**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from sexual abuse for 2 of 15 residents (Resident #1 and Resident #2) reviewed for abuse. 1. The facility failed to prevent sexual abuse for Resident #1 witnessed by CNA A on 06/08/2024 at approximately 2:00 p.m. to be in her room covered with a sheet and lying in bed with the Floor Tech. 2. The facility failed to prevent sexual abuse for Resident #2 that reported to CNA B on 06/08/2024 at 2:15 p.m. that the Floor Tech approximately two weeks prior had touched her hip, rubbed his penis against her while clothed, and asked if she was interested while making sexual body gestures. The noncompliance was identified as PNC. The IJ began on 06/08/2024 and ended on 06/08/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for psychosocial harm, impaired quality of life in unsafe environment, and further abuse. Findings included: 1. Review of a face sheet for Resident #1, dated 06/25/2024, indicated she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses including: cerebral infarction (stroke), dysphagia (difficulty swallowing), UTI, mononeuropathy (nerve damage outside of brain and spinal cord), and anorexia (eating disorder). Review of Resident #1's quarterly MDS, dated [DATE], indicated she had a Brief Interview for Mental Status (BIMS) score of 08, indicating moderate impairment, and a short-term memory score of 1 indicating she had a memory problem. Resident #1's functional status indicated she was non-ambulatory and required substantial/maximal assistance with ADL's. Review of Resident #1's care plan, dated 06/25/2024, indicated she rejects care such as skin assessments and evaluation with a suspected history of personal trauma with interventions to include identifying staff that result in least resistance, talk to resident/family about reasons for refusal of care, and ensure physical and emotional safety. Review of written interview statement by Social Worker with Resident #1, dated 06/08/2024, reflected the following: .Social Worker attempted to interview patient regarding reported sexual assault. Patient was unable to provide appropriate responses to questions asked. Patient is alert oriented with confusion, able to make her needs known. She requires total assistance of staff for ADL care and transfers. Review of hospital records for Resident #1, dated 06/08/2024, indicated she was sent to the ER after being found in bed with male staff member. Hospital records indicated Resident #1 reported she was sleeping and does not remember a staff member being in bed with her. Hospital records indicated Resident #1 denied pain or discomfort, and GU and skin exam were negative for abnormalities, pelvic pain, or vaginal bleeding. Review of progress notes signed by the ADON, dated 06/09/2024, indicated a head to toe assessment was completed 06/08/2024 on Resident #1 with no adverse findings. Review of progress notes signed by LVN C, dated 06/09/2024, indicated CNA A reported that staff member was found in the bed under the covers with Resident #1 at 2:10 p.m. Progress notes indicated staff member was fully dressed and immediately rolled out of the bed to his knees stating, it's not what it looks like. Progress notes indicated LVN C ensured patient safety by removing staff member from room, police interviewed resident, and resident was sent to the hospital. Review of Psychosocial Well-Being signed by the Social Worker, dated 06/12/2024, indicated Resident #1 was alert and oriented with confusion, no signs and symptoms of distress noted or verbalized, was sent to the ER for evaluation and treatment, and referral was warranted to psychology and psychiatry services. 2. Review of a face sheet for Resident #2, dated 06/25/2024, indicated she was a [AGE] year-old female, admitted on [DATE] and transferred to another nursing facility on 06/24/2024. Resident #2's face sheet indicated she had diagnoses including vascular dementia (impaired thought process due to brain damage from impaired blood flow to the brain), major depressive disorder, heart failure, and UTI. Review of Resident #2's discharge MDS, dated [DATE], indicated she had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate impairment. Resident #2's mood indicated she had felt down, depressed, hopeless, with little interest in doing things for several days. Review of Resident #2's care plan, dated 06/25/2024, indicated she had interventions for suspected trauma to include ensure physical and emotional safety. Review of employee statement by CNA B, dated 06/08/2024, indicated the following: To whom it may concern I went to change [Resident #2] and she told me [Floor Tech], the housekeeper had got in the bed with her and was rubbing on her body with his hand and body. The resident told me that this has been going (on) 2 weeks on the weekends. Review of hospital records for Resident #2, dated 06/08/2024, reflected she was sent to the ER for complaints of being molested for 2 weeks and stated he rubbed his penis on the outside of her clothes two weeks ago. Resident #2's GU was negative for injury, bleeding, or discharge, and skin was negative for abnormalities. Review of progress notes signed by LVN C, dated 06/09/2024, indicated CNA B reported Resident #2 needed to talk to the nurse at 2:13 p.m. and Resident #2 told LVN C that a short black man with thick rimmed glasses with a lazy eye went into her room two weeks ago and rubbed his stuff on her, kissed her neck, and touched her breasts and hips. Progress Notes indicated LVN C notified the DON and ED was aware at 2:17 p.m., head to toe assessment was completed with no adverse