**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the rights of the residents to be free from abuse and neglect for 1 of 7 residents (Resident #2) reviewed for abuse A. The facility failed to keep Resident #2 safe from Resident #1 on an unknown date when Dietary Aide B reported that Resident #1 had touched Resident #2's breast in the dining room on an unknown date to the Interim DON and to Regional Director J on an unknown date multiple times between May 2024-November 2024). An Immediate Jeopardy (IJ) was identified on 11/19/24 at 2:48 PM. The IJ template was provided to the facility on [DATE] at 2:48 PM. While the IJ was removed on 11/20/24 at 1:28 PM, the facility remained out of compliance at a severity level of actual harm and a scope of widespread due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk for serious psychosocial harm from abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Record review of the facility policy, Abuse Prevention Program, Revised December 2016 revealed: Policy Statement: Our Residents have the right to be free from abuse, neglect .Policy Interpretation and Implementation: As a part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone including, but not necessarily limited to other residents .Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Identify and assess all possible incidents of abuse; Investigate and report any allegations of abuse within timeframes as required by federal requirements; Protect residents during abuse investigations. Record review of the facility policy, Abuse Investigation and Reporting, revised July 2017 revealed: Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Policy interpretation: If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Role of the investigator: The individual conducting the investigation will as a minimum; Review the completed documentation forms; Review the resident's medical record; Interview the persons reporting the incident; Interview the resident as medically appropriate; Interview staff members on ALL shifts Interview the resident's roommate; Review all events leading up to the alleged incident; and Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the administrator. Reporting: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility; The resident's representative (sponsor) of record an alleged violation of abuse, neglect . Two hours if the alleged violation involves abuse . Record review of the facility policy, Recognizing Signs and Symptoms of Abuse/Neglect, Revised April 2021, revealed: Policy Statement: All types of resident abuse, neglect, exploitation, or misappropriation of resident property are strictly prohibited. All personnel are expected to report any signs and symptoms of abuse/neglect to their supervisor or to the director of nursing services immediately. Policy Interpretation: The following are signs and symptoms of abuse/neglect that should be promptly reported. This listing is not all-inclusive. Other signs and symptoms or actual abuse/neglect may be apparent. Psychological or behavioral signs of abuse or neglect: Expression of fear of a person or place, or of being left alone, or of the dark; Paranoia . There were no provider investigation reports available for review from 04/01/24-11/01/24 that involved any of the residents listed in the sample or that pertained to the identified deficient practice. Resident #1 Record Review of Resident #1's face sheet, dated 11/01/24, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 14, indicating the resident was not cognitively impaired. Section E did not reveal any documented behaviors for Resident #1. Record Review of Resident #1's Quarterly MDS assessment dated [DATE], revealed Section E did not reveal any documented behaviors for Resident #1. Record review of Resident #1's progress notes dated from 03/02/24- 11/01/24 did not reveal any information regarding the allegation of touching Resident #2's breast or his flirtatious behavior with female residents. Record Review of Resident #1's nursing progress notes entered by the Interim DON dated 05/14/24 at 11:47 PM indicated she spoke with the SW to speak with Resident #1 about calling female staff pet names. A letter was given outlining the facility expectations regarding not calling female staff pet names. Record review of Resident #1's care plan, dated 05/14/24, did not reveal any information regarding his flirtatious behavior towards female residents or allegations regarding touching Resident #2's breast. Resident #2 Record Review of Resident #2's face sheet, dated 11/01/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: dementia (memory loss) and depression (prolonged period of sadness). Record Review of Resident #2's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 08, indicating the resident was moderately cognitively impaired. Section E did not reveal any documented behaviors for Resident #2. Record Review of Resident #2's Quarterly MDS assessment dated [DATE], revealed Section E did not reveal any documented behaviors for Resident #2. Record review of Resident #2's care plan, dated 08/06/24, did not reveal any information regarding her being touched by another male resident. Further review revealed a focused area, initiated on 08/06/24, that indicated Resident #2 wanted to be in an affectionate relationship with male residents. The goal initiated on 08/06/24 and revised 10/18/24, was based on family wishes for Resident #2 to visit with male resident (unidentified) in the common area. The interventions initiated 08/06/24 included avoid improper touching, avoid going into other residents' room, keeping the family updated with family status, and talking happy about relationships with male residents. Record review of Resident #2's progress notes dated from 03/02/24- 11/01/24 did not reveal any information regarding the allegation of her breast being touched by Resident #1. Record Review of Resident #2's nursing progress notes entered by LVN H dated 08/02/24 at 7:02 PM indicated Resident #2 was in a male (unidentified) room sitting in her wheelchair and a CNA (unidentified) observed the male resident with his pants around his ankles claiming that he was going to have sex with her. During an interview on 11/01/24 at 9:22 AM, [NAME] A stated Resident #1 was a ladies' man. She said he had a history of flirting since his admission. [NAME] A stated there was a history between Resident #1 and #2. She said Resident #1's attempt to flirt and approach Resident #2 caused issues with the other resident, who was no longer at the facility. She said she had not been given any instructions or training regarding Resident #1. She said outside of the incident (Resident #1 touching Resident #2's breast) with Resident #2, she had seen him touch other residents' hands. She said Resident #4 would play with herself. She said she had been told (she could not remember by who) that she would do this when she was nervous. She said this was a known behavior (unable to report for how long) but that male residents would watch her rub on herself in a circular motion. She said staff talked to her about it as much as they could. She said there was an indication that she was about to do it because she would raise her leg. At first, she thought she (resident #4) was itching, but she believed she was checked to rule that out. She said the staff knew to redirect her, offer her a drink, or engage her in another activity. She said she had not received additional training about Resident #4's behavior, but some staff knew how to redirect her. She said if they did not see her raise her legs, it was easy to identify because all the male resident's heads would be turned towards her doing that behavior in the dining room or any common area. She said no other residents have become offended or complained that she was aware of. She said she could not confirm if the other residents were looking at Resident #4 for pleasure or out of shock. During an interview on 11/01/24 at 11:33 AM, CNA E stated over the past month, Resident #4 had a behavior of rubbing herself in her genital area. She said other staff had also noticed it. She said naturally, she and other staff would redirect her. She said they had not received specific training regarding Resident #4 rubbing her genital area. She said they had general knowledge to redirect her since sometimes she would do this in common areas. She said Resident #3 would sit and watch Resident #4 rub herself in her genital area. She said Resident #1 was her (CNA E) family member, and although she had not seen him touch the breasts of anyone, he was known as a big flirt. She said she had observed Resident #1 hold hands with Resident #2 but that Resident #2 was friendly and did not care. She said Resident #2 had a boyfriend who was no longer at the facility, and Resident #1 would stir the pot and upset the resident who was no longer at the facility by flirting with Resident #2. During an interview on 11/01/24 at 9:55 AM, the DM stated Dietary Aide B did report to her that Resident #1 had grabbed Resident #2's breast. She said she was unsure of the exact date. She said she did not witness it, but it was considered inappropriate touching. She said when it was reported to her, she told Dietary Aide B that someone needed to know. She said the ADM was not the administrator and did not know which nurse Dietary Aide B reported the incident to. She said she did not personally report the incident to anyone because she did not personally observe the incident. She said it was her understanding that Dietary Aide B reported the incident to Regional Director J and the charge nurse. She said she could not remember who the charge nurse was. She said she had observed Resident #1 to be social but not overly attentive to any one resident. She said she had not received any special instructions regarding Resident #1. She said although she did not remember the exact date, she did remember the day Dietary Aide B reported the incident. Resident #2 seemed fine and not in any distress. She said she felt if Resident #2 felt threatened, she could tell someone. She said the ADM was the abuse preventionist and had been trained that if she suspected or witnessed abuse, she was to report the allegation to the ADM immediately. She said she had not been interviewed by anyone regarding the incident. During an interview on 11/01/24 at 11:06 AM, the Interim DON stated she no longer worked at the facility. She said she was notified of the incident between Resident #1 and Resident #2. She said she was unsure of the exact date of the incident between Resident #1 and #2, but it was first reported when the Former ADM was employed by Dietary Aide B. She said an investigation was conducted, and it was unfounded by the Former ADM. She said Regional Director J took over after the former ADM left. She said when Regional Director J took over, the incident involving Resident #1 and #2 was brought back up. She said she interviewed Residents (Resident #1 and #2), and nothing was found. She said she was unable to list all she interviewed as she did not work there anymore . She said this may have been in April or May 2024. She said she remembered when she interviewed Resident #1 and Resident #2, both residents denied anything happening and therefore she unfounded the incident. She said there were concerns because each time the new administration would come, the incident of Resident #1 touching Resident #2's breast would come up. She said she did not believe anything had happened because no other allegations had been made since the report. She said it was her understanding that Resident #1 had not approached Resident #2 since the allegation. She said she was unsure why the allegation continued to be addressed, and it seemed to be the kitchen staff that had concerns. She said during her investigation, she found that the people named to be present were not working the day of the incident. The Interim DON said she could not list the people who worked the day of the incident, the date of the incident, and anyone she interviewed, but she unfounded the incident . She said this had been reported to her a total of three times, and she did not report the incident to HHSC during any of those times. She said she did not report the allegation of sexually inappropriate touching because Residents #1 and #2 stated the incident had not occurred, and they unfounded the incident. She said she did keep her eye on Resident #1. She said Family Member G had been notified. She said she had not received any additional reports that Resident #1 had touched any other residents. She said she did not know if she had any written documentation to support her efforts to address the allegations of sexually inappropriate touching from Resident #1. She said she never typed anything up. She said she should have typed something in his progress notes since this was brought up many times. She said she could not pinpoint specific training related to the incident because she had done so many in-services on ANE. She said she did discuss the incident with Regional Director I, and they had decided the incident was not a facility reportable incident because both residents had dementia, and both parties stated nothing happened. She said they agreed that since the kitchen staff kept reporting it, it was retaliation. She said it was not reported to HHSC because there was no proof that it happened and no witnesses. She said that it was known that Dietary Aide B was married into the family of Resident #1 and that she must also protect Resident #1's rights. She said the purpose of following the abuse policy, reporting, and investigating allegations of ANE was to protect the population from ANE, make sure their needs were met, and avoid neglect. She said she had been trained that it was all or none. She said this meant that she was to collect data, have credible witnesses, and then report the incident to HHSC. She said she felt Resident #1 was being painted as a perpetrator based on community rumors. She said she wanted to also protect Resident #1 from false allegations. In regard to documentation, she said she would have to see if she had anything. (The Interim DON did not provide any documentation during the investigation) During an interview on 11/01/24 at 11:33 AM, CNA E stated she said Resident #1 was her (CNA E) family member, and although she had not seen him touch the breasts of anyone, he was known as a big flirt. She said she had observed Resident #1 holding hands with Resident #2 but Resident #2 was friendly and did not care. She said Resident #2 had a boyfriend who was no longer at the facility, and Resident #1 would stir the pot and upset the resident who was no longer at the facility by flirting with Resident #2. During an interview on 11/01/24 at 11:55 AM, RN C stated she was notified a few months ago (unknown exact date and time) by Dietary Aide B that she witnessed Resident #1 touching Resident #2's breast. She said she was told by Dietary Aide B that it did not seem mutual. RN C said she asked Dietary Aide B if she had reported the incident to the Interim DON as they did not have an administrator at the time. She said Dietary Aide B said she had. RN C asked if anything had been