due to his dementia. The RP stated the last thing she heard from the facility was Resident #1 was placed on 1 to 1 supervision and was told she would have to pay for it to continue. The RP stated she was informed she could not afford to pay, and she also could not bring Resident #1 home with her, and that was the last time she heard from them. In an observation and interview on 5/19/25 at 4:52 PM, revealed Resident #1 was sitting in a wheelchair in his room. He was dressed and well-groomed . Resident #1 stated he had just returned to the facility from dialysis and was tired. Resident #1 stated he was fine then refused to answer any other questions. This state surveyor was unable to obtain any information from Resident #1 regarding the incident. In an interview on 5/20/25 at 1:25 PM, CNA C stated she worked with Resident #1 and he was always sexually inappropriate with staff. She stated Resident #1 would grab at her breast and thighs while she was showering him, and it made her very uncomfortable. CNA C stated she reported this to the DON, and she placed the resident on 2-person assist with care but there was not always an extra staff to help when needed. CNA C stated she was aware of the incident that happened on 4/23/25 when Resident #1 touched a student inappropriately. CNA C stated later that evening, a man who said he was the student's father came to the facility and asked to speak to someone about the incident. CNA C stated that made the staff concerned for the safety of everyone in the facility. CNA C stated it was reported to the Administrator and DON . Record review of the facility's policy titled Abuse Prevention Program, revised January 2011, reflected in part the following: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. . 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. 4. Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. 5. Implement measures to address factors that may lead to abusive situations, for example: a. Provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation. b. Instruct staff regarding appropriate ways to address interpersonal conflicts; and c. Help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts. 6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements; 8. Protect residents during abuse investigations; 9. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse; and 10. Involve the resident council in monitoring and evaluating the facility's abuse prevention program . This was determined to be an Immediate Jeopardy (IJ) on 05/19/25 at 3:22 PM. The Administrator and DON were notified. The Administrator was provided with the template on 05/19/25 at 3:25 PM. The following Plan of Removal submitted by the facility was accepted on 05/20/25 at 1:32 PM: [Nursing Facility] 1. F600 | Free from Neglect - The facility failed to ensure Resident #1 was free from neglect when he was not provided appropriate good or services to prevent his sexually inappropriate behaviors to potentially cause harm to himself and to others. 2. Identification of Residents Affected or Likely to be Affected: The DON, Social Services Director, and designee(s) interviewed/assessed residents all residents for potential abuse by conducting safe surveys on each resident. Concerns were identified. Concerns identified were resident keeps staring at them and touching his privates-3 residents). (Completion Date: 4/23/2025): The following actions were taken to prevent Resident # 1 from perpetrating additional abusive behaviors. Resident evaluated by primary care provider on 5/14/25 and provided a medication update. Resident will have a psych consult, medication adjustment, and follow-up as needed. Psych referral has been submitted on 5/20/2025. Psych consult provided (5/23/2025). Resident will not be seated near female resident(s) at activities, dining, etc . when at all possible. IDT reviewed and revised care plan to identify patterns in resident's behaviors and implement interventions. Care plan revisions and interventions communicated to front line staff caring for resident. 3. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 5/20/2025) Abuse policies were reviewed/updated to include all sources of abuse, including resident to resident. Abuse investigation procedure and documentation process were reviewed and revised. Administrator and DON educated all staff on changes. Social Services Director, DON, and Administrator re-educated all staff on facility abuse policies. Social Services Director, DON and Administrator re-education all staff on abuse prevention and reporting. Corporate will in-service Director of Nursing, Social, Administrator, and ADON on abuse and neglect, by 5/20/2025. Started 5/19/2025. DON and designee educated Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director or designee and care plans will be updated as indicated. Staff will be educated on new interventions either verbally or in written form by the Care Plan Coordinator or designee. Started 5/19/2025 Process will be on going. In the event of any future allegation of sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. Started 5/19/2025. Process will be on going . The DON and/or administrator will in-service the staff on proper interventions of misconduct and abuse and neglect. Started 5/19/2025 In-service will be on going. QAPI meeting will be held monthly, and findings discussed. The DON will monitor the effectiveness of interventions will be ongoing. A pre/posttest on abuse and neglect will be on going starting 5/20/2025. Started 5/20/2025. The facility is still looking for proper placement of resident . Trainings and in-service will be provided to staff before the start of their shift, and ongoing for any PRN, new staff, or staff that has not participated in training. Review the following: Regulation: F-600 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Intent §483.12(a)(1) Each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. Highlight the deficient practice and specifics of the citation. Facility Policy and Practice Facility's Action Plan regarding the deficiency. Facility's Policies and Procedures related to the deficiency. Facility's Checklists and Monitoring tools used to verify compliance. Facility's Abuse investigation procedure and documentation process. Record of Training Complete Record of In-service Training and Attendance Form. Be sure that all participants sign in. Monitoring of the POR included the following: Interviews on 5/08/25at 1:20 PM-2:35 PM, conducted with the Administrator, DON, ADON, SSD, MDS Nurse, nurses, CMAs, and CNAs : LVN B (2nd shift), CNC C (1st shift/rotating), LVN E (1st shift), LVN F (1st shift), CNA G (1st shift/rotating), LVN H (3rd shift), RN I (2nd shift), CMA J (2nd shift), CNA K (3rd shift/rotating), LVN L (2nd shift), CNA M (2nd shift), CNA N (2nd shift), and RN O (3rd shift/weekends) indicated they all participated in in-service trainings regarding the facility's policy on abuse/sexual abuse, neglect, and exploitation starting on 5/19/25-5/20/25. All staff were able to identify abuse/sexual abuse, neglect, and exploitation, state when to report it, and who to report it to. All staff were able to state the updated procedure for sexual abuse which included removing any residents who exhibited inappropriate sexual behaviors from the area, placing them on 1 to 1 supervision until further advised, immediately reporting the behaviors to the MD, DON, and family, and following any new orders. The nurses were able to state all behaviors had to be documented and reported to the DON. The SSD was able to state she was responsible for monitoring documentation for any changes in residents' behaviors and ensure the care plans were updated and assist in the discharge process as necessary. The Administrator and DON were able to state it was the facility's expectation to identify, report, and investigate any suspected or alleged abuse/sexual abuse, neglect, and exploitation. The Administrator and DON understood it was their responsibility to implement and monitor the effectiveness of interventions put in place. Observation, interview and record review on 5/20/25 at 3:00 PM-4:00 PM, of Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10 and #11, who were all at risk for abuse, neglect, and exploitation , revealed no further concerns. Record review of residents' EHRs reflected no concerns for changes in physical, mental, or psychosocial status or a lack in necessary goods and services. Observation of the residents revealed no signs of abuse or neglect. Interviews with residents and/or RPs revealed no concerns for abuse, neglect, or exploitation. Record review of an in-service titled Abuse and Neglect, dated 5/19/25, reflected all staff were educated on the facility's policy on recognizing and reporting abuse and neglect. Record review of an in-service titled Abuse and Neglect, dated 5/19/25, reflected the Administrator, DON, and SSD were educated on implementing the facility's policy to assess, investigate, and report any alleged abuse and neglect. Record review of an in-service titled Sexual Assault, dated 5/20/25, reflected all staff were educated on recognizing and reporting any signs of sexual abuse and inappropriate sexual behaviors. Record review of documents provided by the Regional Nurse Consultant titled Abuse, Neglect, and Exploitation-Pre/Post Test, dated 5/20/25, reflected the DON tested all staff over their knowledge on recognizing and reporting abuse, neglect, and exploitation. Record review of a progress note, dated 5/20/25 at 11:25 AM, reflected Resident #1 was connected to psychiatric services to address sexual behaviors . Record review of documents provided by the Regional Nurse Consultant titled [Nursing Facility] QAPI/Corrective Action Pla Meeting, dated 5/20/25, reflected a QAPI meeting was held regarding the correction plan for the facility's deficiency in neglect. The Administrator was informed the Immediate Jeopardy was removed on 05/20/25 at 4:34 PM. The facility remained out of compliance at a scope of pattern and severity level of no actual harm with the potential for more than minimal harm that was 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 develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for one of eleven residents (Resident #1) reviewed for abuse, neglect, and exploitation. -The facility failed to implement policies and procedures to ensure Resident #1 was free from deprivation of goods and services abuse when the facility failed to have effective interventions and services in place to address the resident's inappropriate sexual behaviors and in-service staff on measures to properly handle the behaviors to prevent Resident #1 from sexually abusing others. An Immediate Jeopardy (IJ) situation was identified on 5/19/25. While the IJ was removed on 5/20/25, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems . These failures could place residents at an increased risk for abuse and neglect. Findings include: Record review of Resident #1's face sheet, dated 5/20/25, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: dementia (brain disorder that affects memory, thinking, and behavior), metabolic encephalopathy (brain disorder that causes confusion) COPD (lung disease), type II diabetes (inability to regulate blood sugar levels, chronic respiratory failure (lack of oxygen), end-stage renal failure (kidney disease), and hypertension (high blood pressure). Record review of Resident #1's admission MDS assessment, dated 4/08/25, reflected his BIMS score was 10, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required partial to moderate assistance with most ADLs, used a walker, and was independent with most mobility tasks. The MDS Assessment under Section E-Behaviors, reflected Resident #1 did not have any physical or verbal behaviors. Record review of Resident #1's care plan, revised 4/23/25, reflected the resident had a history of socially inappropriate behaviors: sexually inappropriate behavior. Interventions included: administering medication as ordered, eliciting family input for best approaches, praising the resident for demonstrating desired behavior, providing all care with another staff member, and removing the resident from public area when behavior was disruptive and/or unacceptable. Further review of this document reflected Resident #1 was not care planned for sexually inappropriate behaviors upon admission. Record review of Resident #1's clinical notes, dated 3/21/25 and signed by the MD, from previous nursing facility reflected in part the following: HPI: LTC on therapy Today: . [Resident #1] has had multiple complaints and issues regarding inappropriate sexual behavior with staff and residents, He currently has a sitter, Psychiatry also following, Vitals stable. I believe patient is no longer safe to remain at the facility given sexual aggression towards other residents. I believe patient would be more appropriate to reside in a male only locked unit given behaviors. . Record review of Resident #1's progress note, dated 4/23/25 at 9:34 AM by the SSD, reflected the following: [SSD] contacted [RP] to make her aware of [Resident #1's] behavior and what all took place during the activity with the high school students. [RP] shared that [Resident #1] had already told her he spanked a high [NAME] on the butt. Record review of Resident #1's progress note, dated 4/23/25 at 9:53 AM by the DON, reflected the following: [DON] was notified by [Activity Director] that [Resident #1] has 'inappropriately touched' a student that was in facility for a activity. [Activity Director] stated that another student told him but didn't say who the student was. [DON] asked if police was made aware, was told that they have already gone, [DON] told director to notify abuse coordinator. Nursing placed [Resident #1] on Q15 min monitoring, until alternate placement can be made, immediate discharge to be given, MD made aware. Record review of Resident #1's progress note, dated 4/23/25 at 10:12 AM