findings, police interview resident, and was sent to the hospital. Review of progress notes signed by the ADON, dated 06/09/2024, indicated a head to toe assessment was completed 06/08/2024 on Resident #2 with no adverse findings. Review of employee statement by CNA A, dated 06/08/2024, indicated the following: I [CNA A] walked in [Resident #1's] room and (saw) the housekeeper [Floor Tech] in the bed with her (and) [Resident #2] told me and [CNA B] that [Floor Tech] had been in the bed with her and rubbing on her body. Review of written interview statement by Social Worker with Resident #2, dated 06/12/2024, reflected the following: Patient stated that two weeks ago, a short black guy, who wore maroon clothing, wearing big and bulky glasses with a soft voice meandered into her room and said hi. Patient stated that she did not remember his name. She wasn't sure if he told her his name. The patient says she was lying down in bed, and he was standing by bedside moving his body suggestively. Patient told him that she was not interested. He then made a sarcastic statement voicing his opinion that it was ok. Patient stated that he touched her left hip and started moving his body so she would get the idea. He was moving suggestively his thing back and forth in front of her. Patient stated that this same type of incident has happened twice. Patient says he never got in bed or touched her in any other places. Review of provider investigation report, dated 06/13/2024, reflected the following: . Facility Investigation Findings: Confirmed . Investigation Summary Incident: Per staff member [CNA A] staff member [Floor Tech] was found in the bed with [Resident #1]. [Resident #2] reported that a man that wears thick glasses and a lazy eye rubbed his stuff on her and touched her . Summary of Assessments: Both resident[s] received a head-to-toe assessment with no adverse findings. Timeline 06/08/2024 1410 (2:10 p.m.) [CNA A] Nurse Aide reported to charge nurse [LVN C], that during rounds she noted [Floor Tech] lying in bed under the covers with [Resident #1]. Per [CNA A], [Floor Tech] was fully dressed and immediately rolled out of bed to his knees stating, It's not what it looks like. Nurse assessed patient with no adverse findings. 1412 (2:12 p.m.) [LVN C] reported events to [DON]. DON called [ED] to report what was reported to her. Per our [CNA A] [Floor Tech] was following her around the building repeatedly telling her it's not what you think, and it's not what it looks like. [LVN A] was instructed to get the staff together and search the building for [Floor Tech] and get him to the front of the building and away from the resident care areas. 1415 (2:15 p.m.) [CNA B], nurse aide, reported to [LVN A], that resident [Resident #2] needed to talk to her. Stating it is the same thing going on as the other one. Per [LVN A] she went directly to the room and spoke with [Resident #2] in room [Resident #2's room] while staff searched for [Floor Tech]. 1417 (2:17 p.m.) [LVN A] reported to [DON], that resident [Resident #2] reported that a shirt black man with thick rimmed glasses with a lazy eye went into her room two weeks ago and rubbed his stuff on her, kissed her neck, and touched her breasts and hips. [DON] made [ED] aware of what was reported. [Police Department] called for an officer to come to the building. 1424 (2:24 p.m.) [LVN A] escorted [Floor Tech] to the front of the building. He was not in the resident care areas and [LVN A] stayed with him one to one until police arrived. [6:00 a.m. to 2:00 p.m.] staff were phoned to come back to the facility to give statements and provide an interview with the police. 1434 (2:34 p.m.) [Police Department] arrived and took [Floor Tech] into the conference room for questioning and instructed [LVN A] to await questioning in the chapel. 1440 (2:40 p.m.) MD made aware of incident with noted new orders to send both residents to the ER for evaluation and treatment. 1447 (2:47 p.m.) [CNA B], nurse aide arrived back to the facility for interview and statement retrieval and was asked to await questioning in the admissions office. 1449 (2:49 p.m.) Resident families notified per [Social Worker]. Family voice understanding of information given. 1450 (2:50 p.m.) Two police officers joined [CNA B] in the admissions office for questioning and statement collection. 1455 (2:55 p.m.) [CNA A], nurse aid, arrived back to facility for statement and interview and was asked to stay at the receptionist desk area and await interviewing. Four police officers question [LVN C], as to where the residents live and she escorted them to the residents rooms. Two police officers entered the room of [Resident #1] and two others entered the room of [Resident #2] to question and take statements. [Social Worker] made aware of the situation, and she reported that she was headed to the building to start life safety rounds. 1507 (3:07 p.m.) [CNA B]' interview completed, and she was asked by police to wait in the lobby until the detective arrived. 1508 (3:08 p.m.) [LVN A] was taken into the Chapel and [CNA A] was taken into the admissions office for interview and questioning by [Police Department]. Statements retrieved and staff were asked to wait for the investigator to arrive for additional questioning. Police kept all staff separate from each other. [Social Worker] at building performing life safety rounds. 1515 (3:15 p.m.) Police reported to [LVN A] that the interview was completed at this, and she was free to go back to the floor and finish her tasks. 