done and was told by Dietary Aide B that she did not think anything had been done. RN C stated she encouraged Dietary Aide B to report it again. She said it would have been reported to Regional Director J at this time. She said it was her understanding that it was reported to Regional Director J, who responded that he was aware the incident had been investigated and unfounded. She said she was unaware if it had been reported to HHSC. She said Resident #1 had a history of being friendly with female residents since his admission. She said he would grab the female resident's hands and kiss them. She said she had never seen him grab Resident #2's breast. She said she had not received special instruction regarding Resident #1, nor had she been interviewed regarding the allegation of sexually inappropriate touching between Resident #1 and #2. During an interview on 11/01/24 at 12:01 PM Dietary Aide B stated she was aware of an instance where Resident #1 touched the breast of Resident #2 in the dining room. She said she reported the incident to the Interim DON. She said the incident happened right after Mother's Day in 2024. She said she had seen other inappropriate things from Resident #1. She said she had observed him touch Resident #2's breast more than one time. She said she observed when she opened the door that entered the dining room from the kitchen him touching Resident #2's breast, and when he saw her, he put his hands down, and his face turned red. She said she immediately reported the incident to the Interim DON in the presence of LVN L. She explained to the Interim DON that this was not the first time Resident #1 had been inappropriate with female residents. She said she told the Interim DON that the touching was against Resident #2's will. She said she knew this because Resident #2 did not participate; it was just Resident #1. She said when she reported the incident to the Interim DON, she was told by the Interim DON that she would speak to Resident #2. She said she was also told that because Resident #2 had a boyfriend (no longer at the facility at the time of the investigation), it was ok for Resident #2 to have two boyfriends if she wanted. She said the Interim DON said she would ask Resident #2 if she wanted two boyfriends. She said the Interim DON had also explained to her that the laws had changed. She said she was told that if Resident #2 could not say what happened and if she had memory loss or dementia, there was nothing they could do about it. She said the Interim DON told her to let her know if she saw anything else. She said the former ADM was the administrator at the time of the incident. She said the Interim DON reported the incident to Regional Director J, and he spoke with her about it once. She said Regional Director J asked her what happened, she explained that the incident occurred under the Former ADM and told her to let him know if it happened again. She said it had not happened again, but nothing was done. She said she had not received any special instructions or additional training on what to do regarding Resident #1. She said Regional Director J was the only person who ever asked her anything about the incident. She explained there was another incident involving Resident #1. Still, she did not report it because she was unsure if it was considered inappropriate touching. She said nothing had been done with the incident between Resident #1 and #2. She said she did report the incident between Resident #1 and #2 to the DM but was told for her to report the incident herself. She said her DM told her to report the incident because she did not personally see the incident. She said outside of the interview with the HHSC investigator, she felt the incident had not been thoroughly investigated. During an interview on 11/01/24 at 12:40 PM, Resident #2 stated no one had touched her inappropriately. She said she had a boyfriend but did not remember his name. She said she knew Resident #1, but he had never touched her inappropriately. She said if someone did touch her, she would tell the people at the front. She said no one had asked her any questions before the HHSC investigator about inappropriately being touched. During an interview on 11/01/24 at 1:25 PM, LVN F stated that she knew of the incident between Resident #1 and Resident #2. She stated she was told about the incident by RN C. She said she could not remember the exact date of the incident, but that RN C stated that it was reported to her (RN C) by Dietary Aide B. She (LVN F) stated that she was not questioned or trained in regard to Resident #1 but remembered that the Interim DON said to Dietary Aide B that Resident #2 could have more than one boyfriend if she wanted. She said the incident was also reported to Regional Director J, and it was her understanding that he did an investigation and unsubstantiated the incident, according to RN C. LVN F said Resident #1 had a history of flirting with female residents and holding their hands. She said she had not seen anything to indicate the other female residents were uncomfortable. She said no instructions had been given regarding the behavior of Resident #1 flirting or holding the female resident's hands. She said they told Resident #1 to leave the female residents alone. She said Resident #1 laughed about it. She said it appeared Resident #1 found humor because he reported to them that Resident #2 was his schoolteacher. During an interview on 11/01/24 at 2:39 PM, LVN H stated she said she was unaware of any incidents that involved Resident #1. She said Resident #1 had a history of being with the female residents. She said he liked to sit with them (female residents ). During an interview on 11/01/24 at 2:59 PM, Regional Director I stated he did not know anything about a male resident touching the breast of a female resident. He said he could not recall a specific conversation with the Interim DON. He said he had multiple discussions with the Interim DON. He said the Former DON's last day was May 15th or 16th of 2024. He said there were 10 days without an administrator, and then Regional Director J came to run the facility. He said it was his expectation that if staff suspect or witness abuse, they should follow the facility policy. He said it should be reported to HHSC and investigated thoroughly. He said he was unaware of the allegation between Resident #1 and #2. He said the potential negative outcome for the residents would depend on the allegation. During an interview on 11/01/24 at 3:06 PM, Regional Director J stated he was unaware of any incident that occurred between Resident #1 and Resident #2 that involved breast touching. Regional Director J said he was aware that there was a resident who was no longer at the facility and felt that Resident #1 had stolen his woman (Resident #2). He said if there was an allegation of ANE, it should be reported and investigated. He said investigating the incident was important to ensure the resident was safe. He said the investigation process should be documented. During an interview on 11/01/24 at 3:25 PM, Resident #1 stated he had never been questioned about inappropriate behavior or accused of doing anything inappropriate. He stated he did not have a girlfriend but all the ladies at the facility liked him. He said he recently turned [AGE] years old and found out he was a lesbian because he liked girls. He said he does not touch anyone who does not want to be touched. He said he had not touched anyone since he had been at the facility. During an interview on 11/01/24 at 4:43 PM, the DON stated he said he was unaware of any incidents that occurred between Resident #1 and Resident #2. He said he knew Resident #1 would hold people's hands, but it was not specific to female residents. He said he was unaware that Resident #1 would kiss the female residents' hands. During an interview on 11/01/24 at 4:55 PM, the ADM stated he had been trained and was familiar with the facility's ANE policy. He said he was unaware of the incident involving Resident #1 touching Resident #2's breast. He said the potential negative outcome was there could have been the continuation of abuse or whatever was going on. He said not following the abuse policy could place the resident at unnecessary risk. He said the system to monitor abuse was education and communication. He said he had not observed any of the behaviors of the residents discussed. He said he expected the facility abuse policy to be followed. He said it should have been reported to HHSC and investigated. He said everyone was responsible for following the ANE policy, but the administration oversaw the investigation process and reported the allegation to HHSC. He said he did not have a reason why following the facility policy (reporting to HHSC and investigating) was not conducted. He said the investigation process should have been documented if it was conducted . HHSC Investigator re-entered the facility on 11/19/24 at 8:45 AM to gather additional information at the request of Region 1. The ADM, the DON, the ADON, Regional Director J, and the Regional Nursing Consultant were notified on 11/19/24 at 2:48 PM and IJ situation was identified due to the above failures and the IJ template was provided. The following Plan of Removal submitted by the facility was accepted on 11/20/24 at 8:31 AM: Plan of Removal: 607: Investigate/Prevent/Correct Alleged Violations F607 Based on interviews and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect for 2 of 6 residents (Resident #1 and #2) reviewed for abuse. 1. Immediate Actions Taken for Those Residents Identified: Action: Residents #1, and #2 received a head-to-toe assessment and an emotional assessment. Person(s) Responsible: Charge Nurse & Social Worker and/or Designee Date: 11/19/2024 Action: Resident #1 was placed on 1:1 for 72-hours from 11/1-11/4. Resident #1 was no longer deemed a risk to others. Person(s) Responsible: Administrator, Director of Nursing, and/or Designee Date: 11/4/2024 2. How the Facility Identified Other Possibly Affected Residents: Action: Resident safe surveys completed to establish affected residents. Any other concerns noted will received a head-to-toe assessment and an emotional assessment. Person(s) Responsible: Administrator, Social Worker, and/or Designee Date: 11/19/2024 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Education provided to Administrator and Regional Director by Regional Nurse Consultant. Further, all available facility staff were in-serviced by the Administrator starting immediately after IJ was called. All identified staff that continues to work for the nursing facility by Administrator will be in-serviced over the abuse policy and investigating and reporting abuse per HHS and CMS regulations. Person(s) Responsible: RNC, Administrator or designee Date: 11/19/2024 Action: All staff educated on immediately intervening to protect residents in the event of abuse, reporting to the abuse coordinator, assessing the resident, and following up with the abuse coordinator. All staff will be educated prior to working their next shift. Person(s) Responsible: Administrator, Director of Nursing, and/or Designee Date: 11/19/2024 4. How the Corrective Actions Will be Monitored, by whom and for how long: Action: 5 staff and 5 residents will be interviewed weekly to ensure any allegations of abuse have been reported to the administrator per the regulation x4 weeks. Any allegations made during the interview will be reported immediately. Staff noted not following policy will be reeducated on the facility's abuse policy. Person(s) Responsible: Administrator and/or Designee Date: 11/20/2024 QAPI- Action: Medical Director notified of the Immediate Jeopardy template and the facility's plan to remove it. No additional recommendations at this time. Person(s) Responsible: Administrator Date: 11/19/2024 On 11/20/24 at 11:23 AM the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of the facility provider investigation report, dated 11/09/24, revealed the following: A written statement signed 11/09/24 by the Interim DON said that Dietary Aide B came to her office (date not disclosed) and reported that she witnessed Resident #1 touch Resident #2 on breast in the dining room. She (the Interim DON) reported the incident to the Former ADM, but she (the Former DON) did nothing. She said some of the witnesses that Dietary Aide B reported saw the incident did not work on the day Dietary Aide B stated the incident happened. (The written statement did not contain the witnesses' or the alleged incident date). The Interim DON wrote that she spoke with Resident #1, who denied sexual contact with Resident #2, but Resident #1 did admit to holding Resident #2's hands. The Interim DON wrote in her statement that Resident #1 had no allegations of sexual contact with any resident or staff at the facility. The Interim DON wrote that Resident #2 denied anyone had touched her anywhere on her body and that she (Resident #2) felt safe. She wrote that Resident #2 confirmed that she held hands with Resident #1. She wrote that she notified Resident #2's POA. She said Dietary Aide B voiced the allegations to Resident #1, two Administrators, and the Interim DON. (The written statement did not include the names of the two administrators. A letter dated 4/4/24, signed/acknowledged by Resident #1, addressed him using pet names such as baby and honey, which made the staff feel uncomfortable. Record review of a facility in-service, ANE, and resident Rights, dated 11/02/24, revealed the following:28 Staff were in-serviced on the following: Every individual was responsible for identifying abuse, neglect, exploitation, and misappropriation in the facility and reporting any allegation or suspicion of these events to the abuse coordinator. It stated that in the event that the abuse coordinator was unavailable, the alternate abuse coordinator was the DON. Record review of facility in-service, ANE, and Reporting, dated 10/17/24, revealed the following: Regional Director J in-serviced the ADM, the DON, the ADON, and LVN K on Long-Term Care Regulation Provider 2024-14, dated 08/29/24, which discussed Reportable incidents and Timeframes. Record review of facility in-service, Event Reporting, dated 11/19/24, revealed the following: The ADM, the DON, and Regional Director J were in-serviced on event reporting. The in-service discussed key aspects (confidentiality, analysis, feedback/learning, and regulatory compliance) of event reporting. The in-service also included the required parties to be notified: the resident responsible party, emergency contact, the DON, the administration, and the abuse preventionist. Record

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect for 5 of 7 residents (Resident #1, #2, #3, #4, and #5) reviewed for abuse. A. The Interim DON failed to follow the facility's abuse policy by not reporting the allegation of sexual abuse to HHSC and documenting her investigation measures regarding Resident #1 and Resident #2 reported by Dietary Aide B on an unknown date. B. The Former ADM failed to follow the facility's abuse policy by not reporting the allegation of sexual abuse to HHSC and documenting her investigation measures regarding Resident #1 and Resident #2 reported by Dietary Aide B on an unknown date. C. The Interim DON failed to follow the facility's abuse policy by not reporting the allegation of inappropriate sexual touching to HHSC and documenting her investigation measures regarding Resident #3 and Resident #5 reported by an unknown staff on 03/07/24. D. The Former ADM failed to follow the facility's abuse policy by not reporting the allegation of inappropriate sexual touching to HHSC and documenting her investigation measures regarding Resident #3 and Resident #5 reported by an unknown staff on 03/07/24. E. Cook A failed to follow the facility's abuse policy by not reporting the allegation of sexual abuse to the abuse preventionist. F. The DM failed to follow the facility's abuse policy by not reporting the allegation of sexual abuse to the abuse preventionist that involved Resident #1 and Resident #2 that was reported to her by Dietary Aide B on an unknown date. G. LVN F failed to follow the facility's abuse policy by not following up, assessing Resident #4 after CNA E reported that Resident #4 felt uncomfortable around Resident #3 on an unknown date. H. The Former ADM failed to follow the facility's abuse policy by not reporting the allegation of sexual abuse to HHSC and documenting her investigation measures regarding Resident #3 and Resident #5 reported by unknown staff on an unknown date. I. The Former ADM and Interim DON failed to follow the facility's abuse policy by not notifying Family Member G that Resident #4 had expressed she felt uncomfortable around a male resident. An Immediate Jeopardy (IJ) was identified on 11/19/24 at 2:48 PM. The IJ template was provided to the facility on [DATE] at 2.48 PM. While the IJ was removed on 11/20/24 at 1:28 PM, the facility remained out of compliance at a severity level of actual harm and a scope of widespread due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents as risk for abuse and neglect. Findings included: Record review of the facility policy, Abuse Prevention Program, Revised December 2016 revealed: Policy Statement: Our Residents have the right to be free from abuse, neglect .Policy Interpretation and Implementation: As a part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone including, but not necessarily limited to other residents .Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Identify and assess all possible incidents of abuse; Investigate and report any allegations of abuse within timeframes as required by federal requirements; Protect residents during abuse investigations. Record review of the facility policy, Abuse Investigation and Reporting, revised July 2017 revealed: Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Policy interpretation: If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Role of the investigator: The individual conducting the investigation will as a minimum; Review the completed documentation forms; Review the resident's medical record; Interview the persons reporting the incident; Interview the resident as medically appropriate; Interview staff members on ALL shifts Interview the resident's roommate; Review all events leading up to the alleged incident; and Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the administrator. Reporting: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility; The resident's representative (sponsor) of record an alleged violation of abuse, neglect . Two hours if the alleged violation involves abuse . Record review of the facility policy, Recognizing Signs and Symptoms of Abuse/Neglect, Revised April 2021, revealed: Policy Statement: All types of resident abuse, neglect, exploitation, or misappropriation of resident property are strictly prohibited. All personnel are expected to report any signs and symptoms of abuse/neglect to their supervisor or to the director of nursing services immediately. Policy Interpretation: The following are signs and symptoms of abuse/neglect that should be promptly reported. This listing is not all-inclusive. Other signs and symptoms or actual abuse/neglect may be apparent. Psychological or behavioral signs of abuse or neglect: Expression of fear of a person or place, or of being left alone, or of the dark; Paranoia . There were no provider investigation reports available for review from 04/01/24-11/01/24 that involved any of the residents listed in the sample or that pertained to the identified deficient practice. Resident #1 Record Review of Resident #1's face sheet, dated 11/01/24, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 14, indicating the resident was not cognitively impaired. Section E did not reveal any documented behaviors for Resident #1. Record Review of Resident #1's Quarterly MDS assessment dated [DATE], revealed Section E did not reveal any documented behaviors for Resident #1. Record review of Resident #1's progress notes dated from 03/02/24- 11/01/24 did not reveal any information regarding the allegation of touching Resident #2's breast or his flirtatious behavior with female residents. Record Review of Resident #1's nursing progress notes entered by the Interim DON dated 05/14/24 at 11:47 PM indicated she spoke with the SW to speak with Resident #1 about calling female staff pet names. A letter was given outlining the facility expectations regarding not calling female staff pet names. Record review of Resident #1's care plan, dated 05/14/24, did not reveal any information regarding his flirtatious behavior towards female residents or allegations regarding touching Resident #2's breast. Resident #2 Record Review of Resident #2's face sheet, dated 11/01/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: dementia (memory loss) and depression (prolonged period of sadness). Record Review of Resident #2's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 08, indicating the resident was moderately cognitively impaired. Section E did not reveal any documented behaviors for Resident #2. Record Review of Resident #2's Quarterly MDS assessment dated [DATE], revealed Section E did not reveal any documented behaviors for Resident #2. Record review of Resident #2's care plan, dated 08/06/24, did not reveal any information regarding her being touched by another male resident. Further review revealed a focused area, initiated on 08/06/24, that indicated Resident #2 wanted to be in an affectionate relationship with male residents. The goal initiated on 08/06/24 and revised 10/18/24, was based on family wishes for Resident #2 to visit with male resident (unidentified) in the common area. The interventions initiated 08/06/24 included avoid improper touching, avoid going into other residents' room, keeping the family updated with family status, and talking happy about relationships with male residents. Record review of Resident #2's progress notes dated from 03/02/24- 11/01/24 did not reveal any information regarding the allegation of her breast being touched by Resident #1. Record Review of Resident #2's nursing progress notes entered by LVN H dated 08/02/24 at 7:02 PM indicated Resident #2 was in a male (unidentified) room sitting in her wheelchair and a CNA (unidentified) observed the male resident with his pants around his ankles claiming that he was going to have sex with her. During an interview on 11/01/24 at 9:22 AM, [NAME] A stated Resident #1 was a ladies' man. She said he had a history of flirting since his admission. [NAME] A stated there was a history between Resident #1 and #2. She said Resident #1's attempt to flirt and approach Resident #2 caused issues with the other resident, who was no longer at the facility. She said she had not been given any instructions or training regarding Resident #1. She said outside of the incident (Resident #1 touching Resident #2's breast) with Resident #2, she had seen him touch other residents' hands. She said Resident #4 would play with herself. She said she had been told (she could not remember by who) that she would do this when she was nervous. She said this was a known behavior (unable to report for how long) but that male residents would watch her rub on herself in a circular motion. She said staff talked to her about it as much as they could. She said there was an indication that she was about to do it because she would raise her leg. At first, she thought she (resident #4) was itching, but she believed she was checked to rule that out. She said the staff knew to redirect her, offer her a drink, or engage her in another activity. She said she had not received additional training about Resident #4's behavior, but some staff knew how to redirect her. She said if they did not see her raise her legs, it was easy to identify because all the male resident's heads would be turned towards her doing that behavior in the dining room or any common area. She said no other residents have become offended or complained that she was aware of. She said she could not confirm if the other residents were looking at Resident #4 for pleasure or out of shock. During an interview on 11/01/24 at 11:33 AM, CNA E stated over the past month, Resident #4 had a behavior of rubbing herself in her genital area. She said other staff had also noticed it. She said naturally, she and other staff would redirect her. She said they had not received specific training regarding Resident #4 rubbing her genital area. She said they had general knowledge to redirect her since sometimes she would do this in common areas. She said Resident #3 would sit and watch Resident #4 rub herself in her genital area. She said Resident #1 was her (CNA E) family member, and although she had not seen him touch the breasts of anyone, he was known as a big flirt. She said she had observed Resident #1 hold hands with Resident #2 but that Resident #2 was friendly and did not care. She said Resident #2 had a boyfriend who was no longer at the facility, and Resident #1 would stir the pot and upset the resident who was no longer at the facility by flirting with Resident #2. During an interview on 11/01/24 at 9:55 AM, the DM stated Dietary Aide B did report to her that Resident #1 had grabbed Resident #2's breast. She said she was unsure of the exact date. She said she did not witness it, but it was considered inappropriate touching. She said when it was reported to her, she told Dietary Aide B that someone needed to know. She said the ADM was not the administrator and did not know which nurse Dietary Aide B reported the incident to. She said she did not personally report the incident to anyone because she did not personally observe the incident. She said it was her understanding that Dietary Aide B reported the incident to Regional Director J and the charge nurse. She said she could not remember who the charge nurse was. She said she had observed Resident #1 to be social but not overly attentive to any one resident. She said she had not received any special instructions regarding Resident #1. She said although she did not remember the exact date, she did remember the day Dietary Aide B reported the incident. Resident #2 seemed fine and not in any distress. She said she felt if Resident #2 felt threatened, she could tell someone. She said the ADM was the abuse preventionist and had been trained that if she suspected or witnessed abuse, she was to report the allegation to the ADM immediately. She said she had not been interviewed by anyone regarding the incident. During an interview on 11/01/24 at 11:06 AM, the Interim DON stated she no longer worked at the facility. She said she was notified of the incident between Resident #1 and Resident #2. She said she was unsure of the exact date of the incident between Resident #1 and #2, but it was first reported when the Former ADM was employed by Dietary Aide B. She said an investigation was conducted, and it was unfounded by the Former ADM. She said Regional Director J took over after the former ADM left. She said when Regional Director J took over, the incident involving Resident #1 and #2 was brought back up. She said she interviewed Residents (Resident #1 and #2), and nothing was found. She said she was unable to list all she interviewed as she did not work there anymore. She said this may have been in April or May 2024. She said she remembered when she interviewed Resident #1 and Resident #2, both residents denied anything happening and therefore she unfounded the incident. She said there were concerns because each time the new administration would come, the incident of Resident #1 touching Resident #2's breast would come up. She said she did not believe anything had happened because no other allegations had been made since the report. She said it was her understanding that Resident #1 had not approached Resident #2 since the allegation. She said she was unsure why the allegation continued to be addressed, and it seemed to be the kitchen staff that had concerns. She said during her investigation, she found that the people named to be present were not working the day of the incident. The Interim DON said she could not list the people who worked the day of the incident, the date of the incident, and anyone she interviewed, but she unfounded the incident. She said this had been reported to her a total of three times, and she did not report the incident to HHSC during any of those times. She said she did not report the allegation of sexually inappropriate touching because Residents #1 and #2 stated the incident had not occurred, and they unfounded the incident. She said she did keep her eye on Resident #1. She said Family Member G had been notified. She said she had not received any additional reports that Resident #1 had touched any other residents. She said she did not know if she had any written documentation to support her efforts to address the allegations of sexually inappropriate touching from Resident #1. She said she never typed anything up. She said she should have typed something in his progress notes since this was brought up many times. She said she could not pinpoint specific training related to the incident because she had done so many in-services on ANE. She said she did discuss the incident with Regional Director I, and they had decided the incident was not a facility reportable incident because both residents had dementia, and both parties stated nothing happened. She said they agreed that since the kitchen staff kept reporting it, it was retaliation. She said it was not reported to HHSC because there was no proof that it happened and no witnesses. She said that it was known that Dietary Aide B was married into the family of Resident #1 and that she must also protect Resident #1's rights. She said the purpose of following the abuse policy, reporting, and investigating allegations of ANE was to protect the population from ANE, make sure their needs were met, and avoid neglect. She said she had been trained that it was all or none. She said this meant that she was to collect data, have credible witnesses, and then report the incident to HHSC. She said she felt Resident #1 was being painted as a perpetrator based on community rumors. She said she wanted to also protect Resident #1 from false allegations. In regard to documentation, she said she would have to see if she had anything. (The