by the SSD, reflected the following: [Resident #1's] [RP] reached out and shared that she won't be able to properly care for [Resident #1]so she is not able to pick him up. [SSD] informed [RP] that she will be sending over clinical information to several nursing homes and facilities. Record review of documents provided by the DON titled Resident 15 Minute Checks, dated 4/23/25-5/04/25, reflected Resident #1 remained on Q15 monitoring during this time. Record review of documents provided by the DON titled [Nursing Facility] Resident Safe Survey Questionnaire for Staff, dated 4/23/25, reflected 30 residents were surveyed regarding abuse and neglected from staff with no concerns. Further review of this document reflected there were no questions directly regarding concerns for sexual abuse by staff or other residents. Attempted interview on 5/16/25 at 10:30 AM with Resident #1 was unsuccessful due to the resident being away from the facility at the dialysis clinic. Record review of Resident #1's active consolidated physician orders, dated 5/20/25, reflected in part the following: -Estradiol Oral Tablet 2 mg; give 1 tablet by mouth one time a day for hypersexuality. Start Date: 5/15/25. Further review of this document reflected Resident #1 did not have an order for psychological/psychiatric services. In an interview on 5/16/25 at 12:35 PM with the DON and Administrator, the DON denied knowing Resident #1 had a history of exhibiting sexually inappropriate behaviors. The Administrator stated the facility did not have a policy that required the facility to check a resident's background or the sex offender registry prior to admission. The DON stated per regional managers, the facility did not discriminate against residents regarding criminal background. The Administrator and the DON failed to mention Resident #1 was involved in an incident on 4/23/25 where he exhibited sexually inappropriate behavior by touching a student visitor during this interview. In an interview on 5/16/25 at 1:35 PM, Resident #3 stated she felt uncomfortable around Resident #1, who she called a sex offender, because he always stared at her while making sexual gestures. Resident #3 stated a lot of female residents were uncomfortable around Resident #1 and it was reported to the Administrator and the DON, and they never did anything about it. Resident #3 stated students from the local high school used to visit and paint the female residents' fingernails; however, they stopped after Resident #1 touched one of the students inappropriately last month. She denied ever being touched by Resident #1. In an interview on 5/16/25 at 2:15 PM, Resident #11 stated Resident #1 was creepy because he would come up to her room door and stick his tongue out, wink, and blow kisses at her. Resident #11 stated Resident #1 did that to a lot of other female residents, and they were all uncomfortable around him. Resident #11 stated she reported this to her nurse ; however, Resident #1's behavior did not stop. Resident #11 denied ever being touched by Resident #1 but stated he touched a student while they were visiting the facility to participate in activities with the residents. Resident #11 stated after the incident Resident #1 had 1 to 1 supervision and that stopped the behaviors, but he was not on it long. In an interview on 5/16/25 at 4:20 PM with the Administrator and DON, the DON stated she was aware of Resident #1 touching a student visitor inappropriately. The DON stated she did not know the state surveyor was referring to that incident during the earlier interview. The DON stated the Activity Director reported to her the students were in the dining room areas doing an activity with the residents when one of the students ran out upset and another student reported she was touched inappropriately by Resident #1. The DON stated Resident #1 was placed on Q 15-minute supervision and issued an immediate discharge notice; however, they were unable to find placement and Resident #1's RP stated she could not care for the resident. The DON stated she was responsible for reviewing clinical notes before admitting a resident; however, she did not remember seeing in Resident #1's clinical notes that he had a history of exhibiting sexually inappropriate behaviors or that it was recommended he be placed on an all-male secured unit. The DON stated if she saw the recommendation, she probably would not have admitted Resident #1, or she would have put appropriate interventions in place. The DON stated the MD recently placed Resident #1 on medication for his hypersexual behaviors and he was care planned to have 2 staff when care was being provided. The Administrator stated he was aware of the incident and after reviewing the camera footage he was unable to determine exactly what happened due to a pole blocking the view. He stated he only saw the student jump back then get up and run from the area. The Administrator stated since he could not determine what happened from the footage, he did not proceed with a full investigation, report it to the state agency, or notify law enforcement. The Administrator stated it was the facility's policy to investigate and report abuse and neglect; however, he did not think he needed to investigate or report the incident based on the information he had. He stated the risk of not investigating and reporting incidents of alleged abuse or neglect could place the residents at risk of being harmed. In an interview on 5/16/25 at 4:40 PM, the Ombudsman stated she had an open case for Resident #1 regarding the resident being sexually inappropriate with a student who was visiting the facility. The Ombudsman stated Resident #1's RP called her because the facility was trying to discharge the resident to a group home which was inappropriate for his level of care. The Ombudsman stated the RP informed that Resident #1 was unaware of his actions and the consequences of it due to his dementia and did not feel it was right for him to be punished. The Ombudsman stated she never received a discharge notice Resident #1. She stated she visited the facility to investigate and felt the facility should have reported the incident to the state agency. The Ombudsman stated she reviewed Resident #1's clinical notes from the previous facility and found that it was recommended the resident be placed on a male secured unit. The Ombudsman stated Resident #1 should not have been admitted to the current nursing facility if they could not accommodate his care needs as they did not have a male secured unit. The Ombudsman expressed deep concerns that the incident was not reported, and the facility had considered discharging the resident to a group home. In an interview on 5/19/25 at 9:26 AM, the Activity Director stated students from the local high school would come to the facility twice a month to do activities with the residents. The Activity Director stated on 4/23/25, the students were at the facility doing an activity with the residents in the dining area. He stated a student came up to him visibly upset then pointed at Resident #1 and stated he grabbed one of the student's thighs. The Activity Director stated he saw the student run out of the area but did not know her name and the other students refused to identify her. The Activity Director stated he immediately removed Resident #1 from the area until the students left the facility. He stated he reported the incident to the Administrator and the DON. The Activity Director stated Resident #1 was placed on 1 to 1 supervision for some time, but he was not sure what else was done. He stated the Administrator did not ban the students from the facility because he was still expecting them to show up; however, they never returned. The Activity Director stated he heard Resident #1 was sexually inappropriate with the aides, but he never heard of Resident #1 doing anything to other residents. Further interview on 5/19/25 at 3:00 PM with the Administrator and DON, the DON stated after the incident she did not in-service the staff on abuse/neglect and sexually inappropriate behaviors. The DON stated the staff received routine trainings and in-services as needed on abuse and neglect, but she did not know if they received trainings specifically regarding sexual behaviors other than upon hire. The DON stated staff knew to document daily on Resident #1 and the staff who were assigned to do Q 15-miute checks were informed about the incident and knew what to monitor for; however, this was not documented as an in-service. The Administrator stated he had a meeting with management regarding the incident, but it was not documented. The Administrator stated he had a memo typed up that had not been sent out yet because he was waiting to see if the students would return to the facility. He did not state what information was included in the memo . The DON stated not having effective interventions in place, placed residents and visitors at risk of being sexually abused. She stated this also placed Resident #1 at risk of being harmed because he could be sexually inappropriate towards someone who could hurt him. In an interview on 5/19/25 at 4:36 PM, Resident #1's RP stated the facility notified her sometime last month to inform her the resident was being discharged to a group home for being sexually inappropriate with a student that was visiting the facility. The RP stated she was aware Resident #1 exhibited sexually inappropriate behaviors from his previous facility; however, he could not help it due to his dementia. The RP stated the last thing she heard from the facility was Resident #1 was placed on 1 to 1 supervision and was told she would have to pay for it to continue. The RP stated she was informed she could not afford to pay, and she also could not bring Resident #1 home with her, and that was the last time she heard from them. In an observation and interview on 5/19/25 at 4:52 PM, revealed Resident #1 was sitting in a wheelchair in his room. He was dressed and well-groomed . Resident #1 stated he had just returned to the facility from dialysis and was tired. Resident #1 stated he was fine then refused to answer any other questions. This state surveyor was unable to obtain any information from Resident #1 regarding the incident. In an interview on 5/20/25 at 1:25 PM, CNA C stated she worked with Resident #1 and he was always sexually inappropriate with staff. She stated Resident #1 would grab at her breast and thighs while she was showering him, and it made her very uncomfortable. CNA C stated she reported this to the DON, and she placed the resident on 2-person assist with care but there was not always an extra staff to help when needed. CNA C stated she was aware of the incident that happened on 4/23/25 when Resident #1 touched a student inappropriately. CNA C stated later that evening, a man who said he was the student's father came to the facility and asked to speak to someone about the incident. CNA C stated that made the staff concerned for the safety of everyone in the facility. CNA C stated it was reported to the Administrator and DON . Record review of the facility's policy titled Abuse Prevention Program, revised January 2011, reflected in part the following: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. . 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. 4. Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. 5. Implement measures to address factors that may lead to abusive situations, for example: a. Provide staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation. b. Instruct staff regarding appropriate ways to address interpersonal conflicts; and c. Help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts. 6. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements; 8. Protect residents during abuse investigations; 9. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse; and 10. Involve the resident council in monitoring and evaluating the facility's abuse prevention program. This was determined to be an Immediate Jeopardy (IJ) on 05/19/25 at 3:22 PM. The Administrator and DON were notified. The Administrator was provided with the IJ template on 05/19/25 at 3:25 PM The following Plan of Removal submitted by the facility was accepted on 05/20/25 at 1:32 PM: [Nursing Facility] 1. F600 (F607)| Free from Neglect - The facility failed to ensure Resident #1 was free from neglect when he was not provided appropriate good or services to prevent his sexually inappropriate behaviors to potentially cause harm to himself and to others. 2. Identification of Residents Affected or Likely to be Affected: The DON, Social Services Director, and designee(s) interviewed/assessed residents all residents for potential abuse by conducting safe surveys on each resident. Concerns were identified. Concerns identified were resident keeps staring at them and touching his privates-3 residents). (Completion Date: 4/23/2025): The following actions were taken to prevent Resident # 1 from perpetrating additional abusive behaviors. Resident evaluated by primary care provider on 5/14/25 and provided a medication update. Resident will have a psych consult, medication adjustment, and follow-up as needed. Psych referral has been submitted on 5/20/2025. Psyche consult provided (5/23/2025). Resident will not be seated near female resident(s) at activities, dining, etc. when at all possible. IDT reviewed and revised care plan to identify patterns in resident's behaviors and implement interventions. Care plan revisions and interventions communicated to front line staff caring for resident. 3. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 5/20/2025) Abuse policies were reviewed/updated to include all sources of abuse, including resident to resident. Abuse investigation procedure and documentation process were reviewed and revised. Administrator and DON educated all staff on changes. Social Services Director, DON, and Administrator re-educated all staff on facility abuse policies. Social Services Director, DON and Administrator re-education all staff on abuse prevention and reporting. Corporate will in-service Director of Nursing, Social, Administrator, and ADON on abuse and neglect, by 5/20/2025. Started 5/19/2025. DON and designee educated Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director or designee and care plans will be updated as indicated. Staff will be educated on new interventions either verbally or in written form by the Care Plan Coordinator or designee. Started 5/19/2025 Process will be on going. In the event of any future allegation of sexual abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psych evaluations can be complete. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management. Started 5/19/2025 Process will be on going. The DON and/or administrator will in-service the staff on proper interventions of misconduct and abuse and neglect Started 5/19/2025 In-service will be on going. QAPI meeting will be held monthly, and findings discussed. The DON will monitor the effectiveness of interventions will be ongoing. A pre/posttest on abuse and neglect will be on going starting 5/20/2025. Started 5/20/2025. The facility is still looking for proper placement of resident. Trainings and in-service will be provided to staff before the start of their shift, and ongoing for any PRN, new staff, or staff that has not participated in training. Review the following: Regulation: F-600 (F607) §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Intent §483.12(a)(1) Each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. Highlight the deficient practice and specifics of the citation. Facility Policy and Practice Facility's Action Plan regarding the deficiency. Facility's Policies and Procedures related to the deficiency. Facility's Checklists and Monitoring tools used to verify compliance. Facility's Abuse investigation procedure and documentation process. Record of Training Complete Record of In-service Training and Attendance Form. Be sure that all participants sign in. Monitoring of the POR included the following: Interviews on 5/08/25, 1:20 PM-2:35 PM, conducted with the Administrator, DON, ADON, SSD, MDS Nurse, nurses, CMAs, and CNAs: LVN B (2nd shift), CNC C (1st shift/rotating), LVN E (1st shift), LVN F (1st shift), CNA G (1st shift/rotating), LVN H (3rd shift), RN I (2nd shift), CMA J (2nd shift), CNA K (3rd shift/rotating), LVN L (2nd shift), CNA M (2nd shift), CNA N (2nd shift), and RN O (3rd shift/weekends) indicated they all participated in in-service trainings regarding the facility's policy on abuse/sexual abuse, neglect, and exploitation starting on 5/19/25-5/20/25. All staff were able to identify abuse/sexual abuse, neglect, and exploitation, state when to report it, and who to report it to. All staff were able to state the updated procedure for sexual abuse which included removing any residents who exhibited inappropriate sexual behaviors from the area, placing them on 1 to 1 supervision until further advised, immediately reporting the behaviors to the MD, DON, and family, and following any new orders. The nurses were able to state that all behaviors had to be documented and reported to the DON. The SSD was able to state that she was responsible for monitoring documentation for any changes in residents' behaviors and ensure the care plans were updated and assist in the discharge process as necessary. The Administrator and DON were able to state it was the facility's expectation to identify, report, and investigation any suspected or alleged abuse/sexual abuse, neglect, and exploitation. The Administrator and DON understood it was their responsibility to implement and monitor the effectiveness of interventions put in place. Observation, interview, and record review on 5/20/25, 3:00 PM-4:00 PM, of Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11, who were all at risk for abuse, neglect, and exploitation, revealed no further concerns. Record review of residents' EHRs reflected no concerns for changes in physical, mental, or psychosocial status or a lack in necessary goods and services. Observation of the residents revealed no signs of abuse or neglect. Interviews with residents and/or RPs revealed no concerns for abuse, neglect, or exploitation. Record review of an in-service titled Abuse and Neglect, dated 5/19/25, reflected all staff were educated on the facility's policy on recognizing and reporting abuse and neglect. Record review of an in-service titled Abuse and Neglect, dated 5/19/25, reflected the Administrator, DON, and SSD were educated on implementing the facility's policy to assess, investigate, and report any alleged abuse and neglect. Record review of an in-service titled Sexual Assault, dated 5/20/25, reflected all staff were educated on recognizing and reporting any signs of sexual abuse and inappropriate sexual behaviors. Record review of documents provided by the Regional Nurse Consultant titled Abuse, Neglect, and Exploitation-Pre/Post Test dated 5/20/25, reflected the DON tested all staff over their knowledge on recognizing and reporting abuse, neglect, and exploitation. Record review of a progress note, dated 5/20/25 at 11:25 AM, reflected Resident #1 was connected to psychiatric services to address sexual behaviors. Record review of documents provided by the Regional Nurse Consultant titled [Nursing Facility] QAPI/Corrective Action Pla Meeting, dated 5/20/25, reflected a QAPI meeting was held regarding the correction plan for the facility's deficiency in neglect. Record review of the facility's policy titled Abuse Prevention Program, revised January 2011, reflected in part the following: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. As part of the resident abuse prevention, the administration will: . 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. The Administrator was informed the Immediate Jeopardy was removed on 05/20/25 at 4:34 PM. The facility remained out of compliance at a scope of pattern and severity level of no actual harm with the potential for more than minimal harm that was 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 that each resident received adequate supervision and assistance devices to prevent accidents for one of five residents (Resident #2) reviewed for accidents. -The facility failed to ensure Resident #2 was provided with adequate supervision to prevent the resident from using nonprescription drugs at the facility. On 2/15/25 Resident #2 was found exhibiting signs of an overdose and was transported to the local hospital where he tested positive for marijuana. An Immediate Jeopardy (IJ) situation was identified on 5/19/25. While the IJ was removed on 5/20/25, the facility remained out of compliance at a scope of pattern with a potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for accidents that could lead to serious injury or harm. Findings include: Record review of Resident 2's face sheet, dated 5/16/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: COPD (lung disease), multiple sclerosis (nerve disorder), bipolar disorder (mood disorder) and legal blindness. Record review of Resident #2's Quarterly MDS assessment, dated 5/02/25, reflected he had a BIMS score of 11, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #2 required partial to moderate assistance with most ADLs. The MDS Assessment under Section N-Medications, reflected Resident #2 was prescribed medication under the high-risk drug class which included an antidepressant, diuretic, and anticonvulsant. Record review of Resident #2's progress notes, dated 2/06/25 at 10:01 AM by the SSD, reflected the following: [Social Worker] reached out to [Resident #2's] Parole Officer to inform her that he is bringing drugs into the building to sell to other residents. Record review of Resident #2's progress notes, dated 2/11/25 at 2:36 PM by the SSD reflected the following: [Resident #2] 30-day discharge notice was issued and signed due to lack of facility compliance. Record review of Resident #2's progress notes, dated 2/13/25 at 3:01 PM by the SSD reflected the following: [SSD] spoke with [Resident #2's] [PO]. [PO] shared she would be help to his discharge process and help him look for housing. Record review of Resident #2's progress notes, dated 2/15/25 at 8:00 AM by LVN A, reflected the following: [LVN A] was notified by staff that [Resident #2] is not acting like himself. This nurse assessed [Resident #2] and observed resident with the following symptoms: Weakness abnormal from baseline with moments of limpness noted to both sides of body, pinpoint pupils, Confusion, difficulty talking and supporting self on the side of the bed. [Resident #2] asked by staff if he's taken any new medications or anything not prescribed by current MD, resident shook his head no. MD notified new order to send resident out to ER for further evaluation. This nurse attempted to contact RP and LVM [sic]. [Resident #2] transferred to [local hospital] MD aware. Record review of Resident #2's hospital records, dated 2/15/25, reflected in part the following: Today's Visit (continued) Reason for Visit: Drug / Alcohol Assessment Diagnosis: Bladder infection . Labs: Marijuana (Cannabinoid)- Positive . Record review of Resident #2's progress notes, dated 2/17/25 at 9:57 AM by the SSD, reflected the following: [SSD] reached out to [Resident #2's] [PO] to inform her of his resent [sic] drug overdose hospital visit. Record review of Resident #2's care plan, dated 2/20/25 , did not reflect a care plan for the resident's behavior related to substance abuse. Record review of Resident #2's consolidated physician orders, dated 5/20/25, reflected in part the following: -Gabapentin Capsule 300 mg-give 3 capsule by mouth three times a day for nerve pain give (3) 300 mg caps to equal 90 mg. Start date: 5/16/25. -Hydrocodone-Acetaminophen Tablet 7.5-325 mg-give 1 tablet by mouth three times a day for pain. Start date: 5/15/25. -Tylenol Oral Tablet 325 mg (Acetaminophen)-give 2 tablets by mouth three times a day for pain. Further review of this document reflected Resident #2 did not have an order for medical marijuana. Interview on 5/16/25 at 11:45 AM, Resident #10 stated he was the Resident Council President at the facility. He stated there was a lot of talk going around the facility about residents bringing in drugs to use and give to other residents. Resident #10 stated it was never said which resident was bringing drugs into the facility. Resident #10 stated he often smelled marijuana in the facility. He stated the Administrator and DON were aware of this problem. In an interview on 5/16/25 at 12:35 PM with the Administrator and DON, they both stated being aware of concerns the residents were using drugs in the facility. The Administrator stated during a smoke break about a week ago there was a smell of marijuana, and he gave staff permission to stop the smoke break that day, and there had been other reports of marijuana being smelled . The Administrator stated he had never seen marijuana in the facility and the smell could be coming from anywhere in the area. The DON stated there was a day a package arrived at the facility for Resident #3 that had to be signed for, and Resident #3 admitted there was THC in the package, but it was for her family. The DON stated the package was not accepted at the facility and it was not opened to confirm if it was THC. The Administrator stated Resident #3 used a vape that she was very protective of and would become verbally aggressive towards staff when questioned about it. The Administrator stated he did not know what was in the vape and could not violate Resident #3's rights by searching her belongings . The Administrator and DON both stated they were not aware of any concerns for staff using or bringing illegal drugs into the facility. The Administrator stated all staff were drug tested upon hire. They stated if there were drugs in the facility, they were unsure how it was getting in. The Administrator stated they had several residents who went out into the community. The DON stated if residents showed any obvious s/sx of drug use they would be sent out to the hospital for a drug screening. The Administrator stated he did not initiate an investigation or report to the state agency when marijuana was smelled during the smoke break or when Resident #3 admitted to having THC delivered to the facility. He could not state why he did not investigate or report these incidents. In an interview on 5/16/25 at 1:35 PM, Resident #3 stated she had concerns about residents using drugs in the facility that was being brought in by staff and other residents. She stated the Administrator and DON were aware and were not doing anything about it. Resident #3 stated she had a meeting with the Administrator, DON, and SSD on 5/12/25 where she expressed all her concerns, which included the drugs in the facility, and nothing had been done yet. She stated she had a package delivered to the facility that contained THC that she ordered from a local smoke shop, but it was not for her. Resident #3 stated she was going to visit family and was going to give it to them, but the facility did not allow her to get the package. She stated she knew it was wrong to have the package delivered to the facility, but they allowed everything else. She stated she would not order THC to the facility again. In an interview on 5/16/25 at 2:09 PM, the SSD stated to her knowledge, the DON addressed the drug issue that was brought to their attention by other residents. The SSD stated there were residents in the facility who were on parole and must complete drug screenings. She stated Resident #2 was on parole for a sex offense and drug use. The SSD stated the parole officers informed the facility of any failed drug screenings. The SSD stated Resident #2 failed a drug screening on 2/11/25 and his PO was informed he would be discharged from the facility for bringing drugs into the facility. She stated Resident #2 had already failed a drug screening that was