1526 (3:26 p.m.) [DON] and [ADON] arrived at the building and spoke to police and were escorted to the admission office. An officer came into the office and gave a summary of events and allegations. In-service education started on abuse, neglect, exploitation, reportable incident protocol, accident and incidents, abuse prevention program, abuse prohibition protocol, HIPPA and privacy laws, and media policy. 1618 (4:18 p.m.) The detective arrived at the building and entered the conference room with [Floor tech]. Noted questioning started at that time. Background checks [of] 100% of employees to be completed. The detective and two police officers approached CNA A and CNA B and asked if they would be willing to testify in court as to what they saw and what happened. Noted both said yes, that they would. 1723 (5:23 p.m.) [Floor Tech] was taken out of the building in handcuffs and transported to a police SUV. DON spoke with the detective to see if there was any other needed information or details that he could share with us. Perfect detective, [Floor Tech] will be charged with a state grade felony and taken to jail. 1733 (5:33 p.m.) Residents [Resident #1] and [Resident #2] transportation was set up via (by) [transportation service] to [hospital] for evaluation and treatment as well as SANE evaluation. 1745 (5:45 p.m.) [transportation service] arrived with two ambulances and transferred each resident x2 people to the stretcher, tolerated well. No complaints of pain/discomfort. VS stable. 1800 (6:00 p.m.) 100% audit completed on skin assessment her LVN D, LVN E, LVN F, LVN G. No new adverse findings. 2100 (9:00 p.m.) [Resident #2] return from the hospital with no new orders. SANE Visit unable to be performed due to reported event being over 180 hours ago. New suggestion for the resident to be seen at [an intermediate care facility] for counseling. Per [MD] resident can use in-house psych services instead. 0400 (4:00 a.m.) Resident [Resident #1] return from the hospital. Her hospital no new diagnosis. Wrote order for Macrobid but house MD reported that current treatment is better for UTI and not to change the treatment at this time. Resident in stable condition. 06/10/2024 0830 (8:30 a.m.) Emergency QAPI performed and in-servicing continued. Investigation continued and employee questionnaires and acknowledgements. 06/12/204 1100 (11:00 a.m.) DON called and spoke with dispatch with [Police Department] to inquire about the police report. Per dispatch the detective was out of the office and a message must be left. Message left for [Detective] at [phone number] and awaiting a call back for case number 24-18035. 06/13/2024 1030 (10:30 a.m.) [Medical records] requested hospital records for both patients' ER visit on 06/08/2024 be sent to facility. Awaiting records. 1400 (2:00 p.m.) Received records from hospital. 1500 (3:00 p.m.) DON placed follow up call to psych services regarding psychological evaluation on both patients 1515 (3:15 p.m.) DON placed follow up call to police department to request report. 06/14/2024 0840 (8:40 a.m.) [Psychologist] on site to evaluate both patients. Notes to be sent. Actions taken by facility: Reported to HHSC. Employee was immediately removed from the patient care area until police arrived. Police department notified. Both patients were sent to the ER for evaluation and treatment as indicated. 100% Abuse Questionnaires/safe surveys of interviewable patients. 100% head to toe assessments of non-interviewable patients. 100% rounds of all patients to ensure their safety. Request video footage from family to review incident, if available. Psychosocial assessments completed. Referrals to [psych service]. Abuse Questionnaire for 100% of staff. 100% audit of employee background checks. 100% of interview/statements from staff members. Note any history of unusual behaviors with the suspected employee. Sex registry check on suspect. Grievances. Completion of Accident/Incident Reports. Review of employee's schedule and time punch detail. Review of employee file and prior BGC (background check}. In-service on abuse and identify sexual abuse. In-service Abuse Prohibition Protocol. In-service on Media Police and HIPPA. Notification to RPs. Physician Notification. Notification to the Ombudsman. Conclusion: After questioning the staff and alleged perpetrator, [Floor Tech] was taken to jail by police. He was terminated from [the facility] and a criminal trespass would be issued per police officer. Review of psychiatric consult by Psychologist, dated 06/14/2024, reflected the following: .[Resident #1] Diagnostic assessment was completed with (patient) indicating informed consent. (Patient) required intermittent support to remain adequately engaged. She gestured indicating she feels depressed and anxious. Patient demonstrated poor eye contact and actively turned away at one point. When psychoeducation related to sexual assault was provided. (Patient) made eye contact and asked how anyone could possibly understand how she feels. She went on to provide she worked as a nurse in the past. Patient cried and ceased to speak in an easily understandable manner, but repeated the word 'fear' and referred to difficulty with urination. Collateral information indicates patient's communication function, as demonstrated in assessment, is typical. Additionally, (patient) reportedly demonstrates periods of agitation at times. (Patient) indicated emotions including anger, fear, depression, and anxiety difficulty with reliable and consistent communication complicates assessment and treatment. Available data indicates evidence of depression, anxiety, and PTSD. Diagnostic clarity may improve over time and (diagnosis) should be updated accordingly. As {patient} demonstrates ability to communicate effectively at times, it is recommended psychotherapy services be provided to determine whether she may benefit . Review of psychiatric consult by Psychologist, dated 06/14/2024, reflected the following: .