Interim DON did not provide any documentation during the investigation) During an interview on 11/01/24 at 11:33 AM, CNA E stated she said Resident #1 was her (CNA E) family member, and although she had not seen him touch the breasts of anyone, he was known as a big flirt. She said she had observed Resident #1 holding hands with Resident #2 but Resident #2 was friendly and did not care. She said Resident #2 had a boyfriend who was no longer at the facility, and Resident #1 would stir the pot and upset the resident who was no longer at the facility by flirting with Resident #2. During an interview on 11/01/24 at 11:55 AM, RN C stated she was notified a few months ago (unknown exact date and time) by Dietary Aide B that she witnessed Resident #1 touching Resident #2's breast. She said she was told by Dietary Aide B that it did not seem mutual. RN C said she asked Dietary Aide B if she had reported the incident to the Interim DON as they did not have an administrator at the time. She said Dietary Aide B said she had. RN C asked if anything had been done and was told by Dietary Aide B that she did not think anything had been done. RN C stated she encouraged Dietary Aide B to report it again. She said it would have been reported to Regional Director J at this time. She said it was her understanding that it was reported to Regional Director J, who responded that he was aware the incident had been investigated and unfounded. She said she was unaware if it had been reported to HHSC. She said Resident #1 had a history of being friendly with female residents since his admission. She said he would grab the female resident's hands and kiss them. She said she had never seen him grab Resident #2's breast. She said she had not received special instruction regarding Resident #1, nor had she been interviewed regarding the allegation of sexually inappropriate touching between Resident #1 and #2. During an interview on 11/01/24 at 12:01 PM Dietary Aide B stated she was aware of an instance where Resident #1 touched the breast of Resident #2 in the dining room. She said she reported the incident to the Interim DON. She said the incident happened right after Mother's Day in 2024. She said she had seen other inappropriate things from Resident #1. She said she had observed him touch Resident #2's breast more than one time. She said she observed when she opened the door that entered the dining room from the kitchen him touching Resident #2's breast, and when he saw her, he put his hands down, and his face turned red. She said she immediately reported the incident to the Interim DON in the presence of LVN L. She explained to the Interim DON that this was not the first time Resident #1 had been inappropriate with female residents. She said she told the Interim DON that the touching was against Resident #2's will. She said she knew this because Resident #2 did not participate; it was just Resident #1. She said when she reported the incident to the Interim DON, she was told by the Interim DON that she would speak to Resident #2. She said she was also told that because Resident #2 had a boyfriend (no longer at the facility at the time of the investigation), it was ok for Resident #2 to have two boyfriends if she wanted. She said the Interim DON said she would ask Resident #2 if she wanted two boyfriends. She said the Interim DON had also explained to her that the laws had changed. She said she was told that if Resident #2 could not say what happened and if she had memory loss or dementia, there was nothing they could do about it. She said the Interim DON told her to let her know if she saw anything else. She said the former ADM was the administrator at the time of the incident. She said the Interim DON reported the incident to Regional Director J, and he spoke with her about it once. She said Regional Director J asked her what happened, she explained that the incident occurred under the Former ADM and told her to let him know if it happened again. She said it had not happened again, but nothing was done. She said she had not received any special instructions or additional training on what to do regarding Resident #1. She said Regional Director J was the only person who ever asked her anything about the incident. She explained there was another incident involving Resident #1. Still, she did not report it because she was unsure if it was considered inappropriate touching. She said nothing had been done with the incident between Resident #1 and #2. She said she did report the incident between Resident #1 and #2 to the DM but was told for her to report the incident herself. She said her DM told her to report the incident because she did not personally see the incident. She said outside of the interview with the HHSC investigator, she felt the incident had not been thoroughly investigated. During an interview on 11/01/24 at 12:40 PM, Resident #2 stated no one had touched her inappropriately. She said she had a boyfriend but did not remember his name. She said she knew Resident #1, but he had never touched her inappropriately. She said if someone did touch her, she would tell the people at the front. She said no one had asked her any questions before the HHSC investigator about inappropriately being touched. During an interview on 11/01/24 at 1:25 PM, LVN F stated that she knew of the incident between Resident #1 and Resident #2. She stated she was told about the incident by RN C. She said she could not remember the exact date of the incident, but that RN C stated that it was reported to her (RN C) by Dietary Aide B. She (LVN F) stated that she was not questioned or trained in regard to Resident #1 but remembered that the Interim DON said to Dietary Aide B that Resident #2 could have more than one boyfriend if she wanted. She said the incident was also reported to Regional Director J, and it was her understanding that he did an investigation and unsubstantiated the incident, according to RN C. LVN F said Resident #1 had a history of flirting with female residents and holding their hands. She said she had not seen anything to indicate the other female residents were uncomfortable. She said no instructions had been given regarding the behavior of Resident #1 flirting or holding the female resident's hands. She said they told Resident #1 to leave the female residents alone. She said Resident #1 laughed about it. She said it appeared Resident #1 found humor because he reported to them that Resident #2 was his schoolteacher. During an interview on 11/01/24 at 2:39 PM, LVN H stated she said she was unaware of any incidents that involved Resident #1. She said Resident #1 had a history of being with the female residents. She said he liked to sit with them (female residents). During an interview on 11/01/24 at 2:59 PM, Regional Director I stated he did not know anything about a male resident touching the breast of a female resident. He said he could not recall a specific conversation with the Interim DON. He said he had multiple discussions with the Interim DON. He said the Former DON's last day was May 15th or 16th of 2024. He said there were 10 days without an administrator, and then Regional Director J came to run the facility. He said it was his expectation that if staff suspect or witness abuse, they should follow the facility policy. He said it should be reported to HHSC and investigated thoroughly. He said he was unaware of the allegation between Resident #1 and #2. He said the potential negative outcome for the residents would depend on the allegation. During an interview on 11/01/24 at 3:06 PM, Regional Director J stated he was unaware of any incident that occurred between Resident #1 and Resident #2 that involved breast touching. Regional Director J said he was aware that there was a resident who was no longer at the facility and felt that Resident #1 had stolen his woman (Resident #2). He said if there was an allegation of ANE, it should be reported and investigated. He said investigating the incident was important to ensure the resident was safe. He said the investigation process should be documented. During an interview on 11/01/24 at 3:25 PM, Resident #1 stated he had never been questioned about inappropriate behavior or accused of doing anything inappropriate. He stated he did not have a girlfriend but all the ladies at the facility liked him. He said he recently turned [AGE] years old and found out he was a lesbian because he liked girls. He said he does not touch anyone who does not want to be touched. He said he had not touched anyone since he had been at the facility. During an interview on 11/01/24 at 4:43 PM, the DON stated he said he was unaware of any incidents that occurred between Resident #1 and Resident #2. He said he knew Resident #1 would hold people's hands, but it was not specific to female residents. He said he was unaware that Resident #1 would kiss the female residents' hands. During an interview on 11/01/24 at 4:55 PM, the ADM stated he had been trained and was familiar with the facility's ANE policy. He said he was unaware of the incident involving Resident #1 touching Resident #2's breast. He said the potential negative outcome was there could have been the continuation of abuse or whatever was going on. He said not following the abuse policy could place the resident at unnecessary risk. He said the system to monitor abuse was education and communication. He said he had not observed any of the behaviors of the residents discussed. He said he expected the facility abuse policy to be followed. He said it should have been reported to HHSC and investigated. He said everyone was responsible for following the ANE policy, but the administration oversaw the investigation process and reported the allegation to HHSC. He said he did not have a reason why following the facility policy (reporting to HHSC and investigating) was not conducted. He said the investigation process should have been documented if it was conducted. Resident #3 Record Review of Resident #3's face sheet, dated 11/01/24, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #3's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 15, indicating the resident was not cognitively impaired. Section E did not reveal any documented behaviors for Resident #3. Record Review of Resident #3's Quarterly MDS assessment dated [DATE], revealed Section E did not reveal any documented behaviors for Resident #3. Record Review of Resident #3's nursing progress notes entered by LVN K dated 03/07/24 at 7:04 PM indicated Resident #3 was in the TV room and his pants were unzipped by Resident #5. The CNA (unidentified) hollered out for the residents to stop. Resident #3 did not attempt to stop Resident #5. Record Review of Resident #3's progress notes entered by the SW dated 03/12/24 at 11:36 AM indicated Resident #3 was in the activity room with a female resident unzipping his pants. It was reported that Resident #3 was allowing Resident #5 to unzip his pants. It was reported that Resident #5 had severe dementia and sought out male residents, in particular Resident #3. The SW discussed with Resident #3 about the issue of female resident having dementia and not understanding their actions. The SW informed Resident #3 about notifying staff entering the room and for him to leave the room if it happened again. Record review of Resident #3's care plan, dated 5/03/24, revealed a focused area, initiated on 05/03/24, Resident #3 had been sexually inappropriate allowing a female resident to unzip his pants in a community setting. The goal initiated on 05/03/24, was Resident #3 would have no evidence of sexually inappropriate behavior problems. The interventions included to intervene as necessary to protect the rights and safety of others, discuss the resident's behavior, and monitor behavior episodes. Resident #4 Record Review of Resident #4's face sheet, dated 11/01/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #4's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 10, indicating the resident was moderately cognitively impaired. Section E did not reveal any documented behaviors for Resident #4. Record Review of Resident #4's Quarterly MDS assessment dated [DATE], revealed Section E did not reveal any documented behaviors for Resident #4. Record review of Resident #4's progress notes dated from 03/02/24- 11/01/24 did not reveal any information concerning Resident #3 or the behavior of rubbing herself outside of her clothing. Record review of Resident #4's care plan, dated 09/19/24, did not reveal any information regarding her concerns for Resident #3 or any behaviors of her rubbing herself outside of her clothing near her genital area. During an interview on 11/01/24 at 9:00 AM, the ADM stated he said there had been no issues since he had been at the facility but that he had to educate Resident #3 on not being flirtatious as he had touched another resident's (Resident #4) knee, but nothing out of line. During an interview on 11/01/24 at 11:33 AM, CNA E stated Resident #4 reported to her that she felt uncomfortable with Resident #3. She said other nurses had noticed her discomfort with Resident #3. She said over the past month, Resident #4 had a behavior of rubbing herself in her genital area. She said other staff had also noticed it. She said naturally, she and other staff would redirect her. She said they had not received specific training regarding Resident #4 rubbing her genital area. She said they had general knowledge to redirect her since sometimes she would do this in common areas. She said Resident #3 would sit and watch Resident #4 rub herself in her genital area. She said she was keeping an eye on them both. She