positive for marijuana on 2/06/25. The SSD stated the facility was trying to find a facility for Resident #2 to transfer to, but it was difficult due to his background. In an interview on 5/16/25 at 2:15 PM, Resident #11 stated there was always the smell of marijuana in the facility and residents would do other drugs like methamphetamines. Resident #11 stated she could tell by the smell what type of drug was being used. Resident #11 stated it mostly happened during smoke breaks and sometimes in resident rooms, and she just tried to stay away from it. Resident #11 stated she reported her concerns to the DON; however, it was still going on. She stated the residents were supposed to be drug tested if they were suspected of using, but they would refuse, and the nurses would not force them to do it and would just let it go. Attempted interview on 5/16/25 at 4:32 PM with LVN A, who worked with Resident #2 when he was sent out to the hospital on 2/15/25, was unsuccessful due to no response to call. Callback information was left on the voicemail. In an observation and interview on 5/19/25 at 9:14 AM, Resident #2 was well-groomed, alert and oriented, and showed no s/sx of drug use or intoxication. Resident #2 stated he ended up at the local hospital on 2/15/25 due to his stupid ways of using drugs. Resident #2 admitted to using marijuana. Resident #2 stated he had a long history of heavy drug use but stopped and had only been using marijuana sometimes. Resident #2 stated he had been clean since because his PO found out about the incident, and it risked him going back to prison and it caused the MD to take him off his pain medication temporarily. Resident #2 stated residents were always bringing drugs into the facility, but he did not state who. He stated the staff were also aware drugs were being brought into the facility. Further interview on 5/19/25 at 3:00 PM with the Administrator and DON, the DON stated she was aware of Resident #2 being sent out to the local hospital after showing signs of drug use and failing his drug screening. The DON stated the MD discontinued all of Resident #2's pain medication and put in a standing order to drug screen any resident who exhibited s/sx of drug use. The DON stated she did not drug test any residents the day it smelled like marijuana during the smoke break and could not state why. She also stated staff were not in-serviced on recognizing s/sx of drug use and reporting it after the incidents. The Administrator stated the facility was waiting on Resident #2's PO to find placement for him. He stated the PO informed he was either going to find another facility or Resident #2 would go back to jail. The Administrator stated the facility was waiting on the PO to find something since the incident happened on 2/15/25. The Administrator stated not addressing the concerns for drug use at the facility or implementing effective interventions could place residents at risk of being able to obtain and use drugs at the facility that could cause serious harm . Record review of the facility's, undated, policy titled Illegal Drug Use, reflected in part the following: Policy: This facility is an illegal drug-free facility. Illegal drugs are defined for the purpose of this policy as the use, possession or distribution of any substance which is unlawful under the Controlled Substances Act. This facility reserves the right to inspect staff only areas, conduct staff alcohol and drug testing, and terminate staff employment for violation of this policy. Policy Explanation and Compliance Guidelines: 1. No one is allowed to possess, be under the influence of, or use any of said illegal drugs on the premises of this facility. 2. No one is allowed to sell, buy, transfer, distribute or use said illegal drugs on the premises of this facility. 3. No one is allowed to sell, buy, transfer, distribute or use any drug paraphernalia on the premises of this facility. 4. Anyone that is under a physician's care and requires the use of prescription or over-the-counter drugs must follow these rules: a. Use prescription drugs only if a licensed health care provider has prescribed them within the last year. b. Directions must be followed as written by the physician. c. Prescribed drugs must be in the original container. 5. The facility reserves the right to consult with said physician if prescription or over-the counter drugs create risk. 6. All facility staff that enter the facility may be subject to an investigation of substance abuse to include tests that detect the use of alcohol or any substance which is unlawful under the Controlled Substance Act . This was determined to be an Immediate Jeopardy (IJ) on 05/19/25 at 3:22 PM. The Administrator and DON were notified. The Administrator was provided with the IJ template on 05/19/25 at 3:25 PM The following Plan of Removal submitted by the facility was accepted on 05/20/25 at 1:32 PM: [Nursing Facility] F689 IJ plan of removal The facility failed to ensure Resident #2 received adequate supervision to prevent a serious accident when the resident went to the hospital on 2/15/25 and was found to have marijuana in his system, after the facility was made aware that he was bringing nonprescription drugs into the facility. 1. Resident #2 was assessed and found to not have any signs or symptoms of current drug use. Date completed 5/19/25. MD was notified of the use of illegal drugs related to the past incident. Resident was drug tested on [DATE]. Drug test was negative. 2. All residents have the potential to be affected although no other residents have been affected. 3. All residents will be in-serviced on the facility policy regarding illegal drug use. (5/20/2025). All residents will be assessed upon return from any leave from the facility to look for signs and symptoms of illegal drug use to include limpness on both sides of body, pinpoint pupils, confusion, and difficulty talking. All nursing staff will be in-serviced to perform and document the assessment upon return and if any signs and symptoms are noted the Administrator and DON will be notified, and the facility will follow the illegal drug use policy. 5/20/2025 4. The DON/designee will monitor the documentation for each resident return to ensure the assessments are complete. This will be completed on 5/20/25. 5. Resident is still being discharged pending acceptance. 6. The DON/designee will monitor the effectiveness of assessments completed of residents . 7. QAPI meeting will be held monthly, and findings will be discussed. 8. A pre/posttest will be completed by staff on signs/symptoms of drug use Completion 5/20/2025 and ongoing. 9. Trainings and in-service will be provided to staff before the start of their shift, and ongoing for any PRN, new staff, or staff that has not participated in training. Monitoring of the POR included the following: Interviews on 5/08/25, 1:20 PM-2:35 PM, conducted with the Administrator, DON, ADON, SSD, nurses, CMAs, and CNAs : LVN B (2nd shift), CNC C (1st shift/rotating), LVN E (1st shift), LVN F (1st shift), CNA G (1st shift/rotating), LVN H (3rd shift), RN I (2nd shift), CMA J (2nd shift), CNA K (3rd shift/rotating), LVN L (2nd shift), CNA M (2nd shift), CNA N (2nd shift), and RN O (3rd shift/weekends) indicated they all participated in in-service trainings regarding the facility's drug policy and recognizing and reporting any s/sx of drug use in residents and staff starting on 5/19/25-5/20/25. All staff were able to state drugs were not tolerated at the facility by staff or residents, and residents could only have drugs and alcohol if ordered by the MD and administered by a nurse. All staff were able to state residents would be monitored for s/sx of drug use in general and when they went out into the community and returned to the facility. All staff were able to provide s/sx of drug use and stated if residents exhibited any of the s/sx it would be reported to the charge nurse and administration immediately. The nurses were able to state s/sx of drug use and residents who exhibited any s/sx would be assessed and the MD, DON, Administrator, and family would be notified, and any new orders followed. The nurses were able to state all assessments and incidents would be documented . The DON stated there was a town hall meeting held with the residents to educate them on the facility's drug policy. The Administrator and DON understood it was their responsibility to implement and monitor the effectiveness of all interventions put in place. Observation, interview and record review on 5/20/25 from 3:00 PM-4:00 PM, of Residents #2, #3, #4, #6, and #7, who were all at risk for accidents due to inadequate supervision. Record review of residents' EHRs reflected no concerns for changes in physical, mental, or psychosocial status or concerns for the potential of accidents that could cause serious injury. Observation of the residents revealed no s/sx of drug use, intoxication, or harm from inadequate supervision. Interviews with residents and/or RPs revealed no concerns for inadequate supervision or harm. Further interview with the residents revealed they were aware of the facility's drug policy and understood illegal and nonprescription drugs were not allowed at the facility. Record review of an in-service titled Illegal Drug Use, dated 5/19/25, reflected all staff were educated on the facility's drug policy and on recognizing and reporting any s/sx of drug use in residents and staff. Record review of an in-service titled Assessment of signs and symptoms of drugs, dated 5/20/25, reflected the DON, ADON, and all nurses were educated on recognizing, assessing for, and reporting any s/sx of drug use. Record review of documents provided by the Regional Nurse Consultant, titled F689-Pre/Post Test, dated 5/20/25, reflected all staff were tested over their knowledge on recognizing and reporting s/sx of drug use. Record review of documents provided by the Regional Nurse Consultant titled [Nursing Facility] QAPI/Corrective Action Plan Meeting, dated 5/20/25, reflected a QAPI meeting was held regarding the correction plan for the facility's deficiency in quality of care. Record review of document provided by the Regional Nurse Consultant, dated 5/20/25, reflected Resident #2 had a negative drug screening. The Administrator was informed the Immediate Jeopardy was removed on 05/20/25 at 4:34 PM. The facility remained out of compliance at a scope of pattern and severity level of no actual harm with the potential for more than minimal harm that was 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 residents had the right to be from abuse for 1 of 4 residents (Residents #1) reviewed for abuse. The facility failed to protect Residents #1 from a physical and verbal altercation on 01/22/25 with the Administrator. The Administrator pushed Resident#1, causing Resident#1 to fall. The incident was not reported or documented until after surveyor intervention on 01/23/25.The Administrator was not suspended until 01/23/25 at approximately 11:30 AM. An IJ was identified on 01/23/25. The IJ template was provided to the facility on [DATE] at 5:15 PM. While the IJ was removed on 01/25/25, the facility remained out of compliance at a scope of Isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems . This failure placed residents at risk of subsequent abuse, mental anguish, and emotional distress. Findings included: Record review of Resident #1's face sheet, dated 01/23/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Schizophrenia (Serious mental health condition that affects how people think, feel and behave), Type 2 Diabetes Mellitus with Diabetic, Unspecified Psychosis not due to substance or known major depressive disorder. Record review of Resident #1's Quarterly MDS assessment, dated 10/28/24, reflected Resident #1 had a BIMS of 12, which indicated cognition moderate impaired. Record review of Resident #1's care plan, revised 09/20/24, revealed the resident at risk for altered status due to a traumatic life experience while at a previous group home or [Nursing Facility]. Certain male figures in authority positions, with similar physical attributes or appearance at times trigger him. Interventions in place included: Administer medication as ordered, approach resident from the front and speak in a calm, unhurried manner .Identify cause/trigger for behavior and reduce factors that may provoke resident .Call [Family Member#1] if need to calm down or get him to comprehend the situation] . Record review of Record review of Psychological Services Progress Note, dated 10/08/24and completed by Psy services reflected, Resident#1 was negative for Trauma Informed Care. Record review revealed no incident/accident report was completed about the incident on 01/22/25. Record review of Resident#1 progress noted dated, 11/01/23 to 01/22/25 reflected: Resident#1 had other incidents with other staff but not the Administrator. Record review of Resident#1 progress notes revealed no documentation about the incident on 01/22/25. Record review of Resident#1 assessments revealed no documentation about incident on 01/22/25. Record review of Resident#1 incident provided to surveyor on 01/25/25 reflected: it was initiated on 01/22/25 with no completed/ locked date on the incident report. Incident description section reflected: This [LVN K] was notified by staff after the incident that [Resident#1] slapped [MA N] and physically attacked Administrator and [Resident#1] fell to the floor. Resident description reflected: [Resident#1] stated he was approached by Administrator, in what he felt was an aggressive manner so I just swung on his . Immediate action taken section reflected: [Resident#1] assessed for injuries. None noted, denied pain or any discomfort. Physician notified, In the agencies/people notified section reflected: no notification found, An interview on 01/23/25 at 10:20 AM Family Member#1 approached surveyor at the facility and stated the Administrator fought [Resident#1] last night. Family Member#1 