[Resident #2] Diagnostic assessment was completed with (patient) providing informed consent and participating fully in session. She responded to rating scales in a manner consistent with interview and collateral data. (Patient) acknowledged she was sexually assaulted recently and feels angry about the violation(s). (Patient declined to discuss details of the assault(s). (Patient) commented on feeling overwhelmed by the combination of recent sexual assault with existing somatic and dependence-related stressors. (Patient_ was in favor of pursuing psychotherapy services to address affective and behavioral symptoms. Initial impressions suggest (patient) is demonstration sx (symptoms) consistent with moderate anxiety disorder, mild depression, and acute PTSD. (Patient) made no requests for changes or supports at present. She reported feeling safe in the NF (Nursing Facility) . During an interview on 06/21/2024 at 3:21 p.m., the Administrator and DON said the Administrator was the abuse coordinator and that he had been employed for one week at the facility and the DON had been employed since December 2023. The Administrator said he was aware of a sexual abuse allegation that was self reported but that it occurred prior to his employment at the facility. The DON said she was aware of the sexual abuse allegation that was a self reported incident concerning the Floor Tech. The DON said there was an allegation of sexual abuse on 06/08/2024 when CNA A was making rounds in the hallway she had noticed a residents door was shut and when she opened the door the Floor Tech was in the bed with Resident #1. The DON said there was no harm to the resident noted and she was sent to the ER for an evaluation and she came back to the facility with a suggestion for UTI and no other orders. The DON said Resident #1 was evaluated by a SANE nurse and the DON had been calling the Investigator daily to get those results because the hospital would not release them since they were under investigation. The DON said there were no concerns with the Floor Tech's background history and that he had a clear record. The DON said the Floor Tech was brought to the front of the building immediately to ensure resident safety and two staff members sat with him until the police came and he was escorted off the property. The DON said he was arrested, did not know he was currently in jail but that he got bonded out on Sunday, 06/09/2024. The DON said the family was notified and was not sure if they decided to press charges. The DON said it was important residents were free from sexual abuse to ensure their well-being and safety and in response to the incident the facility completed 100% of skin assessments on residents, social life safety rounds,and in-servicing on abuse. The DON said there was one other resident, Resident #2, identified with related concerns. The DON said Resident #2 reported about 2 weeks prior the Floor Tech had came into her room and was rubbing his private area on her body and had touched and kissed her neck. The DON said Resident #2 did not mention any other times and said it only happened once. During an interview on 06/21/2024 at 4:09 p.m., the Ombudsman said she had a concern that she received a self report that a staff member was found in the bed with a resident. During an observation on 06/21/2024 at 4:28 PM, Resident #1 was laying in bed on her left side covered with sheet, bed in low position, and the door to room was open with her television on. Resident #1 did not respond to greeting or questions and appeared in no apparent distress. During an interview on 06/25/2024 at 9:30 a.m., CNA A said she had been employed at the facility since April 2024. CNA A said on 06/08/2024 around or after 1:00 p.m., she walked in the room and saw the Floor Tech lying behind Resident #1. CNA A said Resident #1 had her eyes closed facing the door, lying on her side and the Floor Tech was lying on his side behind her under the covers. CNA A said the Floor Tech appeared to have his clothes on and when he rose up he spinned the covers around and started to act like he was cleaning her bed. CNA A said she did not notice any facial grimacing on Resident #1 at the time of the incident and could see her brief was on and it appeared to be on appropriately and there were no other individuals in the room. CNA A said Resident #1's door was closed and she was a fall risk so staff leave the door open. CNA A said when the Floor Tech rose up from the bed he put his hand across her wiping the bed off and said the bed was wet and grabbed the covers off of her and went to put it in the laundry. CNA A said it was important to protect residents from abuse to ensure their safety and told CNA B that she had to report something to the nurse and when she saw LVN C she reported to her immediately. CNA A said CNA B was a witness that saw the Floor Tech come out of the room. CNA A said LVN C checked on Resident #1 and was calling and notifying management when the Floor Tech was following CNA A around trying to persuade her she did not see anything. CNA A said after she reported to LVN C, she entered Resident #2's room with CNA B and Resident #2 began to report a related concern of staff being inappropriate with her and described the Floor tech's appearance. CNA A said after they reported Resident #2's concern to