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure allegations of abuse, neglect, exploitation, or mistreatment have evidence that all alleged violations were thoroughly investigated and prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress and reported the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation was verified appropriate corrective action were taken, for 5 of 7 residents (Resident #1, #2, #3, #4, and #5) reviewed for abuse. A. The Interim DON failed to follow the facility's abuse policy by not documenting her investigation measures and implementing protective measures regarding Resident #1 and Resident #2 involvement in inappropriate sexual touching reported by Dietary Aide B on an unknown date. B. The Former ADM failed to follow the facility's abuse policy by not documenting her investigation measures and implementing protective measures regarding Resident #1 and Resident #2 involvement in inappropriate sexual touching reported by Dietary Aide B on an unknown date. C. The Interim DON failed to follow the facility's abuse policy by not documenting her investigation measures and implementing protective measures regarding Resident #3 and Resident #5 involvement of inappropriate touching reported by an unknown staff on 03/07/24. D. The Former ADM failed to follow the facility's abuse policy by not documenting her investigation measures and implementing protective measures regarding Resident #3 and Resident #5 involvement of inappropriate touching reported by an unknown staff on 03/07/24. E. The Interim DON, LVN F, and CNA E failed to follow the facility's abuse policy by not documenting her investigation measures and implementing protective measures regarding Resident #3 and Resident #4 after Resident #4 expressed that she felt unsafe around Resident #3. An Immediate Jeopardy (IJ) was identified on 11/19/24 at 2:48 PM. The IJ template was provided to the facility on [DATE] at 2:48 PM. While the IJ was removed on 11/20/24 at 1:28 PM, the facility remained out of compliance at a severity level of actual harm and a scope of widespread due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents as risk for abuse and neglect by not investigating and implementing preventative measures in place. Findings included: Resident #1 Record Review of Resident #1's face sheet, dated 11/01/24, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 14, indicating the resident was not cognitively impaired. Section E did not reveal any documented behaviors for Resident #1. Record Review of Resident #1's Quarterly MDS assessment dated [DATE], revealed under Section E did not reveal any documented behaviors for Resident #1. Record review of Resident #1's progress notes dated from 03/02/24- 11/01/24 did not reveal any information regarding the allegation of touching Resident #2 breast or his flirtatious behavior with female residents. Record Review of Resident #1's nursing progress notes entered by the Interim DON dated 05/14/24 at 11:47 PM indicated she spoke with the SW to speak with Resident #1 about calling female staff pet names. A letter was given outlining the facility expectations regarding not calling female staff pet names. Record review of Resident #1's care plan, dated 05/14/24, did not reveal any information regarding his flirtatious behavior towards female residents or allegation regarding touching Resident #2's breast. Resident #2 Record Review of Resident #2's face sheet, dated 11/01/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with the following diagnoses: dementia (memory loss), and depression (prolonged period of sadness). Record Review of Resident #2's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 08, indicating the resident was moderately cognitively impaired. Section E did not reveal any documented behaviors for Resident #2. Record Review of Resident #2's Quarterly MDS assessment dated [DATE], revealed under Section E did not reveal any documented behaviors for Resident #2. Record review of Resident #2's care plan, dated 08/06/24, did not reveal any information regarding her being touched by another male resident .Further review revealed a focused area, initiated on 08/06/24, that indicated Resident #2 wanted to be in an affectionate relationship with male residents. The goal initiated on 08/06/24 revised 10/18/24, was based on family wishes for Resident #2 to visit with male resident (unidentified) in the common area. The interventions initiated 08/06/24 included avoid improper touching, avoid going into other residents room, keeping resident family updated with relationship status and talking often about being happy when she is in a relationship with male residents. Record review of Resident #2's progress notes dated from 03/02/24- 11/01/24 did not reveal any information regarding the allegation of her breast being touched by Resident #1. Record Review of Resident #2's nursing progress notes entered by LVN H dated 08/02/24 at 7:02 PM indicated Resident #2 was in a male (unidentified) room sitting in her wheelchair and a CNA (unidentified) observed the male resident with his pants around his ankles claiming that he was going to have sex with her. During an interview on 11/01/24 at 9:55 AM, the DM stated Dietary Aide B did report to her that Resident #1 had grabbed Resident #2's breast. She said she was unsure of the exact date. She said she did not witness it but considered inappropriate touching. She said when it was reported to her, she told Dietary Aide B that someone needed to know. She said the ADM was not the administrator and did not know which nurse Dietary Aide B reported the incident to. She said she did not personally report the incident to anyone because she did not personally observe the incident. She said it was her understanding that Dietary Aide B reported the incident to Regional Director J and the charge nurse. She said she could not remember who the charge nurse was. She said she had observed Resident #1 to be social but not overly attentive to any one resident. She said she had not received any special instructions regarding Resident #1. She said although she did not remember the exact date, she did remember the day Dietary Aide B reported the incident. Resident #2 seemed fine and not in any distress. She said she felt if Resident #2 felt threatened, she could tell someone. She said the ADM was the abuse preventionist and had been trained that if she suspected or witnessed abuse, she was to report the allegation to the ADM immediately. She said she had not been interviewed by anyone regarding the incident. During an interview on 11/01/24 at 11:06 AM, the Interim DON stated she no longer worked at the facility. She said she was notified of the incident between Resident #1 and Resident #2. She said she was unsure of the exact date of the incident between Resident #1 and #2, but it was first reported when the Former ADM was employed by dietary Aide B. She said an investigation was conducted, and it was unfounded by the Former ADM. She said Regional Director J took over after the former ADM left. She said when Regional Director J took over, the incident involving Resident #1 and #2 was brought back up. She said she interviewed Residents (Resident #1 and #2), and nothing was found. She said she was unable to list all she interviewed as she did not work there anymore. She said this may have been in April or May 2024. She said she remembered when she interviewed Resident #1 and Resident #2, both residents denied anything happening and therefore unfounded the incident. She said there were concerns because each time the new administration would come, the incident of Resident #1 touching Resident #2's breast would come up. She said she did not believe anything had happened because no other allegations had been made since the report. She said it was her understanding that Resident #1 had not approached Resident #2 since the allegation. She said she was unsure why the allegation continues to be addressed, and it seemed to be the kitchen staff that had concerns. She said during her investigation, she found that the people named to be present were not working the day of the incident. The Interim DON said she could not list the people who worked the day of the incident, the date of the incident, and anyone she interviewed, but she unfounded the incident. She said this had been reported to her a total of three times, and she did not report the incident to HHSC during any of those times. She said she did not report the allegation of sexually inappropriate touching because Residents #1 and #2 stated the incident had not occurred, and they unfounded the incident. She said she did keep her eye on Resident #1. She said Family Member G had been notified. She said she had not received any additional reports that Resident #1 had touched any other residents. She said she did not know if she had any written documentation to support her efforts to address the allegations of sexually inappropriate touching from Resident #1. She said she never typed anything up. She said she should have typed something in his progress notes since this was brought up many times. She said she could not pinpoint specific training related to the incident because she had done so many in-services on ANE. She said she did discuss the incident with Regional Director I, and they had decided the incident was not a facility reportable incident because both residents had dementia, and both parties stated nothing happened. She said they agreed that since the kitchen staff kept reporting it, it was retaliation. She said it was not reported to HHSC because there was no proof that it happened and no witnesses. She said that it was known that Dietary Aide B was married into the family of Resident #1 and that she must also protect Resident #1's rights. She said the purpose of following the abuse policy, reporting, and investigating allegations of ANE was to protect the population from ANE, make sure their needs were met, and avoid neglect. She said she had been trained that it was all or none. She said this meant that she was to collect data, have credible witnesses, and then report the incident to HHSC. She said she felt Resident #1 was being painted as a perpetrator based on community rumors. She said she wanted to also protect Resident #1 from false allegations. In regard to documentation, she said she would have to see if she had anything. (The Interim DON did not provide any documentation during the investigation) During an interview on 11/01/24 at 11:33 AM, CNA E stated she said Resident #1 was her (CNA E) family member, and although she had not seen him touch the breasts of anyone, he was known as a big flirt. She said she had observed Resident #1 hold hands with Resident #2 but Resident #2 was friendly and did not care. She said Resident #2 had a boyfriend who was no longer at the facility, and Resident #1 would stir the pot and upset the resident who was no longer at the facility by flirting with Resident #2. During an interview on 11/01/24 at 11:55 AM, RN C stated she was notified a few months ago (unknown exact date and time) by Dietary Aide B that she witnessed Resident #1 touching Resident #2's breast. She said she was told by Dietary Aide B that it did not seem mutual. RN C said she asked Dietary Aide B if she had reported the incident to the Interim DON as they did not have an administrator at the time. She said Dietary Aide B said she had. RN C asked if anything had been done and was told by Dietary Aide B that she did not think anything had been done. RN C stated she encouraged Dietary Aide B to report it again. She said it would have been reported to Regional Director J at this time. She said it was her understanding that it was reported to Regional Director J, who responded that he was aware the incident had been investigated and unfounded. She said she was unaware if it had been reported to HHSC. She said Resident #1 had a history of being friendly with female residents since his admission. She said he would grab the female resident's hands and kiss them. She said she had never seen him grab Resident #2's breast. She said she had not received special instruction regarding Resident #1, nor had she been interviewed regarding the allegation of sexually inappropriate touching between Resident #1 and #2. During an interview on 11/01/24 at 12:01 PM Dietary Aide B stated she was aware of an instance where Resident #1 touched the breast of Resident #2 in the dining room. She said she reported the incident to the Interim DON. She said the incident happened right after Mother's Day in 2024. She said she had seen other inappropriate things from Resident #1. She said she had observed him touch Resident #2's breast more than one time. She said she observed when she opened the door that entered the dining room from the kitchen him touching Resident #2's breast, and when he saw her he put his hands down, and his face turned red. She said she immediately reported the incident to the Interim DON in the presence of LVN L. She explained to the Interim DON that this was not the first time Resident #1 had been appropriate with female residents. She said she told the Interim DON that the touching was against Resident #2's will. She said she knew this because Resident #2 did not participate; it was just Resident #1. She said when she reported the incident to the Interim DON, she was told by the Interim DON that she would speak to Resident #2. She said she was also told that because Resident #2 had a boyfriend (no longer at the facility at the time of the investigation), it was ok for Resident #2 to have two boyfriends if she wanted. She said the Interim DON said she would ask Resident #2 if she wanted two boyfriends. She said the Interim DON had also explained to her that the laws had changed. She said she was told that if Resident #2 could not say what happened and if she had memory loss or dementia, there was nothing they could do about it. She said the Interim DON told her to let her know if she) saw anything else. She said the former ADM was the administrator at the time of the incident. She said the Interim DON reported the incident to Regional Director J, and he spoke with her about it once. She said Regional Director J asked her what happened, she explained that the incident occurred under the Former ADM, and told her to let him know if it happened again. She said it had not happened again, but nothing was done. She said she had not received any special instructions or additional training on what to do regarding Resident #1. She said Regional Director J was the only person who ever asked her anything about the incident. She explained there was another incident involving Resident #1. Still, she did not report it because she was unsure if it was considered inappropriate touching. She said nothing had been done with the incident between Resident #1 and #2. She said she did report the incident between Resident #1 and #2 to the DM but was told for her to report the incident herself. She said her DM told her to report the incident because she did not personally see the incident. She said outside of the interview with the HHSC investigator, she felt the incident had not been thoroughly investigated. During an interview on 11/01/24 at 12:40 PM, Resident #2 stated no one had touched her inappropriately. She said she had a boyfriend but did not remember his name. She said she knew Resident #1, but he had never touched her inappropriately. She said if someone did touch her, she would tell the people at the front. She said no one had asked her any questions before the HHSC investigator about inappropriately being touched. During an interview on 11/01/24 at 1:25 PM, LVN F stated that she knew the incident between Resident #1 and Resident #2. She stated she was told about the incident by RN C. She said she could not remember the exact date of the incident but that RN C stated that it was reported to her (RN C) by Dietary Aide B. She (LVN F) stated that she was not questioned or trained in regard to Resident #1 but remembered that the Interim DON said to Dietary Aide B that Resident #2 could have more than one boyfriend if she wanted. She said the incident was also reported to Regional Director J, and it was her understanding that he did an investigation and unsubstantiated the incident, according to RN C. LVN F said Resident #1 had a history of flirting with female residents and holding their hands. She said she had not seen anything to indicate the other female residents were uncomfortable. She said no instructions had been given regarding the behavior of Resident #1 flirting or holding the female resident's hands. She said they told Resident #1 to leave the female residents alone. She said Resident #1 laughed about it. She said it appeared Resident #1 found