stated that was wrong and he is elderly. Family Member#1 stated the Administrator was always picking on him when Resident#1 wanted to play his piano. Resident#1 did not speak to the Administrator when the Administrator would try to speak to him An in-person interview on 01/23/25 at 10:45 AM, the Administrator and MA N entered the conference room to explain the incident on 01/22/25. The administrator stated Resident#1 assaulted a medication aide around 7pm on 01/22/25. The Administrator stated the medication aide and himself went to Resident#1s room. Resident#1 was asked why he hit the medication aide. The Administrator stated Resident#1 started punching and kicking the Administrator and made threats. The Administrator stated he put his hands up to protect himself. The Administrator stated Resident#1 tripped over his own leg and fell. The Administrator stated [CNA J], [CNA L] and [LVN P] intervened and pulled Resident#1 away. The Administrator stated he was told by Resident#1 and Family member that he reminded Resident#1 of males from his past that made fun of him and were aggressive towards him because he was gay. The Administrator stated it did not have to be reported because it was an altercation between staff and a resident. An interview on 01/23/25 at 10:45 AM, MA N stated Resident#1 took snacks off the snack tray and hit MA N's face when she asked him what he was doing. MA N immediately reported to the Administrator who went to Resident#1 to ask what happened and Resident#1 hit the Administrator. An interview on 01/23/25 at 11:00 AM, the DON stated she was not made aware of the incident until after 10:15 AM on 01/23/25 when Resident#1 family member came into her office. The DON immediately called her nurse consultant and informed her of the situation. An interview and observation on 01/23/25 at 11:05 AM of the camera in the Administrator office with the PD revealed, Resident was punching and kicking the Administrator. The Administrator open hand pushed Resident#1 face area and caused Resident#1 to fall. Observed a linen cart pushed between the Administrator and Resident#1. Observation of additional staff stepped in between Resident#1 and Administrator. Staff were observed holding the Administrator back and grabbing Resident#1. PD stated an incident would be put on file but no arrest or charges because the resident started the altercation. Surveyor did not recall observing a date and time on the footage. An interview on 01/23/25 at 11:30 AM, Ombudsmen stated she had not been notified about the physical altercation between the Administrator and Resident#1. An over the phone interview on 01/23/25 at 1:30 PM the Corporate Operations Manager and Nurse Consultant stated they were not made aware of the abuse allegation until 1/23/25 at approximately 10:30 AM. The Administrator (Abuse coordinator) was asked to go home until the investigation was completed. Both stated it did not have to be reported to State since there was not an allegation of abuse at the time of the incident. Operations Manager stated that is the company policy for all that when an investigation of abuse had been reported the staff member would be suspended until the investigation was completed. Corporate Operations Manager and Nurse Consultant both stated the Administrator was suspended until the investigation was completed. Both stated there was no risk to residents, as soon as they found out about the incident the facility took immediate action. An interview with Resident#1 on 01/23/25 at 2:15 PM he stated he would not feel safe in the facility if the Administrator returned. Resident#1 stated the Administrator hit him and he hit him back. An interview on 01/23/25 at 4:11PM CNA J stated it was chaos in the hallway and he did not see how the incident started. CNA J stated he saw Resident#1 kicking and hitting the Administrator. CNA J stated he tried to intervene but did not want to get hit by Resident#1 so, he pushed a linen cart between them. CNA J stated he did not see how the resident fell. CNA J stated he grabbed Resident#1 and took him outside to smoke. An interview on 01/23/25 at 4:20 PM LVN P stated he witnessed Resident#1 swinging both of his arms towards the Administrator LVN P stated they separated Resident#1 and the Administrator. An interview on 01/24/25 at 4:30 PM CNA L stated Resident#1 was kicking and hitting the Administrator in the hallway. CNA L stated he did not see how Resident#1 fell but, he jumped back up and continued to attack the Administrator. CNA L stated the Administrator and Resident#1 were separated. An interview on 01/24/25 at 4:50 PM DON stated the Administrator who is the abuse coordinator is responsible for completing and reporting investigation to corporate and State office. DON stated while the Administrator was suspended, she would be responsible. Record review of facility policy titled; Usual Occurrence Reporting revised 12/07 reflected: H. Other occurrences that interfere with facility operations band affect welfare, safety, or health of residents, employees or vistors.2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations. Record review of facility policy titled; Abuse, Neglect, Exploitation or Misappropriation-Reporting and investigating revised 09/22 reflected: All reports of resident abuse . Are reported to local state and federal agencies add (current regulations) is thoroughly investigated by facility management . findings of all investigations are documented and reported . Policy interpretation and inflammation reporting allegations to the administrator and authorities upon receiving any allegations of abuse the administrator is responsible for determining what actions (if any) are needed for protection of residents . Investigation allegations 1. all allegations are thoroughly investigated the administrative initiates investigations any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete . 9. the investigator notifies the ombudsman that in abuse investigation is being conducted the ombudsman is invited to participate in the review process B. the ombudsman is notified of the result of the investigations as well as any corrective measures taken . follow up report #1 within 5 business days of the incident the administrator will provide a follow-up investigation report direct action number one all relevant professional and licensing boards are notified when an employee is found to have committed abuse #2 if the investigation reveals that the allegations of abuse are founded the employee is terminated #3 any allegations of its view in our files in the huge employees personal records along with any statement by the employee disputing the allegation if the employee chose make one . The Director of Nursing was notified that an Immediate Jeopardy situation was identified and record review request of ANE policy due to the above failure and provided with the Immediate Jeopardy template on 1/23/25 at 5:15 PM. A Plan of Removal was requested. The facility's Plan of Removal was accepted on 1/24/2025 at 1:50 PM and included: Plan of Removal: 1. Immediate action(s) taken for the resident(s) found to have been affected include: Resident # 1 was assessed by the Nurse on 1/22/25 . A thorough investigation was initiated by the Corporate Office and Director of Nursing Services. The Medical Director was notified by the DON at 3:33pm and The DON called and left a message for the Ombudsman 1/23/25, at 5:30PM. The RP was notified on 1/22/25 by the Administrator. The accused Team Member was placed on Administrative Leave pending investigation. The Police Department was called and arrived at the facility. The Incident Report was completed on 1/23/25. The SIMS was initiated on 1/23/25 at 2:30pm. In-services have been done by the DON for: Completing Incident reports, Notifications to MD/Ombudsman, Reporting Abuse/Neglect, Abuse Policy including timeline for reporting and What to do When a Team Member is accused (investigation requires for Team Member to be placed on Administrative Leave until the investigation is concluded). De-escalation of aggressive behaviors and resident to staff altercations. The Post Test will be administered by the DON/designee after education is completed. Staff are required to pass at least 80%. Staff who do not achieve 80% passing rate will be re-educated and will retake the test. TEXAS Abuse hotline number, [PHONE NUMBER] posted in strategic areas within the facility, staff made aware of postings. 2. Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents have the potential to be affected. Supervisor Rounds have been started and will be completed by 1/24/25 to interview residents for issues related to care, respect and dignity. The rounding will be done by the Supervisors and the monitoring will be completed on the Supervisor Daily Rounds form. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: An in-service education program was conducted by the Director of Nursing Services and the Assistant Director of Nursing with all staff addressing circumstances that require reporting including appropriate timeframes, reporting to the Corporate Office, reporting to the Ombudsman, timely completion of Incident Reports and SIMS reports and policy regarding Team Member involvement will be completed by 1/24/25. The Corporate Nurse Team will conduct a Zoom meeting at 10 am on 1/24/25 with [Facility] Director of Nursing. The purpose of the in-service is to provide education for the following areas: Our Abuse/Neglect Policy as it relates to Reporting Timelines to Corporate/State/Law Enforcement/Ombudsman/Medical Director Steps to take when a Team Member is involved or is allegedly involved-Contact Corporate HR and place on Administrative Leave pending investigation of Abuse. Conducting Education and Training with all Departments Follow up and Monitoring that is required such as Rounding on Halls, Talking with Residents and Staff, Re-education with Staff to help Ensure There is No Breakdown in Communication Five day follow up with the State Office 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Director of Nursing Services, or designee, will conduct a random audit of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any incidents or injuries are identified, properly investigated and reported to the appropriate entities. Findings of this audit will be reviewed in the Resident Council meetings. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time the IDT determines consistent substantial compliance has been met. On 1/25/25 beginning at 3:00 PM the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of pre/posttest had been completed by1st, 2nd and 3rd shift nursing staff on ANE. Record review of Director of Nursing in-services by the Nurse on ANE Record review of the Administrator profile reflected, the Administrator was hired on 11/27/23 and terminated on 01/24/25. An observation of the facility on 01/25/25 at 2:00 PM revealed 1-800 HHSC hotline number for abuse was posted at the entry of the facility, social workers door, display board in hallway and employees break room. All staff were able to provide competency regarding in-service over ANE. All staff were able to provide policy, procedure, protocols, appropriate interventions, and when and who to report abuse to. All staff were to provide an example of ANE. Staff interviewed on 01/24/25 between 9:00 AM to 2:00 PM CNA A, CNA B, LVN C (overnight shift) and CNA G, CNA H, LVN I (1st shift) and CNA J, CNA L LVN K, RN O, LVN P (2nd shift). Staff interviewed on 01/25/25 3:40 AM to 3:00 PM: CNA D, CNA E, LVN F, RN N (Weekend shift) and laundry aide M. An interview on 01/25/25 at 3:45PM the Director of Nursing stated she was in-serviced by the Corporate Nurse on 01/24/25 at 10:00 AM. The Director of Nursing stated she is currently the abuse coordinator. The Director of Nursing stated staff have been in-service and pre/posttest have been completed. The Director of Nursing was informed the Immediate Jeopardy was removed on 01/25/25 at 3:00 PM the facility remained out of compliance at a scope of potential of minimum harm and a severity level of isolated, due to the facility's need to evaluation the effectiveness of the corrective systems. An interview on 02/12/25 at 9:30 AM, Resident#1 stated that he was doing good and did not have any concerns and wanted to stay at the facility. An over the phone interview on 02/12/24 at 9:52 AM Family member stated she was going by what [Resident#1] told her (Previous admin would tell him to stop playing his piano and pick on him that way.). Family member stated the previous Administrator [Current facility] favored someone from [Resident#1] past, but the sister did not know exactly who and people in general would make fun of [Resident#1] because he was gay. Family member stated he was previously, in a group home and wanted to stay there but, he could not care for himself. Since, previous admin is gone there has not been any more issues. Family Member stated he came from a group home, and he was happy there and did not want to leave. Attempted to call PCP on 02/13/24 at 9:27 AM Attempted to call Psy services on 02/13/24 at 9:52 AM An observation and interview on 02/13/25 at 11:30 AM Resident#1 stated [Name] the Administrator hit him last week and he did not know why. Surveyor asked Resident#1 if he knew the previous Administrator name at the current facility that he stayed at and he said that was [Name] Resident#1 stated he felt safe and did not have any concerns. Record review of Psy Subsequent assessment dated [DATE] and completed by Psy services reflected, The provider asked the patient to tell him what transpired since the last few days. The patient replied nothing happened. The provider reframed the question and asked the patient if he had any altercation with anyone in the facility a few days ago. He replied someone pushed me. The provider asked the patient how the incident happened or what prompted the altercation. He replied, I do not know . Record review of Psychological