LVN C it was the end of her shift and she had to return to the facility the same day to write a statement and the police ended up taking the Floor Tech to jail. CNA A said Resident #2 reported they had the wrong people working in this facility and that the little dark man had been rubbing on her. CNA A said Resident #2 reported to CNA B that the Floor Tech had been coming in her room touching and rubbing on her. CNA A said the Floor Tech may have done it to more but no other residents have reported any related concerns that she was aware of and had not noticed any scratches or changes in behavior such as resident being withdrawn. CNA A said Resident #1 is sometimes confused and had been acting normal with no apparent changes. CNA A said Resident #2's family came to get her. CNA A said the facility put interventions in place to prevent sexual abuse by removing the Floor Tech from resident care areas, providing in-services on abuse, and completing assessments on all residents. During an interview on 06/25/2024 at 10:09 a.m., CNA B said she had been employed since November 2015 and had received training on abuse by in-services within the last month and did not suspect abuse at this facility other than the concern with the Floor Tech. CNA B said it was important for residents to be free from abuse to ensure residents safety. CNA B said she noticed the Floor Tech seemed different that day (06/08/2024) and he had his housekeeping cart on her hall and was not cleaning. CNA B said she works with CNA A and felt that the Floor tech was watching what hall they were working on because they had just finished checking on Resident #1's hall. CNA B said they decided to check on the same hall again before ending their shift and realized Resident #1's door was shut. CNA B said they never shut Resident #1's door because she was a fall risk. CNA B said CNA A came out of the room directly across from Resident #1 and when she came out of the room she saw the door was closed and thought CNA B was in there because she was a two person assist. CNA B said CNA A went in the room, came out, and told her what she saw then notified LVN C. CNA B said she finished the room she was in and went to Resident #2's room. CNA B said at that time, Resident #2 said she needed to talk and needed her help. CNA B said she reassured Resident #2 and that she could tell her anything and Resident #2 asked if CNA B could keep a man out of her room that met Floor Tech's description as a short, bald man that wears big glasses and has one eye that is lazy. CNA B said Resident #2 told her the man keeps getting in the bed with her and he was rubbing his hand and body all over her. CNA B said Resident #2 reported the Floor Tech incident always happened on the weekend when he was working and had been going on for two weeks. CNA B said she left out of the door to confront the Floor Tech and CNA A reminded her not to get angry with him and she calmed down. CNA B said the Floor Tech was following them trying to persuade CNA B and CNA A it wasn't what they saw and they told him to leave them alone. CNA B said LVN C got him in the conference room immediately following report of the incident and was instructed she could not leave until the DON and police came. CNA B said she wrote out her statement and the police cuffed him and took him out of the door. CNA B said there was one resident, Resident #3, that reported a week before that the Floor Tech had went in her room and was standing over her bed. CNA B said the facility was thinking Resident #3 was not herself because she is sometimes confused. CNA B said she felt the facility handled the situation appropriately and that there was a sweep of the facility to check on all the residents. During an interview on 06/25/2024 at 11:00 a.m., LVN C said she had been employed since January 2024. LVN C said at that the moment she did not suspect abuse and had received training on abuse by in-services with the most recent this week. LVN C said she was the charge nurse notified when the Floor Tech was found in the room with Resident #1. LVN C said CNA A notified her and she immediately went down to check on the resident and report while she had another nurse aide stay with Resident #1. LVN C said while she was reporting that incident, another aide notified her of Resident #2's similar concern. LVN C said she had that aide stay with Resident #2 and obtained the Floor Tech and notified police. LVN C said when she checked on Resident #1 she was fine and was her normal self, normally confused and disoriented with no new injuries. LVN C said Resident #1 did not know what was going on and she did not remember the Floor Tech had gotten in the bed with her. LVN C said her peri area was checked with no concerns and her diaper was fastened on all 4 contact points appropriately. LVN C said she was wearing clothes that were not disoriented at all. LVN C said Resident #2 reported that about two weeks ago, a short man with thick glasses and a lazy eye came into her room and was rubbing his junk on her and touching on her. LVN C said Resident #2 did not tell anyone and when asked why she said she was out of her mind and was not eating or drinking and had altered mental status due to a fall. LVN C said she assessed Resident #2 and she had no injuries. LVN C said Resident #2 reported she had her clothes on but he was kissing her neck and touching on her and denied that he made penetration. LVN C said Resident #2 told her he had not taken his clothes off around her and she did not say anything about her roommate. LVN C said to ensure residents were safe and free