humor because he reported to them that Resident #2 was his school teacher. During an interview on 11/01/24 at 2:59 PM, Regional Director I stated he did not know anything about a male resident touching the breast of a female resident. He said he could not recall a specific conversation with the Interim DON. He said he had multiple discussions with the Interim DON. He said the Former DON's last day was May 15th or 16th of 2024. He said there were 10 days without an administrator, and then Regional Director J came to run the facility. He said it was his expectation that if staff suspect or witness abuse, they should follow the facility policy. He said it should be investigated thoroughly. He said he was unaware of the allegation between Resident #1 and #2. He said the potential negative outcome for the residents would depend on the allegation. During an interview on 11/01/24 at 3:06 PM, Regional Director J stated he was unaware of any incident that occurred between Resident #1 and Resident #2 that involved breast touching. Regional Director J said he was aware that there was a resident who was no longer at the facility and felt that Resident #1 had stolen his woman (Resident #2). He said if there was an allegation of ANE, it should be investigated. He said investigating the incident was important to ensure the resident was safe. He said the investigation process should be documented. During an interview on 11/01/24 at 3:25 PM, Resident #1 stated he had never been questioned about inappropriate behavior or accused of doing anything inappropriate. He stated he did not have a girlfriend but all the ladies at the facility liked him. He said he recently turned [AGE] years old and found out he was a lesbian because he liked girls. He said he does not touch anyone who does not want to be touched. He said he had not touched anyone since he had been at the facility. During an interview on 11/01/24 at 4:43 PM, the DON stated he said he was unaware of any incident that occurred between Resident #1 and Resident #2. He said he knew Resident #1 would hold people's hands, but it was not specific to female residents. He said he was unaware that Resident #1 would kiss the female resident hands. During an interview on 11/01/24 at 4:55 PM, the ADM stated he had been trained and was familiar with the facility's ANE policy. He said he was unaware of the incident involving Resident #1 touching Resident #2's breast. He said the potential negative outcome was there could have been the continuation of abuse or whatever was going on. He said not following the abuse policy could place the resident at unnecessary risk. He said allegations of ANE should have been investigated. He said the system to monitor abuse was education and communication. He said he had not observed any of the behaviors of the residents discussed. He said he expected the facility abuse policy to be followed. He said allegations of ANE should have been investigated along with preventative measures put in place to protect residents involved. He said everyone was responsible for following the ANE policy, but the administration oversaw the investigation process. He said he did not have a reason why following the facility policy (investigating) was not conducted. He said the investigation process should have been documented if conducted. Resident #3 Record Review of Resident #3's face sheet, dated 11/01/24, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #3's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 15, indicating the resident was not cognitively impaired. Section E did not reveal any documented behaviors for Resident #3. Record Review of Resident #3's Quarterly MDS assessment dated [DATE], revealed under Section E did not reveal any documented behaviors for Resident #3. Record Review of Resident #3's nursing progress notes entered by LVN K dated 03/07/24 at 7:04 PM indicated Resident #3 was in the TV room and his pants was unzipped by Resident #5. The CNA (unidentified) hollered out for the residents to stop. Resident #3 did not attempt to stop Resident #5. Record Review of Resident #3's progress notes entered by the SW dated 03/12/24 at 11:36 AM indicated Resident #3 was in the activity room with a female resident unzipping his pants. It was reported that Resident #3 was allowing Resident #5 to unzip his pants. It was reported that Resident #5 had severe dementia and seeks out male residents in particular Resident #3. The SW discussed with Resident #3 about the issues of female resident having dementia and not understanding their actions. The SW informed Resident #3 about notifying staff entering the room and for him to leave the room if it happens again. Record review of Resident #3's care plan, dated 5/03/24, revealed a focused area, initiated on 05/03/24, Resident #3 had been sexually inappropriate allowing a female resident to unzip his pants in a community setting. The goal initiated on 05/03/24, was Resident #3 would have no evidence of sexually inappropriate behavior problems. The interventions included to intervene as necessary to protect the rights and safety of others, discuss the resident's behavior and monitor behavior episodes. Resident #4 Record Review of Resident #4's face sheet, dated 11/01/24, revealed a [AGE] year-old female that was initially admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of dementia (memory loss). Record Review of Resident #4's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 10, indicating the resident was moderately cognitively impaired. Section E did not reveal any documented behaviors for Resident #4. Record Review of Resident #4's Quarterly MDS assessment dated [DATE], revealed under Section E did not reveal any documented behaviors for Resident #4. Record review of Resident #4's progress notes dated from 03/02/24- 11/01/24 did not reveal any information concerning Resident #3 or the behavior of rubbing herself outside of her clothing. Record review of Resident #4's care plan, dated 09/19/24, did not reveal any information regarding her concerns for Resident #3 or any behaviors of her rubbing herself outside of her clothing near her genital area. During an interview on 11/01/24 at 9:00 AM, the ADM stated he said there had been no issues since he had been at the facility but that he had to educate Resident #3 on not being flirtatious as he had touched another resident's (Resident #4) knee, but nothing out of line. During an interview on 11/01/24 at 1:01 PM, Resident #4 stated she felt safe. She said there was a male who made her feel uncomfortable. She said she did not know his name. She stated no one asked her about him. She was unable to tell why he made her uncomfortable. She said no one had touched her inappropriately. She said that if someone did touch her, she thinks she would tell someone. During an interview on 11/01/24 at 1:25 PM, LVN F stated she said she could not remember if it was reported to her that Resident #4 was uncomfortable around Resident #3. She said she could not remember the date, but the incident occurred about a month ago. She said she could not remember which aide came to her. She said she observed Resident #3 sitting outside Resident #4's room and thought it was weird. She said Resident #4 was in her bed. She said she looked off for a moment, and when she looked back up, Resident #3 was gone. She said she asked the aide (unknown at the time) to go check on him because Resident #3 had an inappropriate sexual incident with another resident in the past. She said it was her understanding that Resident #3 and another Resident #5 were fondling each other. She said she wanted to ensure Resident #3 was not in the room with Resident #4. She said she did report the weird behavior observed by Resident #3 to Regional Director J. She said Resident #3 will follow and target Resident #5 than other residents. She said Regional Director J told her to keep an eye on Resident #3. She said no additional training was given regarding Resident #3. She said she reported it to Regional Director J because of Resident #3's past. She said she did not believe the incident between Resident #3 and #5 was mishandled. She did not know why she thought it was not handled correctly. During an interview on 11/01/24 at 1:37 PM, Resident #3 stated he had only been told about inappropriate touching one time since his admission. He said he did not want to name the other resident but that she had run her hands up his leg. He said he had no other issues since that incident about a year ago. He said he did not remember staring at any other female residents. He asked the HHSC investigator if she knew anyone who could be his girlfriend because he would like one. During an interview on 11/01/24 at 2:39 PM, LVN H stated a couple of weeks ago (exact date unknown) that she was coming from the outside patio and observed Resident #3 had his hand on Resident #4's knee. She said she reported the incident to the ADM because there had been some incidents in the past that included Resident #3 and inappropriate sexual behavior. She said it was known that Resident #3 liked to stare and watch female residents. She said he had a history with Resident #4, where he would watch her and stare at her outside of Resident #4s room. She said they naturally redirect Resident #3 but had never been explicitly trained on what to do with Resident #3. During an interview on 11/01/24 at 3:06 PM, Regional Director J stated if there was an allegation of ANE, it should be investigated. He said investigating the incident was important to ensure the resident was safe. He said the investigation process should be documented. He said he was unaware that Resident #4 reported that she felt unsafe around Resident #3 because this was not reported to him. During an interview on 11/01/24 at 4:43 PM, the DON stated he said he was unaware that Resident #4 was uncomfortable around Resident #3. He said their system to monitor ANE and the following of the facility's abuse policy was education through in-services. He said there are signs posted outside of the administration doors. He said if staff suspected or witnessed abuse, the allegation should be investigated. He said after the incident was reported, the allegation would be investigated and assessed, the resident evaluated, and all witnesses and potential witnesses would be interviewed. He said he did not have a reason why the abuse policy was not followed. He said the investigation was not conducted because he was unaware of the incidents. He said that being new, he was unaware that any of the incidents/allegations discussed had been investigated. He said he was unaware of Resident #3 flirtatious behavior. He was unaware that Resident #3 had an incident where he sat outside of Resident #4's room, which made her uncomfortable. He said nothing was brought up during stand-up meetings regarding the resident issues discussed. He said if there are new or ongoing behaviors, they are also reported during shift changes. He said they also had a nursing group message system. He said Resident #3 touching Resident #4 was not placed in the nursing group message. He said Resident #3 behavior of staring at Resident #4 was also not included in the group message because he did not know anything about it. He said he had not observed any of the behaviors discussed. During an interview on 11/01/24 at 4:55 PM, the ADM stated he had been trained and was familiar with the facility's ANE policy. He said he was aware that Resident #3 had touched Resident #4's leg, but at the time of the report, LVN H reassured him that there was nothing inappropriate. He said he was unaware of his history of staring at Resident #4 outside her door. He said at the time, LVN H reported more information on Resident #3's history. He said he did not interview anyone else outside of LVN H regarding Resident #3 touching Resident #4's leg. He said the potential negative outcome was there could have been the continuation of abuse or whatever was going on. He said not following the abuse policy could place the resident at unnecessary risk. He said the system to monitor abuse was education and communication. He said he had not observed any of the behaviors of the residents discussed. He said he expected the facility abuse policy to be followed. He said allegations of ANE should have been investigated. He said everyone was responsible for following the ANE policy, but the administration oversaw the investigation process. He said he did not have a reason why following the facility policy (investigating) was not conducted. He said the investigation process should have been documented if conducted. During an interview on 11/01/24 at 5:34 PM, the Corporate MDS Consultant stated she went through each resident's progress notes and found the incident between Resident #3 and Resident #5. She said she was unaware if the incident had been reported to HHSC. She said she did not follow up with anything else because the note indicated it had been reported to the Interim DON and the Former ADM. She said she did not follow up with either of them. She said she was unsure if the incident had been investigated. She said she did not assess or speak with the residents. During an interview on 11/01/24 at 5:40 PM, Regional Director J stated he did not find anything showing that the incident between Resident #3 and Resident #5 was investigated. Resident #5 Record Review of Resident #5's face sheet, dated 11/01/24, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with the following diagnoses: dementia (memory loss) and high risk heterosexual behavior. Record Review of Resident #5's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 04, indicating the resident was severely cognitively impaired. Section E did not reveal any documented behaviors for Resident #5. Record Review of Resident #5's Quarterly MDS assessment dated [DATE], revealed under Section E did not reveal any documented behaviors for Resident #5. Record review of Resident #5's Order Summary Report, dated 11/01/24, reflected the resident was to take 1 tablet 2 times a day by mouth of Depakote for dementia with sexual issues related to dementia; Ordered 3/07/2024. Record Review of Resident #5's nursing progress notes [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained free of accident hazards for 3 of 3 residents (Resident #1, Resident #2 and Resident #3) reviewed for quality of care in that: CNA A failed to operate the Hoyer lift with 2 staff per facility policy when transferring Resident #1 from the wheelchair to the bed. As a result Resident #1 sustained a head injury and was sent to the hospital. Resident #2 stated that staff (unknown) lifted him majority of the time with 1 staff using the Hoyer lift. Uncertified Nurses aides (NA B and NA C) admitted to using the Hoyer lift to transfer residents. The Director of Nurses (DON) and the Director of Rehabilitation (DOR) did not ensure that staff were trained according to their lifting policy to use the Hoyer. The DOR and DON did not have a contingency plan in place if the only Hoyer lift was not operational. A confidential staff admitted to utilizing the Hoyer lift with one staff to transfer residents. The Agency Nurse failed to assess/ take vitals of Resident #1 after she sustained a head injury after being dropped out of the Hoyer lift on [DATE]. Observation of staff (CNA E, F, H & J) using the Hoyer lift to transfer residents (Resident# 1 and Resident #3) revealed that they did not inspect the Hoyer sling and lock the wheels during the process. On [DATE] at 5:12 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] at 3:50 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of harm or injury and contribute to avoidable accidents. Findings Included: Resident 01 Record review of Resident #01's face sheet, dated [DATE], revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia and need for assistance with personal care. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #01 usually understood (misses some part/intent of message but comprehends most conversations). The MDS revealed Resident #01 had a BIMS of 00 which indicated the resident's cognition was severely impaired. Section G revealed the resident transfer required (total dependence) with support (two+ person physical assist) Record review of a care plan, dated [DATE] for Resident #01 revealed: Focus: May use Hoyer lift as needed for transfers; Goal: Will have safe transfers through the review date; Interventions: Assisted transfers with 2 licensed staff. Record review of a care plan, dated [DATE] for Resident #01 revealed: Focus: This resident had a fall from the mechanical lift on [DATE] with a laceration to the back of the head r/t improper use of the mechanical lift by staff; The resident's laceration will be healed by the review date without complications; Interventions: Staff training for proper mechanical lift training. Record review of a care plan, dated [DATE] for Resident #01 revealed: Focus: The resident has an ADL self-care performance deficit r/t dementia, impaired balance, limited mobility, stroke; Goal: The resident will maintain current level of function in mobility and ADLs through the review date; Interventions: Transfer: the resident requires total assistance by 2 staff & Hoyer lift to move between surfaces. Record review of hospital records dated [DATE] revealed the following: 95 years female, trauma-dropped out of Hoyer lift Findings: Brain: Small acute left subdural hematoma measuring up to 5 mm in greatest transverse diameter. No abnormal right sided extra-axial fluid collections. Discharge Diagnosis: Fall, laceration of right side of scalp, subdural hematoma Record review of the transfer paperwork titled, SNF/NF to Hospital Transform Form, undated, revealed the following: Vital signs (blood pressure, heart rate, respiration rate, oxygen level) data dated 5 days before the incident ([DATE]) The pain level data dated 2 days before the incident ([DATE]) Form completed and reviewed by On Call Charge Nurse dated [DATE] at 7:20 PM. Resident 02 Record review of Resident #02's face sheet, dated [DATE], revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include dementia, difficulty walking, unsteadiness on feet, need for assistance with personal care and personal injury of traumatic brain injury. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #02 was usually understood (misses some part/intent of message but comprehends most conversation). The MDS revealed Resident #02 had a BIMS of 07 which indicated the resident's cognition was severely impaired. Section G revealed the resident transfer required (Extensive Assistance) with support (two+ person physical assist) Record review of a care plan, dated [DATE] for Resident #02 revealed the following: Focus: The resident has an ADL self care performance deficit r/t history of traumatic brain injury, dementia, cognitive and low vision; Goal: The resident will maintain current level of function through the review date. Staff will meet his needs; Transfer: The resident requires limited to extensive assistance by 1-2 staff to move between surfaces as necessary. Resident 03 Record review of Resident #03's face sheet, dated [DATE], revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia and a history of falling. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #03 was rarely understood. The MDS revealed Resident #03 had a BIMS of 00 which indicated the resident's cognition was severely impaired. Section G revealed the resident transfer required (total dependence) with support (two+ person physical assist) Record review of a care plan, dated [DATE] for Resident #03 revealed: Focus: The resident has an ADL self care performance deficit; Goal: The resident will maintain current level of function through the review date; Interventions: The resident requires total dependence by Hoyer lift to move between surfaces. During an interview on [DATE] at 3:16 PM, CNA A stated Resident #1's roommate needed to go to the restroom. She said since Resident #1's roommate was on the toilet and was by herself, she moved the bed diagonally to observe both residents. She said she had the Hoyer, opened the legs, and slid the lift under Resident #1's wheelchair. She said she hooked the sling onto the Hoyer lift. She said she had checked everything. She said she remembered that she had the top strap on the blue loop, the middle strap on the green, and the bottom straps crossed on the green loop. She said she lifted the resident up to get tension on the straps. She said she guided her safely to the bed. She said she heard a loud pop once she was over the bed. She said she saw Resident #1 hit her head on the headboard. She said she pushed the call light for help. She said she yelled for help. She said she left the resident, but not for long. She said she knew she was not supposed to leave the resident, but she went and got the nurse in charge. She said she was an agency nurse. She said she stayed with Resident #1 after she got the nurse. She said she placed a cold towel on Resident #1 head. She said she did not remember if the nurse took her vitals. She said the other CNA on shift that night was putting her residents down. She said they tried to put their residents at risk for falls down first. She said she would never transfer another resident with the Hoyer alone again. She said this was her first time doing this alone. She said she had been trained when she first started at the facility, but it had been a while. She said she has been at the facility for over a year. She said she has never had to demonstrate her ability to use the Hoyer lift. She said she had signed an in-service. During an interview on [DATE] at 10:45 AM, the Agency Nurse stated she arrived at work at 5:30 PM. She said around 6:30 PM was when the incident with Resident #1. She said CNA A came to her flabbergasted, as something bad had happened. She said that CNA A kept saying, It was an accident, and I did not mean for it to happen. The Agency Nurse said she was in the medication room and was unsure what she would need. She said she gathered gauze and wound cleanser. She said she went to Resident #1s room, and she was laid on her left side. She said Resident #1 was awake. She said CNA A had placed a damp towel on Resident #1 head. She said when she removed the towel, there was a mass of blood mixed in with Resident #1's hair. She said the bleeding stopped, and you could see the laceration. She said CNA A told her that she was transferring Resident #1 from the wheelchair to the bed with the Hoyer by herself, and the strap came loose. The Agency Nurse said she told CNA A that she was not supposed to operate the Hoyer by herself. She said CNA A said she knew she was not supposed to. She said she did not know who she was supposed to call or what the emergency procedure was for the facility. She said she called the on-call charge nurse, and she said she was in the facility. She said she went to the on-call nurse's office. She said the on-call nurse told her to call the nurse practitioner and then gave her the number for the sheriff's department. She said she was told to call the sheriff's department because EMS responds quicker. She said she called the NP at 6:40 PM. She said she called the sheriff's office at 6:42 PM. She said she called the ADM at 6:50 PM. She said the on-call charge nurse would contact the DON. She said she notified Resident #1s family member at 6:53 PM. She said EMS arrived at 7:00 PM. She said the on-call charge nurse helped her get the paperwork to give to the EMS. She said EMS left with the resident around 7:05 PM. She said she forgot to call the hospital and give a report verbally. She said she did not get Resident #1's vitals. She said she was so frantic she did think to do them. She said she was focused on getting Resident #1 out of the facility. She said the purpose of taking vital signs was to get a baseline. She said it was good because neuro checks are also done. Neurological checks could let one know if something was happening in the brain. She said she was not aware that old vital signs were submitted. She said the on-call charge nurse was the person who submitted the vitals. She said she printed off the face sheet and the medication administration record. She said not taking vitals could have caused staff to miss if something was severely wrong. She said vitals could have helped identify the resident's diagnosis (subdural hematoma). She said she could have looked at the resident pupils. She had a subdural hematoma, which was a serious diagnosis. She said it was a pocket of blood outside of the brain but not outside of the skull. She said she had not been oriented to the facility or their processes as an agency nurse. She said she did not receive a tour of the facility and was not oriented to any policies or what to do in an emergency according to the facility policy. During an interview on [DATE] at 11:11 AM, the On Call Charge Nurse stated she was working in her office when she received the call from the Agency Nurse. She said she told her to come to her office. She said CNA A was crying. She said CNA A told her she was putting Resident #1 in bed. She said she heard a popping noise when she pushed the Hoyer down. She said CNA A said the strap popped off. She said once she knew the resident was safe, she had CNA A write a statement and then ask her to leave. She said she had given The Agency nurse a list of things to do. She said she was not sure if the Agency nurse was frantic. She said she gave her the NP and sheriff's department numbers. She also said on the list she had that she needed to put the information in the computer about the incident and notify the family. She said she told The Agency Nurse to update the vitals. She said she did not notice that the vitals were not current until she later found out that the Agency nurse did not give report to the hospital. She said she was at the facility until 2:30 AM on [DATE] & [DATE]. She said Resident #1 was sent to the hospital and was diagnosed with a subdural hematoma. She said a subdural hematoma was a bleed on the brain, and if it continues to bleed, it can lead to death. She said the purpose of taking a resident vitals after a fall was to identify shock, stability, and a baseline for the residents. She said a person's pulse and neurological checks could have identified if there was a bleed on the brain. She said if there was any indication of neurological problems, then EMS would need to know this because that would change how they treat Resident #1. She said the EMS took time to clean the resident up, but if there was knowledge of potential head trauma or vitals that were abnormal, they would have been busy driving getting her to the hospital. She said she did orient the Agency Nurse to the facility procedures two days prior. She said she asked the Agency Nurse and said she did not have any questions. She said all nurses should know what to do in an emergency. She said the Agency Nurse was responsible for getting Resident #1 vitals. During an interview on [DATE] at 8:04 AM, the Hospital Nurse stated a subdural hematoma was a serious diagnosis. She said it was bleeding in the brain. She said a person could die from that diagnosis. She said she had worked with Resident #1 during her hospital visit on [DATE]. She said that Resident #1 came back in on 10/05 for fever and tachycardia (fast heartbeat). She said this diagnosis could be related to her fall on [DATE]. She said her brain may not be regulating properly with the Dx of subdural hematoma. For example, her brain may not properly tell her how to swallow. She said the hospital did have Hoyer lifts, and they use them. She said it should always be two staff. She said the fact they need a Hoyer indicates that it is a lift that cannot be done alone. She said the second person was vital because that ensures the sling is properly placed under the resident, helps with a safe transfer, and has someone there if anything happens. She said not having vitals could aggravate hospital staff because they cannot see the resident's progression or decline. She said it is common nursing sense to obtain vitals and neurological checks. She said having vitals from 5 days before ([DATE]) would not likely be the same at [DATE], especially if she had bleeding in her brain. During an interview on [DATE] at 2:04 PM, Resident #1 could not answer any questions regarding the incident on [DATE] and about past transfers with the Hoyer lift. During an interview on [DATE] at 10:30 AM, the ADM stated CNA A went to place Resident #1 to bed, and she required the Hoyer lift. CNA A went by herself without the second CNA. She said she was told by CNA A that one of the straps was not secure and came off. Resident #1 hit her head on the headboard. She said it caused a laceration to the back of the head. She said the strap did not break; it just came loose. She said she was unsure why CNA A did not have the 2nd CNA for help. She said CNA A told the charge nurse she knew better than using the Hoyer alone. She said this incident occurred Saturday ([DATE]) around 7:00 PM. She said she sent CNA A home around 7:15 PM. Record review of a care plan, dated [DATE] for Resident #01 revealed: Focus: This resident had a fall from the mechanical lift on [DATE] with a laceration to the back of the head r/t improper use of the mechanical lift by staff; The resident's laceration will be healed by the review date without complications; Interventions: Staff training for proper mechanical lift training. During an interview on [DATE] at 10:35 AM, the ADON stated the expectation of the use of the Hoyer was that it had to be 2 certified nurse aides. She said it could not be a nurse aide. She said the CNA A was certified. During a confidential interview, it was revealed that they (unidentified staff) used the Hoyer alone when short-staffed. They said they were often short-staffed when they came in. They said they recently used the Hoyer lift alone. They said they used the Hoyer last week to transfer a resident. They said they were not the only ones to use the Hoyer alone but that other staff members also used the Hoyer lift with one staff. They said that they had never received Hoyer training at the facility. They said they had never had to demonstrate their knowledge of the Hoyer to anyone. They said they did not know the facility staff oriented agency staff to policy and procedures. They said that they have