Services Progress notes dated ,01/30/25 on Resident#1 completed by Psy services reflected, Resident#1 was negative for Trauma Informed Care. The Director of Nursing was informed the Immediate Jeopardy was removed on 01/25/25. The facility remained out of compliance at a scope of actual harm and a severity level of isolated, due to the facility's need to evaluation the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observations and record review, the facility failed to ensure 1 (Resident#3) of 4 residents received adequate supervision and assistance devices to prevent accidents. The facility failed to provide Resident#3 with adequate supervision on 01/20/25 when he eloped from the facility. The non-compliance was identified as past non-compliance (PNC). The IJ began on 01/20/25 and ended on 01/20/25. The facility had corrected the non-compliance before the state's investigation began. These failures could affect all residents at risk of elopement. Findings included: Record review of Resident #3's face sheet dated 01/23/25 reflected Resident #3 was a [AGE] year-old male and was originally admitted to the facility on [DATE]. Resident #3 was readmitted to the facility on [DATE]. Resident #3 was diagnosed with Hyperlipidemia (high levels of lipoproteins in the blood), Schizophrenia (Serious mental health condition that affects how people think, feel and behave) -unspecified, Depression (mood disorder that cause persistent feeling of sadness and loss of interest) -unspecified, anxiety disorder(Repeat episodes of sudden feelings of intense anxiety and fear) (-unspecified, Parkinsonism-unspecified, Epilepsy (A neurological disorder that causes seizures or unusual sensations )and behaviors unspecified. Record review of Resident #3's quarterly MDS assessment, dated 01/03/25, reflected his BIMS score was 08, which indicated moderate cognitive impairment. Record review of Resident #3's care plan, dated 05/09/24, reflected no wandering behaviors. Record review of Resident#3 incident report dated 01/20/25 reflected: night [CNA A] noticed the resident is not in building, notify the nurse. The nurse called code yellow and all staffs in the building looking for resident inside the building and in the smoke patio. Unable to locate resident. Notify Administrator, DON, and all management directors. Call 911 and notify PD of missing resident. Notify [Family Member] of resident. Instructed some of the staff to go outside and look in the surrounding area. Police came to the building to talk to the staff. One of the [CNA A] found resident and brought him back to the building. Resident was shivering and skin very cold to touch .Police immediately called 911 .transfer resident to ER. Record review of Hospital records dated, 01/20/25, reflected: Resident#3 was coughing, sneezing, shivering and had an oral temperature of 99.7 [Resident #3] blood pressure was elevated. [Resident#3] was diagnosed with a viral upper respiratory infection. In an interview on 01/24/25 at 12:55 PM ADON stated she had clocked in 5 minutes to 6:00 AM. She overheard the overnight [CNA A] state he could not find a resident. ADON asked who? and when was the last time he was seen? [CNA A] stated to ADON that Resident#3 was coming in and out of his room and the last time he saw him was at 5:10 AM. The ADON stated she called a yellow code. Staff started looking everywhere inside and around the building and he could not be located. The ADON sent out a text to management team, she called 911, called the Resident#1 family members. The ADON talked with DON over the phone. [CNA A] found Resident#1 outside not too far from the facility. The ADON stated Resident#3 looked very cold, was shivering and he would not talk. ADON Instructed staff to put blankets on him. The DON was in the facility and was on the phone with the Administrator. The police arrived at the facility and called 911. The EMT transported Resident#3 to the ER. The ADON stated when she came in, she did not hear any alarms going off. Record review of temperatures on January 20, 2025, reflected: Temperatures at 6:00 AM range from 23 to 21 degrees. In an interview over the phone on 01/25/24 at 3:50 AM CNA A and CNA B stated Resident#3 was up walking around at 4:30 AM. Resident#3 tried to urinate in the trash at the nursing station and they walked him back to his room to use the bathroom. He did not want to go and continued to walk around. CNA's started last rounds at 5:10 AM. CNA B stated she could not find Resident#3. CNA A and CNA B searched the building for Resident#3. CNA A stated about 5:45 AM the ADON was made aware that Resident#3 was missing. CNA B stated staff searched outside and got in their cars to look for Resident#3. CNA A stated he was concerned for Resident#3 because he was barefoot, did not have a jacket on and it was cold. CNA A had to leave the facility at 6:45 AM. CNA A found Resident#3 three blocks from the facility. CNA A stated Resident#3 did not have any aggressive behaviors when he was asked to come back to the facility. CNA A transported Resident#3 to the facility. In an observation on 01/24/25 at 4:30 PM all exits doors were checked to ensure they were working properly. Three random residents with wander guards and Resident#3 wander guard was checked to ensure they worked properly. The non-compliance was identified as past non-compliance (PNC). The IJ began on 01/24/25 and ended on 01/25/25. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review of incident/accident reports, from 11/01/24-01/23/25, reflected no other elopements. Record review of in-service titled Elopement, dated 01/20/25, reflected all staff were educated by the DON on elopement protocol and code yellow. Record review of Residents #3, EHR revealed his care plans and TAR were updated and had interventions to address all care needs. Record review of service invoice dated, 01/20/25 reflected: both side exits, and back exit was operating fine and egressing a timely manner. The front door, however, would stop annunciating after the egress had been activated .adjusted the dip switches in lock and tested to verify that it was annunciating after egressed. All systems are normal. Record review of Resident #1's care plan, revised 01/20/25, reflected Resident#3 had an elopement on 01/20/25. Interventions included: alert staff to wandering behaviors, check wander guard was properly working every shift by taking to the door if not properly working notify DON and replace the wander guard, in-service staff elopement risk, monitor and document behavior, send to ER for evaluation, skin check every shift to area wander guard is in place and wander guard in place when [Resident#3] returns from ER (wander guard to right ankle). Staff interviewed on 01/24/25 between 9:00 AM to 2:00 PM CNA A, CNA B, LVN C (overnight shift) and CNA G, CNA H, LVN I (1st shift) and CNA J, CNA L LVN K, RN O (2nd shift). Staff interviewed on 01/25/25 3:40 AM to 3:00 PM: CNA D, CNA E, LVN F, RN N (Weekend shift) and laundry aide M. All staff were able to provide competency regarding in-service over elopement. All staff were able to provide policy, procedure, protocols, appropriate interventions, and when and who to report elopements to. All staff were to provide an example on what to do if a resident eloped. Record review of the facility's policy titled Wandering and Elopements revised 03/2019 reflected: 3. If a resident is missing, initiate the elopement/missing resident emergency procedure: b. If the resident was not authorized to leave, initiate a search of the building(s) and premises. c. If the resident is not located, notify the Administrator and the Director of Nursing, the resident's legal representative, the attending physician, law enforcement officials. 4. When the resident returns to the facility, the Director of Nursing services or charge Nurse shall: A. Examine the resident for injuries. E. Complete and file an incident report F. Document relevant information in the resident's medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to immediately consult with the resident's physician and notify the resident representative when there was a significant change in the resident's condition or need to alter treatment significantly for one (Resident #1) of five residents reviewed for change of condition. -The facility failed to notify Resident #1's physician and responsible party when the resident had a fall on 3/27/24 and when the resident showed signs of increased lethargy and altered mental status as the week progressed. An Immediate Jeopardy (IJ) was identified on 04/22/24. An IJ Template was provided to the facility on [DATE] at 1:28 PM. While the Immediate Jeopardy was removed on 04/23/24 at 02:02 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place all residents at risk of not receiving immediate medical attention when there is a change in their condition. Findings included : Record review of Resident #1's face sheet, dated, 04/02/24, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: encephalopathy (change in brain function), sickle cell (blood disorder), type II diabetes, cerebral infarction (stroke), and cirrhosis of liver (chronic liver damage). Record review of Resident #1's EHR revealed she did not have a completed admission MDS assessment. Further review revealed Resident #1 had a BIMs of 11 which indicated moderate cognitive impairment. Record review of Resident #1's baseline care plan, dated, 03/27/24, revealed the resident's level of consciousness was lethargic and she was cognitively impaired. Record review of Resident #1's consolidated admitting orders, dated 3/25/24, reflected an order to make the family/resident/responsible party aware of the resident's conditions. Further review reflected a lack of documentation of an order to make the MD aware of Resident #1's conditions, besides new onset symptoms of COVID-19. Record review of Resident #1's discharge hospital records (prior to admitting to [nursing facility]), dated 3/11/24-3/25/24, reflected the following: Progress note at 3/14/24 1:30 PM: . Assessment/Plan: . -Place NGT if [Resident #1] is lethargic and is unable to take PO. . Discharge Summary at 03/25/24 7:06 PM: Principle Final Diagnosis: Acute hepatic encephalopathy . Test results pending at discharge: none. Follow-up appointments: none Summary of hospital course: Hepatic encephalopathy Known history of cirrhosis secondary to alcohol abuse . Physical therapy and occupational therapy consulted, recommending SNF. [Resident #1] was improving but 03/19/24 worsening in mental status; oriented to person only. Repeat ammonia on 03/20/24 up to 178. . Mental status has now returned to [Resident #1] baseline. . Therapeutic diet, encourage PO intake. . Further review of discharge hospital records reflected no documentation that ammonia levels were rechecked on 03/20/24 or prior to discharge. Record review of Resident #1's hospital records, dated 3/31/24, reflected the following: [Resident #1 is a [AGE] year-old female with history of CKD, cirrhosis (liver damage), encephalopathy (change in brain function), CVA (stroke), diabetes, hypertension (high blood pressure), who presents via EMS from nursing home due to altered mental status and facial droop. Per EMS, [Resident #1] is GCS (scale that assesses consciousness) 15 (mild brain injury) at baseline and able to speak and follow commands. Last known normal was 2 days ago per EMS until noticing change in neurological status today. [Resident #1] was recently admitted on [DATE] for hepatic encephalopathy (loss of brain function due to liver damage). . Laboratory Results: . Ammonia, plasma-205 umol/L (severely elevated) . Imaging results (CT head): 1. No acute intracranial abnormality. Chronic atrophic and chronic ischemic changes (brain damage), similar to the prior. In an interview on 04/02/24 at 9:48 AM, Resident #1's family member stated Resident #1 admitted to the facility after being in the hospital for about two weeks where she was being treated for complications related to her diabetes to her knowledge. The family member stated Resident #1 was visited at the facility on 03/30/24 by another family member and they were upset because Resident #1 did not look good, and staff reported she had been sleeping a lot more. The family member stated she had not been informed of a change in Resident #1's condition by the facility. The family member stated Resident #1 had a fall on 03/27/24 and they were informed of that by the roommate. In an interview on 04/02/24 at 10:48 AM, RN A, who worked at the local hospital, stated Resident #1 was previously admitted to the hospital from [DATE]-[DATE] for altered mental status and hyperglycemia (high blood sugar), and returned to the hospital on [DATE] with similar symptoms. RN A stated Resident #1 returned with altered mental status, encephalopathy (change in brain function), and critically high levels of ammonia from liver failure. RN A stated Resident #1 has been sleeping and nonverbal since admitting and had to get a nasogastric tube placed to receive nutrition and medication. RN A stated Resident #1's CT scans only showed evidence of past stroke with no new changes. In an interview on 04/02/24 at 10:48 AM, LVN B stated she worked at the facility since 02/2024. She stated she worked weekdays, 6am-2pm, and worked with Resident #1. LVN B stated she worked with Resident #1 on the day she was admitted , and Resident #1 was alert x 2 (only aware of person and place) and could respond to her name and answer yes/no questions. LVN B stated Resident #1 was confused and required assistance with eating as she would not initiate eating or drinking on her own. LVN B stated Resident #1 always seemed to have low energy and did not speak most of the time, but one morning during rounds she heard Resident #1 saying she was hungry and wanted a hotdog. LVN B stated she was the nurse who received report from the hospital before Resident #1 admitted to the facility, and they reported that Resident #1 had an altered