from abuse the facility did in-service training, a facility wide skin sweep, and interviews with the social worker. During an interview on 06/25/2024 at 11:38 a.m., the Social Worker said she got the report that one of the CNA's walked in the room and Floor Tech was in bed with Resident #1. The Social Worker said she interviewed the entire building that was interviewable. The Social Worker said she did have one resident, Resident #2, that stated the Floor Tech had came in her room and he was standing in front of her gesturing and saying it would be okay and rubbed her leg that occurred on two occasions and he touched her and posturing himself in front of her to put his body in her face moving his body around. The Social Worker said the facility completes background checks and checks employee history prior to hire. During an interview on 06/25/2024 at 12:00 p.m., LVN E said she had been employed off and on since 2022 and did not suspect abuse at the facility. LVN E said she received in-services on abuse and when they should report to state concerning some reportables that happened within the past couple of weeks. LVN E said it was important to ensure residents were free from abuse to ensure their safety. LVN E said she was not here when the Floor Tech was found in Resident #1's room and that no residents have reported to her of any inappropriate behavior from male staff. During an interview on 06/25/2024 at 1:54 PM, the RP said he was in the process of getting Resident #1 transferred closer to him. RP said the facility reports any problem with Resident #1 and had received a report of staff being inappropriate with Resident #1. RP said he was aware that the facility put him on administrative leave and he did not decided to press charges but has decided to move her to another facility closer to him in the central Texas area. During an interview and observation on 06/25/2024 at 4:35 p.m., Resident #2 was interviewed at her new nursing home facility. Resident #2 was laying in her bed. Resident #2 said she liked being in the new facility. Resident #2 said when she was at her old [facility] a short stocky black man molested her. Resident #2 said she reported the incident, and the facility fired him. Resident #2 said the man put his hands on her sides and rubbed himself on her stomach while she laid in her bed. When asked what she meant by he rubbed himself she said his penis. Resident #2 said he did not take his penis out and he did not take off her clothing. Resident #2 said when the man rubbed himself on her it made her feel sick and terribly dirty. Resident #2 said she was not physically hurt because she did not fight back. Resident #2 said she did not fight back because she wanted to get it over with. When asked if the man said anything to her, she said you mustn't tell anyone. When asked if he said anything else Resident #2 replied a bunch of stupid love stuff. Resident #2 said after the incident she stayed close to her roommate because if her roommate was around, he wouldn't bother her. Resident #2 said her roommate was usually in her room so she would stay in her room. Resident #2 said her roommate was not in her room at the time of the incident. Review of in-service signed by the Floor Tech, dated between 05/13/2024 through 05/16/2024, reflected education was provided to staff [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision and assistance to prevent accidents for 1 of 7 residents reviewed for accidents/supervision (Resident #1). The facility failed to ensure Resident #1's wheelchair was locked during a transfer causing the resident to slide out of the wheelchair and fall. Resident #1 sustained an acute comminuted fracture (when a bone breaks into 3 or more pieces) of the right femur (bone above the knee). The noncompliance was identified as PNC. The Immediate Jeopardy began on 10/24/23 and ended on 10/26/23. The facility had corrected the noncompliance before the survey began. This failure could place all residents at risk of severe injuries or death. Findings included: Record review of Resident #1's face sheet dated 10/31/23 indicated she was a [AGE] year old female admitted to the facility 11/3/22, with diagnoses including Type 2 Diabetes with diabetic neuropathy (a type of nerve damage that can occur if you have diabetes), morbid obesity, acute kidney failure, hypertension (high blood pressure), heart disease , and absence of right leg below the knee. Record review of Resident #1's most recent MDS assessment dated [DATE] indicated she had a Brief Interview for Mental Status of 12, which indicated moderate cognitive impairment. The MDS further revealed Resident #1 required total dependence for transfers, needed 2 person assist, and extensive assist for personal hygiene and dressing with 1 person assist, and no history of falls. Record review of Resident #1's undated care plan indicated Resident #1 was at risk for falls/injury due to amputation of right lower extremity. Interventions included: monitor for proper body alignment and balance-assist with repositioning as needed. Assist with ADL's and transfers using positioning devices as needed. Record review of Resident #1's nurses notes dated 10/24/23 at 12:33 p.m., and signed by LVN A indicated the following, 10:00 CNAs report that resident was being transferred via hoyer lift x 2 nurse aides, wheels on wheelchair were not locked, and as aide was lowering her down in wheelchair resident slid out of the chair, as the aide went to catch her the aide and resident both went to the ground and that resident wanted medication, she felt nauseas. Upon entering room, resident