observed agency staff come in and have to ask questions constantly to provide care to the residents. They said they were relieved that what happened to CNA A and Resident #1 did not happen to them because it could have. During an interview on [DATE] at 1:10 PM, NA B stated she had been an NA for 2 weeks. She said she had used the Hoyer lift with another certified CNA. She said she rolled the resident and paced the net under them. She said they then hooked them up to the Hoyer. She said she had never used the Hoyer alone. She said she had not had recent training from the facility. During an interview on [DATE] at 1:18 PM, NA C stated that she had used the Hoyer lift with the assistance of a certified CNA. She said they had placed a resident in bed and left the sling under them in case they needed to be changed. She said she had not had any formal training. During an interview on [DATE] at 3:05 PM, the Director of Rehabilitation stated they had Hoyer lift training several months ago. He said it was an orientation for everyone. He said during the Hoyer lift training, they discussed the use of the Hoyer, transfers, and gait belts. He said they talked about how to place the sling under the resident. He said they trained the staff to use two people. He said he did not have staff demonstrate the use of the Hoyer. He said the staff present watched him. He said he was not familiar with CNA A. He said he had seen Resident #1 and said the Hoyer lift was an appropriate transfer method for Resident #1 because she could not bear weight. He said that the Hoyer sling used to transfer Resident #1 was not damaged that he knew of and the facility only had one Hoyer lift; if it went out, they did not have a contingency plan. He said if they did have a contingency plan this would help the resident. During an interview on [DATE] at 11:30 AM, CNA E stated she had not been checked off on the use of the Hoyer lift. She said she has never had to demonstrate her knowledge and ability to use the Hoyer lift. She said she has not been trained on a contingency plan in what to do if the one Hoyer they have was to stop working. She said she could use a sheet or get another staff to grab an arm and leg. She said the potential negative outcome of not having a contingency plan would be residents could get hurt. During an interview on [DATE] at 11:35 AM, CNA E stated that if Hoyer was not working, she would get the older one. She said they have a crank Hoyer that they can use. She said she does take vitals, but it was a nurse's duty. During an interview on [DATE] at 11:40 AM, CNA G stated she had been checked off to use the Hoyer lift. She said she has never had to demonstrate. She said if the Hoyer lift does not work, the facility has a manual Hoyer lift that they are supposed to use. She said she was agency staff and had never been oriented to the facility policy and procedures. She said she just used her prior knowledge. During an interview on [DATE] at 11:45 AM, CNA H stated she had training with a group while back at the facility but did not demonstrate it for competency. She said she was unaware of a contingency plan if the one Hoyer lift did not work. During an interview on [DATE] at 11:50 AM the DON stated improper use of the Hoyer lift can lead to serious injury even death. She said it could have been worse if CNA A had not been over the bed. She said not taking a resident's vitals after a fall would mean the staff do not know the status of the resident and they could be worse than what was physically seen. She said not having a contingency plan for the Hoyer could lead to the staff not having a way to transfer the resident. She said there was only one Hoyer because the older one had been decommissioned. She said the staff were no longer using the old Hoyer. She said she did not know where the Hoyer was. She said she was unaware that the staff had not demonstrated using the Hoyer. She said she knew that they went over how to use the Hoyer, but this was before she was hired. She said she was unaware that non-certified aides were using the Hoyer lift. She said she was unaware that there was staff using the Hoyer alone because of staffing. She said she was unaware that the Agency Nurse did not take the resident's vitals. She said she was also unaware that there was no formal contingency plan. Regarding systems in place to monitor the deficient practices, she said annual training should cover Hoyer's use. She said in her experience, she had to demonstrate her skills. She said regarding taking vitals, they have their accident policy. She said she did not have any additional support regarding a contingency plan to ensure things such as contingency plans were not missed. She said there was no system in place to monitor the staff using the Hoyer lift or taking vitals. She said she had to trust that they were doing their job. She said there was no documentation to support staff skill competency for the Hoyer lift. She said she had been trained on the use of the Hoyer when she worked at the hospital, but not at the facility. She said she had training regarding taking vitals after a resident had fallen. She said she had not received any training regarding a contingency plan. She said she expected staff to use the Hoyer with 2 staff. She said non-certified nurse aides should not use the Hoyer to transfer residents. She said they should not be a part of the 2 staff. She said non-certified nurse aides can observe. She said she expected the staff to be 100 percent trained and demonstrate their skills and use of the Hoyer. She said she expected agency staff to have all the skills and training before working in their facility. She expected additional staff to be used until they could secure a working lift. The DON did not specify what the staff would use to transfer. She said regarding Resident #1 and CNA A incident, she expected the CNA to use the Hoyer properly with two staff. She said she, as the DON, she was responsible for monitoring the use of the Hoyer lift. She said the policy said the ADON was responsible, but since she was over the ADON, it was her responsibility. She said orienting agency staff was the responsibility of the same disciplines. She said if it was a CNA, a facility CNA staff would orient the staff. She said if it was a nurse, then a facility nurse would orient the agency nurse. She said she and ADM were responsible for ensuring a contingency plan was in place for transferring residents if the one Hoyer they had was unavailable. She said vitals should have been done as a part of the assessments after a resident falls. She said she has seen staff use the Hoyer in the past but never watched CNA A. She said a subdural hematoma was a serious diagnosis. She said it was a bleed under the subdural tissue. She said it was serious, so she was kept overnight. She said it was very important to take vitals because they could miss something, and with this diagnosis, a resident could rapidly deteriorate. During an interview on [DATE] at 12:00 AM, the ADM stated not training and ensuring that the staff know how to use the Hoyer lift would mean that they, as management, do not know if the staff truly know how to use it. She said staff not properly being trained can lead to injury or death. She said regarding the resident #1 incident, she could have died. She said it could have been much worse if Resident #1 had not been over her bed. She said non-certified nurse aides are not trained, and they could also hurt someone. She said that by not orienting the agency staff to facility policies and procedures or emergency response, the agency staff may not know what they are doing. She said agency staff may do things in a way that was not acceptable to the facility. She said not having a contingency plan could result in the staff breaking something on the residents. She said she was unaware that there were no physical competencies and that the staff did not demonstrate the use of the Hoyer back. She said she was unaware that her non-certified nurse aides were using the lift. She said she was unaware that the Agency Nurse did not take resident vitals. Regarding agency staff, she said she had never had to orient the agency staff. She said they should know what they were doing regarding their skills. She said she was unaware there was no contingency plan for if the Hoyer lift was to no longer work. She said she was unaware that CNA A was using the Hoyer alone. She said she had no system to monitor staff training for Hoyer use and demonstration. She said she did not have a system to monitor if the uncertified nurse's aides were using the Hoyer lift because they were not supposed to use the Hoyer because they had not been fully trained. She said there was no system in place to orient the agency staff. She said there was a book with emergency numbers. She said there was no system to monitor contingency plans for the Hoyer lift. She said she was not sure where the old Hoyer lift was. She said the staff should not be using it. She said there was a sit-to-stand lift, but no one knew. She said she was unaware that CNA A had used the Hoyer by herself but believed if she had done it once she had done it more than once. She said she was unaware that other staff were using the Hoyer lift alone without a second staff. She said she had been trained in using the Hoyer and understood that staff should have demonstrated their use of the Hoyer. She said she has not personally been trained in taking vitals but understands that it has to be done after a fall. She said having a contingency plan had never been brought up. She said she expected all clinical staff to have been trained on using the Hoyer and should have physical competencies. She said she expected all staff to demonstrate to the Director of Rehab or the DON that they could properly use the Hoyer lift. She said it was not her expectation for staff to be just shown how to use the Hoyer. She said it was her expectation that the nurse in the facility take vitals after a fall. She said although she had seen CNAs take vitals, she had not seen them take them at her current facility. She said she understood that the CNA was trained to take vitals, but she did not want them taking vitals at the facility. She said the agency staff should know what comes with their respective discipline. The ADM stated For example, if they are a nurse, they should know all the skills and duties of a nurse. She said she expected if the agency staff had questions, they should ask them. She said with having one Hoyer lift, there should be a contingency plan in place to avoid injury and accidents. Regarding Resident #1 and CNA A, she expected the CNA to have retrieved another staff to help her and keep the resident safe from injury and accident. She said the DOR and the DON were responsible for completing physical competencies and ensuring that clinical staff demonstrated the use of the Hoyer per their policy and procedures. She said it was the responsibility of the DON and charge nurse to ensure that the uncertified nurse aides were not using the Hoyer lift and that other staff were not using the Hoyer lift alone. She said it was the responsibility of the charge nurse to ensure that vitals are taken after a resident falls or experiences any type of head trauma. She said not taking vitals after a potential head injury was unacceptable, especially with two nurses in the facility. She said the resident should not have been moved until assessed. She said overall, the DON was responsible for the activity of CNA A. The ADM confirmed that there were no records of physical competencies in the facility because they did not exist. She said Resident #1 Dx of subdural hematoma was serious because it was bleeding in the brain and Resident #1 could have bled out. She said taking vitals could have helped identify a serious issue with the resident neurologically. She said the staff may have had a chance to respond differently if vitals had been taken. During an observation that occurred on [DATE] at 1:37 PM CNA F and CNA I transferred Resident #3 from her wheelchair to the bed using the Hoyer lift. Prior to operation of the Hoyer neither staff inspected the sling to insure it was intact and safe for use. CNA F and CNA I did not lock the wheels of the Hoyer throughout the use of the Hoyer lift. During an observation that occurred on [DATE] at 1:52 PM CNA E and CNA J transferred Resident #1 from her wheelchair to her bed. Prior to operation of the Hoyer neither staff inspected the sling to insure it was intact and safe for use. Resident #1 was one sided in the sling and no adjustments was made to ensure that the sling was evenly under the resident. Neither staff locked the Hoyer lift prior to using it to lift the resident out of her wheelchair. During an interview on [DATE] at 8:04 AM, the Hospital Nurse stated a subdural hematoma was a serious diagnosis. She said it was bleeding in the brain. She said a person could die from that diagnosis. She said she had worked with the resident during her hospital visit on [DATE]. She said that Resident #1 came back in on 10/05 for fever and tachycardia (fast heartbeat). She said this diagnosis could be related to her fall on [DATE]. She said her brain may not be regulating properly with the Dx of subdural hematoma. For example, her brain may not properly tell her how to swallow. She said the hospital did have Hoyer lifts, and they use them. She said it should always be two staff. She said the fact they need a Hoyer indicates that it is a lift that cannot be done alone. She said the second person was vital because that ensures the sling is properly placed under the resident, helps with a safe transfer, and has someone there if anything happens. She said not having vitals could aggravate hospital staff because they cannot see the resident's progression or decline. She said it is common nursing sense to obtain vitals and neurological checks. She said having vitals from 5 days before ([DATE]) would not likely be the same at [DATE], especially if she had bleeding in her brain. During an interview on [DATE] at 8:15 AM, The Dispatcher stated they received their initial call at 6:41 PM. It was reported that they needed resident transport because of a head wound. She said at 6:51, the EMS workers were enroute and arrived at the facility. At 6:55 PM, they received a call from the EMS staff stating they needed to extend their time at the facility because the resident was not ready to pick up. At 7:23 PM, the EMS staff called in and said the resident was still not ready for pickup. She said she did not know why the resident was not ready. She said at 7:29, the EMS was enroute to the hospital. She said they arrived at the hospital at 7:50 PM. She said the medic on duty could give more information. During an interview on [DATE] at 8:27 AM, The Primary Care Physician stated he was not the doctor who was notified. He stated from the notes and his most recent dealings with Resident #1, he knew that The NP mainly took care of Resident #1, but he supervised her work. He said it was his understanding on [DATE] the staff at the facility lifted her with the Hoyer and dropped her. They spoke with NP, and she instructed the st[TRUNCATED]