mental status, hyperglycemia, and encephalopathy (change in brain function). LVN B stated she last worked with Resident #1 on the morning of 03/29/24 and the resident seemed to be less responsive than she had been and now required touch for response; however, before she would respond to her name. LVN B denied that Resident #1 showed signs of a stroke. LVN B stated she was responsible for checking Resident #1's blood sugar every morning and she was a little more responsive during previous mornings. LVN B stated a resident being less responsive was something that would be reported to the MD. LVN B stated she did not notify the MD of the change because she thought Resident #1 could have been sleepy due to it being early in the morning. In an interview on 04/02/24 at 10:48 AM, CNA C stated she worked at the facility for 3 years. CNA C stated she worked 6am-2pm on different halls, but she worked with Resident #1 on 03/28/24 and 03/31/24. CNA C stated on 03/28/24, Resident #1 was alert and eating but was not talking. CNA C stated she worked with Resident #1 again on 03/31/24 and there was a significant change. CNA C stated Resident #1 would not eat and required total assistance with care. CNA C stated before, Resident #1 could help move herself slightly during incontinent care. CNA C stated Resident #1 was weaker and less responsive. She stated she reported it to LVN F on 3/31/24. In an interview on 04/02/24 at 10:48 AM, CNA D stated she worked at the facility for 4 weeks. She stated she worked 6am-2pm on weekdays and worked with Resident #1 on 03/26/24, 03/27/24, and 03/28/24. CNA D stated earlier in the week, Resident #1 was talkative and very feisty. CNA D stated as the week went on, Resident #1 started talking less and was sleeping more. CNA D stated on the last day she worked with Resident #1 she was still sleeping more and had to be woken up for meals. She stated she was able to get Resident #1 to eat some of her food, but she was eating less. CNA D stated this was reported to the nurse; however, staff were still learning Resident #1's baseline and she was not sure what to think about the change. In an interview on 04/02/24 at 01:19 PM, the DON stated she was not at the facility when Resident #1 admitted ; however, she was there the next day and poked her head in to speak to Resident #1 and she responded. The DON stated there were no reports of a significant change in Resident #1 until 03/26/24 when LVN E reported the resident being nonresponsive with a blood glucose level of 50. The DON stated the MD was notified on 03/26/24 regarding the resident's low blood glucose, and after giving Resident #1 emergency Glucagon (medication to regulate blood glucose) and juice, her blood glucose stabilized. The DON stated EMS had already been called out to the facility, but the DON and MD decided not to transport Resident #1 to the hospital since her vitals were stable. The DON stated she did not receive any other report of a significant change in Resident #1 until 03/31/24 when it was reported that the resident was not waking up, eating, or responding. The DON stated staff reported Resident #1 had not eaten a lot in a day or so. The DON stated she went to assess Resident #1 and she was sleeping. The DON stated she pinched Resident #1's skin and she appeared to be dehydrated. The DON stated she told LVN G to call the MD and he gave an order to send Resident #1 to the hospital. The DON stated Resident #1 admitted to the hospital with hyperglycemia and was always lethargic with little response from the beginning. The DON stated the staff were still getting familiar with Resident #1's baseline as she had only been at the facility for a week; however, if there was any change from the day she admitted , the expectation was for the staff to report it to the DON and MD. In an interview on 04/02/24 at 02:05 PM, LVN E stated she admitted Resident #1 to the facility on [DATE]. LVN E stated Resident #1 was unarousable and would not speak or open her eyes when she admitted . LVN E stated Resident #1's baseline remained the same throughout the week and she never saw the resident feisty or very alert. LVN E stated on 03/26/24 she had to call the MD after Resident #1's blood glucose dropped, and she received an order to give the resident Glucagon (medication to regulate blood glucose). LVN E stated Resident #1 then had a fall on 03/27/24 with no injuries and she did not notify the MD although it was protocol. LVN E stated she would normally notify the MD of falls; however, she just forgot to do so for this incident. In an interview on 04/02/24 at 02:53 PM, the MD stated he visited the facility every Wednesday; however, he did not see Resident #1 when he visited on 03/27/24. The MD stated he had been notified of Resident #1's low blood sugar the day prior (3/26/24), but no one reported any other significant change or brought it to his attention that Resident #1 needed to be seen that day. The MD stated he was also not notified that Resident #1 had a fall on 03/27/24. The MD stated it was the expectation for staff to notify him of falls, but if it was late at night with no injury or change of condition, they could report it the following morning. The MD stated with Resident #1 being a new resident and due to her condition, he would have expected staff to notify him of her fall and any other changes. In an interview on 04/02/24 at 03:30 PM, LVN F stated she worked at the facility for 2 weeks. She stated she worked with Resident #1 on 03/30/24 and 03/31/24. LVN F stated Resident #1 was sleeping most of the time and not eating much during both shifts. LVN F stated on 03/31/24 the aide reported Resident #1 did not look like she was going to make it. LVN F stated she went to assess Resident #1 and she was very weak and lethargic, but the resident would open her eyes when spoken to, respond to sternum rub, and her vitals were normal. LVN F stated Resident #1's face was not drooping, and she did not have any other signs of a stroke. LVN F stated she notified the MD on 3/31/24 that Resident #1 had been sleeping more the past two days, was unarousable, and eating less, and the MD ordered Resident #1 to be sent out to the hospital. In an interview on 04/02/24 at 04:00PM, Resident #2 stated Resident #1 was her roommate for about a week. Resident #2 stated Resident #1 would sleep most of the time and only wake up for medication and to eat. Resident #2 stated Resident #1 was not able to converse with her but would sometimes pick up words from the television and repeat them over and over. In an interview on 04/02/24 at 05:05 PM with the DON and the Administrator, the DON stated she expected staff to notify her and the MD of any significant change in a resident's condition. The DON stated the MD wanted to make it clear to Investigator that the facility received a resident who was not stable enough to leave the hospital. The Administrator stated reporting a change of condition was easier said than done, especially with a new resident when staff were not familiar with their baseline. In an attempt to further interview about expectations and risks to the resident, the Administrator stated, no comment. In an interview on 04/23/24 at 10:08 AM with the Regional Nurse revealed she understood the facility failed to notify the physician of significant changes in Resident #1 after multiple opportunities presented, including a fall and other changes in mental and physical status that indicated a decline in health. The Regional Nurse stated her expectation and the facility's policy for any significant incidents and change in condition to be reported immediately. The Regional Nurse stated the risk of not notifying the MD of significant incidents and change of condition could result in a resident having serious harm or death. Review of the facility's policy titled Notification of Change, undated, revealed in part the following: Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. . Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: . 2. Significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health mental. Or psychosocial status [sic]. This may include: a. Life-threatening conditions, or b. Clinical complications An Immediate Jeopardy (IJ) was identified on 04/22/24 at 11:45 AM. On 04/22/24 at 12:35 PM, the Administrator and the DON were notified of the IJ. The IJ template was provided to the Administrator and a plan of removal (POR) was requested at that time. The POR was accepted on 04/23/24 at 10:11 AM. The POR reflected the following: Issue Cited: Failure to Notify the Physician of a Significant Change of Condition Preparation and/or execution of this plan do not constitute admission or agreement by the provider that immediate jeopardy exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or may be discussed in this response and immediate jeopardy removal plan. This immediate jeopardy removal plan is submitted as the facility's immediate actionable plan to remove the likelihood that serious harm to a resident will occur or recur. 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 4/22/24) o The DON or designee notified the facility Medical Director of the incident. o Nursing supervisors/designees completed physical assessments on all residents to identify any changes in condition and notification was made to the physician of any noted changes. Concerns were/were not identified. (Provide details if concerns were identified from the physical assessments). 2. Actions to Prevent Occurrence/Recurrence: The facility took, the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 4/23/24) o All licensed nurses will be educated by the DON/designee on change of condition and physician notification regulations, as well as facility policy and procedure. o Nurse aides will be educated by the DON/designee on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurses. o Staff members are not permitted to work a shift until education was completed. o New hires (licensed nurses and nurse aides) will be educated on change of condition and physician notification regulations, as well as facility policy and procedure, accordingly in orientation by human resources/designee. o The DON implemented a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) with a focus on physician notification of significant changes. o The PIP resulted in implementation of daily DON/designee audits of the 24-hour report to monitor for change in resident condition. o The DON/designee will also complete chart audits/health document assessment as follows: o Three residents weekly for four weeks then; o Two residents weekly for two weeks then; o Two residents a month for two months. o The regional/corporate/consultant nurse will visit the facility monthly to provide general oversight and monitoring of the PIP. Monitoring 04/23/24 (10:15 AM-1:45 PM): Record review of Residents #2, #3, #4, #5, #6, #7, #8, #9 and #10's, who were all at risk of having a physical, mental, or psychosocial change in condition based on diagnoses, electronic health records reflected no documented incidents or change of condition. Record review of in-service on 04/22/24, conducted by the Regional Nurse, reflected the DON and ADON were trained on their responsibility to monitor resident charting for any changes in resident status and follow up accordingly. Record review of in-services on 04/22/24-04/23/24, conducted by the DON, reflected all staff were trained during or prior to their shift on guidelines for notifying the physician of clinical problems, incidents, and change of condition. Record review of a document provided by the DON reflected a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented for the DON and/or designees to audit 24-hour reports to monitor for change of condition of residents and audit resident charts. Record review of a document provided by the DON reflected a fax form for non-emergent notification to ensure the physician is aware of all incidents and residents' conditions. Interview on 4/22/24 at 3:00 PM with the Administrator and the DON revealed the MD was notified of the facility's failure to report a resident's change of condition. Interviews on 4/22/24-4/23/24 (various times) with Residents #2, #3, #4, #5, #6, #7, #8, #9 and #10's, who were all at risk of having a physical, mental, or psychosocial change in condition, revealed they had not experienced any signs or symptoms of a change in their condition. Interviews on 04/23/24 (10:08 AM-1:43 PM) were conducted with DON, ADON, LVN B (1st shift), LVN E (2nd shift), LVN G (1st shift), LVN H (1st shift), CNA I (1st shift), MA J (1st shift), CNA K (1st shift), CNA L (2nd shift), LVN M (2nd shift), CNA N (3rd shift), LVN O (3rd shift), LVN P (double weekends). All interviewed aides were able to provide competency regarding in-services over monitoring for and reporting change of condition to the charge nurse. The aides stated they knew to monitor residents for any changes to skin, behavior, mental/physical status while performing care and to immediately report it to the charge nurse and/or DON. All interviewed licensed staff were able to provide competency regarding monitoring for and acknowledging reports of change of condition and reporting to the physician. The licensed staff stated they were responsible for monitoring resident for any signs of change in condition, assessing a resident after receiving reports of change in condition from the aides, and immediately reporting any concerns to the DON/MD/family. An Immediate Jeopardy (IJ) was identified on 04/22/24. An IJ Template was provided to the facility on [DATE] at 1:28 PM. While the Immediate Jeopardy was removed on 04/23/24 at 02:02 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 (Resident #1) residents reviewed for supervision. The facility failed to adequately supervise Resident #1 and to ensure the back door by the kitchen was secured or monitored while getting groceries delivered. Resident #1, who had dementia and a history of wandering, eloped from the facility through the propped open door at unknown time on 10/10/23. The facility was unaware of Resident #1's elopement until another facility notified them Resident was at their facility. The facility failed to ensure adequate interventions were implemented to prevent residents with a high risk of wandering/elopement from eloping through the same door. An IJ was identified on 11/09/2023. The IJ template was provided to the facility on [DATE] at 2:45pm. While the IJ was removed on 11/10/23 the facility remained out of compliance at a scope of potential for more than minimal harm and severity level of isolated due to the need for the facility to monitor it corrective action for effectiveness. This failure could place residents at risk of not being properly supervised resulting in injury or death. Findings included : Record Review of Resident #1's face sheet dated 11/10/2023 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia, hypertension (high blood pressure), bipolar disorder, and metabolic encephalopathy (brain imbalance). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 03, indicating he was severely cognitive impaired . Record review of Resident #1's admission wandering risk scale assessment dated [DATE] revealed he was high risk. Resident #1 didn't have a wander guard placed at this time of assessment. Observation/interview on 11/09/2023 at 12:30PM revealed Resident #1 sitting in the dining area. Unable to interview resident. Attempted to interview and Resident #1 wasn't able to answer questions. Resident #1 was observed wearing a wander guard on his right foot. Record review of Resident #1's Care Plan dated 09/24/23 revealed he wandered into unsafe situations, cognitive status: dementia. The care plan was updated the day of the incident (elopement) on 10/10/23 to reflect the resident was noted on the porch of a neighbor facility. Interventions included: alert staff to wandering behavior, approach positively and in a calm manner, monitor and document behavior, observe wander guard placement and function every shift and provide diversional activities. Wander Guard placed on right foot. Record review of Resident #1's incident report dated 10/10/2023 revealed at approximately 9:31 AM the administrator was notified by telephone of Resident #1 being at the nursing home behind the facility. Resident #1 was last seen on 10/10/2023 at 9:00 AM walking the halls as normal. Resident #1 was not exit seeking when last observed in the building. Record review of the nursing schedule and staff timecards for 10/10/23 revealed 4 CNAs, 1 LVNs, 2 med-aides, and 2 RNs were working the 6 AM-2 PM shift. Interview at 11/09/2023 at 8:50 AM with the DON revealed on the date of the incident on 10/10/23 groceries were being delivered to the kitchen and the door was left open when Resident #1 eloped from the facility. The nursing home across the street called and stated Resident #1 was at their facility. The DON stated she and the Administrator looked back at the cameras during the investigation and saw Resident #1 going through the delivery doors that lead to outside. Staff were told to put a wander guard on Resident #1 after his return and to complete skin assessments every 15 min and then to move to hourly assessments. Resident #1 had never attempted to go to doors or exit seek at the facility and he was very redirectable but also hads bad dementia. Resident #1 usually would sit at the nursing station with the staff. Thatis was the first time an incident like this has occurred. Interview at 11/09/2023 AM at 10:20 AM with the DON revealed wander guards were not placed on every wanderer until they actually saw the resident trying to elope or saw residents constantly going close to doors all the time. The DON then stated they were now making sure the door was secure and hadve changed the code on the keypad. In-services hadve been done to educate staff on residents who wandered. The biggest thing was making sure the door wasn't propped open, but she stated she couldn't guarantee someone was supervising the door at all times. Interview on 11/09/2023 at 10:35 AM with the Dietary Manager stated most of the time the grocery truck would be gone by the time she comes came to work in the morning during the days grocery delivery came. She also stated she and the kitchen staff triedy to have someone watch the door and the delivery staff usually closed it when they wereget done with delivery. The Dietary Manager stated she and the Administrator have told staff and the delivery staff not to leave the door open. Usually, the kitchen staff triedy to have someone supervise the door, but it was hard since the delivery truck would come at different times. Interview on 11/09/2023 at 12:00 PM with CMA P revealed staff have been in-serviced on elopement and wanderers. The DON and Admin have told staff what signs to look for regarding residents with elopement risks and what to do when it happens. The signs included: resident wandered towards the door and if they were to go in and out of rooms; There is a book at every nursing station to identify the wanderers in the building and where the wander guard was placed on the resident. Interview on 11/09/2023 at 12:20 PM with the DON revealed her definition of a wanderer was a resident who would walk around aimlessly with no direction. She stated elopement is defined as when a resident is actively seeking direction or getting out of the facility. She stated elopement means they left the facility. She stated PCC didn't have an elopement assessment. If the resident had a history of elopement at their last facility or where they were coming from prior to admission, then the facility would place a wander guard on them when they arrived. She stated if a resident scored high on the wander guard scale, then staff knew to monitor those residents to make sure they weren't exhibiting elopement behavior or try to open doors to exit. The DON stated they currently don't have anyone posted at the door because the dietary staff were aware of the wanderers by knowing each resident. Even though the door wasn't supervised, the DON stated they have staff in the hallway. The DON stated she and the Admin were trying to get the delivery truck company to deliver the groceries to the front door, but theis process hadn't been put in place. She then revealed stated that all the residents with wander guards were an elopement risk. She also stated elopement drills have been done for staff so they were aware of what to do when if an elopement ever occurred. Interview on 11/09/2023 at 1:56 PM with the Admin revealed he received a phone call around 9:20 AM that Resident #1 was found at a facility behind the facility. As soon he was aware, he walked over to get Resident #1 and returned around 9:30 AM, approximately. The Admin stated he told the grocery delivery staff they had to close the door and that it couldn't be propped opened or left opened. The door must stay closed at all times. There was a laundry room near where staff were, and they could see the back door (door where Resident #1 eloped) and the staff were there from 6 AM-8 PMpm. The Administrator stated he had educated staff . He stated he had tried to get the groceries delivered to the front door, but the delivery company hadn't been following the instructions. The Admin then revealed the back door should only be used for emergencies. The Admin then stated usually the kitchen was notified via a computer the time the delivery truck would show up. The truck used to come early and the dietary staff would help bring the groceries in but after the situation he talked with staff and educated them that the groceries had to be delivered to the front door. Interview on 11/09/2023 at 2:12 PM with [NAME] K revealed the staff had been educated on not letting groceries come through the back door but the grocery provider was still delivering at the back door. He stated he wasn't sure why they still allowed them to come through the back door. He revealed the risk factors of allowing them to use the back door could cause another elopement that occur red . Interview on 11/09/2023 at 2:20 PM with Dietary Aide Q revealed she has been working at the facility since February 2023 and she had been educated on groceries coming through the back door. She then stated the dietary staff try to have someone watch the door or switch out if they were busy, but they also try to tell the grocery provider to deliver through the front door if possible . Record review of the Elopement and Wandering Residents policy dated March 2019 revealed, The facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1. If identified as a risk for wandering, elopement, or other safety issues, the resident care plan will include strategies and interventions to maintain the resident's safety. The administrator was informed on 11/109/2023 at 3:45 PM that an Immediate Jeopardy (IJ) existed on 10/10/2023, and a copy of the IJ Template was provided and requested a POR at this time. The following Plan of Removal was accepted on 11/10/2023 at 3:20pm: F689 Plan of Removal 1) The identified failure was due to an exit not being supervised by staff and a resident eloped from the building 2) The action that has been taken to remove the immediacy of this issue was 1) all deliveries must come through the front door as this entrance has been monitored and supervised during all hours. This was implemented on 11/09/2023 2) The back door will remain locked with a secure code. 3) The laundry room will have a sign posted Employees only. 3) The in-service that was provided was done by both the [DON] and the [Dietary Manager]. The date that all the in-service will be completed will be by 11/10/2023. This in-service will include all current staff, and the team from the food delivery group. The back door will be used as an exit only. 4) The Policy and Procedures will have an addendum added to them that will state that all deliveries must come through the front door at all times. Policy reviewed on 11/10/2023 and verified of addendum. 5) The way that this will be monitored is the delivery driver will have to sign in and out upon the delivery of what is being delivered. This will be implemented 11/10/23. The DON/designee will monitor the sign in sheet to ensure all signing in and out of the facility and that no delivery is entered through the back door 3 times a week for one week, then weekly for one month and then monthly for 3 months. All findings will be reported to the QAPI team monthly. 2. The back door will be monitored for usage. A sign out sheet will be placed by the back door for employees to sign out when using. This will be monitored by the don/designee 3 times a week for one week, then weekly for one month, and then monthly for three months. 6) Fire Safety will come out today (11/10/23) to secure the laundry room door so that it's not assessable accessible to any residents 7) Maintenance Director, [Maintenance Director], will continue to do weekly audit/checks on alarmed doors and security keypads to ensure proper functioning 8) Dietary and laundry staff will monitor laundry door in 30-minute increments until laundry door is secured with latch or locking mechanism, nursing will monitor on off shifts 9) Once the laundry doors are secured/ locked, all staff will have access to security key pad codes. Monitoring of the POR included: A 100% elopement audit was conducted by the DON; starting 11/09/2023 and was completed by 11/10/2023. - In-service dated 11/09/2023 topic: delivery effective immediately will be made through the front door. If not and the side door is used a dietary staff will stay at the door until they are finished with the delivery. This was confirmed with an observations on 11/10/2023 at 9:25AM of the grocery staff being redirected to go through the front door instead of the back door for grocery delivery. Interview with Receptionist R on 11/10/2023 10:17AM revealed the receptionist was able to verbalize that they now used a sign-in book as well as the computer check in for all guests and vendors. Review of in-services dated 11/09/2023 revealed they were completed on deliveries coming through the front door was also confirmed with observation of deliveries being brought through the front door on 11/10/2023 at 9:20 AM and interviews with staff confirmed by verbalizing expectations. Interviews on 11/10/2023 from 10:14 AM to 3:00 PM with ( Nurse A id A, Nurse Aid B, Dietary G, [NAME] F, [NAME] K, Housekeeper E, Housekeeper O, the Receptionist R, Dietary Manager , RN C, LVN D, MA H, MA I, MA N, MA P, Dietary Aid Q, and Laundry Aid L revealed they were in-serviced on using the front door for deliveries for the facility as well and expressed understanding on the new delivery policies and procedures as well as elopement education from the in-service. Interview and observation on 11/10/2023 at 2:00 PM with the DON revealed until the facility was able to get the door locked properly leading to the outside door, they will have staff switch off to supervise the door. Interview on 11/10/2023 at 2:00 PM the DON stated all staff had been in-serviced on the new delivery process and completed by 11/10/2023. Interview on 11/10/2023 at 3:34 PM with the DON revealed the incident was an IJ because of what could have happened to Resident #1 when he eloped. She also stated the risk factors of not making sure all the doors are secure could lead to death or injury to a resident. The DON stated her expectations of staff are to make sure all doors are secured at all times as well as know who the wandering residents are as well as identify them upon admission An IJ was identified on 11/09/2023. The IJ template was provided to the facility on [DATE] at 2:45pm. While the IJ was removed on 11/10/23 the facility remained out of compliance at a scope of potential for more than minimal harm and severity level of isolated due to the need for the facility to monitor it corrective action for effectiveness.