was noted to be sitting upright in wheelchair, hoyer pad underneath her, with a clear trash bag on chest. VS assessed. No new skin injuries noted. Patient complained of pain in right leg, requested nausea medication and pain medication. PRN (2) Tylenol 325mg as ordered and Ondansetron (medication used for nausea) 4mg. administered. MD notified, new order to obtain x-ray STAT. Mobile x-ray contacted. RP, DON, and unit manager notified. Record review of a mobile x-ray radiology interpretation report dated 10/24/23 indicated Resident #1 received an x-ray of the right femur. Impression of the x-ray indicated an acute comminuted fracture. During an interview on 2/7/24 at 10:40 a.m. the DON stated she was not employed in the facility at the time of Resident #1's incident. The DON stated that staff were trained on hoyer lifts, and transfers using gait belts on hire. The DON said her expectations for staff utilizing the hoyer lift were to have 2 persons present, follow the procedures on the skilled checklist and make sure the wheelchair was in a locked position. During an interview on 2/7/24 at 10:48 am. LVN D said she had worked in the facility since August 2023. LVN D stated she was not working when Resident #1 had a fall, but all staff received mandatory training from the therapist on using the hoyer. LVN D stated all wheelchairs needed to be in a locked position prior to transferring a resident. During an interview on 2/7/24 at 11:20 a.m. the DOR stated that Resident #1 had been on therapy services 5/24/23-6/22/23. The DOR stated that after Resident #1 had her fall in October of 23, he did trainings and in-services on using the hoyer, and transfers. The DOR stated that the training was mandatory for all CNAs, MAs, nurses, and prn staff. The DOR stated that demonstrations were done on using the hoyer, as well as transfers, and staff did return demonstrations. The DOR stated he had 3 different training sessions, and checkoff sheets were reviewed and signed by him, and the employee. During an interview on 2/8/24 at 10:35 a.m. the SW stated that she was acting as interim ED at the time of Resident #1's fall. The SW stated that both CNA B and CNA C were asked to reenact what they did during the transfer of Resident #1. The SW stated she did not remember at what point they were asked to do this. The SW stated both CNA B and CNA C said they did not lock the wheelchair. The SW stated that the brakes should have been locked on the wheelchair at the time of the transfer. The SW stated neither CNA B nor CNA C said why the brakes were not on at the time. The SW stated both CNA B and CNA C were terminated. The SW stated a QA meeting was called the afternoon of the incident and training was initiated. During an interview on 2/8/24 at 11:03 a.m. GVN E stated she had worked in the facility since January of this year. GVN E stated she had received training on hoyer lifts and transfers when she hired on. GVN E stated 2 people were required for all hoyer transfers. The resident is placed on the hoyer pad while in bed, the pad is then secured to the hoyer. I always make sure the pad is intact and secured appropriately to the hoyer. One employee operates the lift and the other staff guide the resident to the wheelchair, which is to be locked and the footrests open before transfer. During an interview on 2/8/24 at 11:20 a.m. the Maintenance Supervisor stated he had worked in the facility for 14 months. The Supervisor stated he had been asked to observe all the wheelchairs in the facility in October 2023. The Supervisor stated on 10/25/23 he checked wheelchairs for any loose brakes and adjusted/tightened any that were loose, and all brakes were found to be in working order. The Supervisor stated there were 6 hoyer lifts in the facility, and there was a company that came out quarterly to do any maintenance needed. During an observation and interview on 2/8/24 at 1:05 p.m. MA/CNA F, and CNA G were observed during a hoyer transfer on Resident #2 from wheelchair to bed. There were no issues identified. Both MA/CNA F, and CNA G stated they were hired in December of 2023. Both MA/CNA F, and CNA G stated they had received training when hired on hoyer lifts and transfers. Both MA/CNA F, and CNA G stated that the wheelchair should have brakes locked when transferring a resident in the hoyer. During an observation and interview on 2/12/24 at 8:45 a.m. CNA H said she had worked in the facility 1 ½ years. During the same interview, Restorative aide M said she had worked in the facility for 14 years. CNA H and Restorative aide M were observed during a wheelchair transfer on Resident #3. Resident #3 was transferred from her wheelchair to her bed. CNA H explained what they were doing, and both washed their hands prior to transfer. The footrests were removed from the wheelchair and a gait belt was placed on Resident #3. The wheelchair was locked on both sides. Resident #3 was safely transferred to the bed with no issues. The bed was placed in a low position and call light placed near Resident #3. Both CNA H and Restorative aide M stated they had received training on transfers and using the hoyer lift and had to do hands on demonstrations and signed skills check off form. Restorative aide M stated that all staff were provided a gait belt. Resident #3 stated she felt safe during her transfer, and they do a good job. During an observation and interview on 2/12/24 at 9:05 a.m. CNA H and Restorative aide M were observed during a hoyer lift on Resident #2 from her wheelchair to her bed. No issues were identified. Resident #2 was unable to answer any questions appropriately. During an observation and interview on 2/12/24 at 9:25 a.m. CNA J said she had worked in the facility for 1 ½ months. CNA K said she had worked in the facility for 1 year. Both aides stated they had received training on using the hoyer lift and doing transfers when they were hired. CNA J and CNA K were observed doing a hoyer transfer on Resident #4. CNA J stated Resident #4 had agreed to get up in the wheelchair, and then be placed back to bed so observation could be done. The transfer to wheelchair and back to bed were observed with no findings. Resident #4 stated she always got nervous when being transferred with the hoyer but had not had any recent problems. Resident #4 stated a long time ago, I can't remember when, the pad broke while I was in the shower. Resident #4 stated she was not hurt, and the staff was good about explaining everything they did. During an observation and interview on 2/12/24 at 9:57 a.m. CNA J was observed doing a bed to wheelchair transfer, and wheelchair to bed transfer on Resident #5. There were no issues identified. Resident #5 stated he felt comfortable with staff transferring him, as he could not do it by himself. Resident #5 stated, this aide is good! Watch her, you will learn a lot from her. During an observation and interview on 2/12/24 at 10:08 a.m. CNA H and CNA L were observed doing a hoyer transfer on Resident #6. There were no issues identified. Resident #6 was non-interviewable. During an observation and interview on 2/12/24 at 10:27 a.m. CNA L was observed doing a bed to wheelchair transfer using a sliding board on Resident #7. There were no issues identified. Resident #7 stated he was receiving therapy but was not able to transfer to his wheelchair by himself at this time. Resident #7 stated he did not like using the hoyer lift as it made him nervous, and using the transfer board made it a lot easier and made him feel more comfortable. During a phone interview on 2/12/24 at 11:24 a.m. CNA B stated she remembered the incident with Resident #1. CNA B stated Resident #1 fell on CNA C and both of us were terminated. CNA B stated, the other girl admitted she did it. CNA B stated the other aide was setting Resident #1 down, and the wheelchair started to tilt and Resident #1 landed on the other CNA. CNA B stated after Resident #1 was on the floor, they grabbed Resident #1 and put her in the wheelchair. She stated Resident #1 did not complain of any pain. CNA B stated Resident #1 could feed herself but was total care. CNA B stated when she was hired, she had received training on the hoyer lift, and transfers. CNA B stated the brakes on the wheelchair were unlocked, and that the brakes to the hoyer were on. CNA B stated the wheelchair brakes should have been on. One side was locked; the other side of the chair was not. The other aide said it was her fault. CNA B stated the wheelchair moved out behind Resident #1 as they were lowering her into the wheelchair. I don't remember what caused it to move. The chair was locked on my side, but not the other side. CNA B stated, if the wheelchair was locked, this probably would not have happened. CNA B stated she knew the wheelchair should have been locked, and not sure why the other side wasn't. During a phone interview on 2/12/24 at 11:34 a.m. CNA C was contacted and voicemail was left. On 2/12/24 at 11:35 a.m. CNA C returned the call. CNA C said she remembered the incident, and stated this happened months ago, and you are just now calling me? CNA C stated she was at work and would return call when she got off around 3:30 p.m. on this date. CNA C did not return call. Record review of a Grievance Report dated 10/24/23 and signed by the SW indicated .Resident #1's RP was notified of a fall that Resident #1 had that was witnessed by the staff transferring her. Family member stated that she was on her way at that time. Upon arrival to the facility, family stated that the Resident told them that she fell during transfer and that they believe she was not transferred with the hoyer. Family then stated that they did not want the aides that did transfer in Resident #1's room. Family member went on to state that she had bail money and I am going to jail today. Both CNAs state that a hoyer transfer was completed and that the resident slipped out of the wheelchair during the transfer. Both aides provided written statements regarding the transfer Record review of an Accident/Incident Report dated 10/24/23 and signed by LVN A indicated the following: .Account of Occurrence- CNAs report that Resident was being transferred via hoyer lift x2 nurse aides, wheels on wheelchair were not locked, and as aide was lowering Resident down in wheelchair, Resident #1 slid out of the chair. As the aide went to catch her, the aide and Resident #1 both went to the ground. Upon assessment, resident complained of pain to the RLE above her amputation site. Resident denies any other pain. Resident was assisted back to wheelchair. PRN pain medicine administered. Received order from MD for STAT x-ray . Record review of a witness statement dated 10/24/23 signed by CNA B revealed the following, I was in the room with Resident #1 and CNA C and I were getting Resident #1 up to put her in the chair and as CNA C was lowering Resident #1 down, she slid out of the chair and CNA C grabbed Resident #1, and Resident #1 fell on top of CNA C, and they both fell on the floor. Record review of an undated witness statement signed by CNA C revealed the following, I CNA C was getting Resident #1 up to put her in her chair. As I was lowering Resident #1 down, she slid out of the chair and I was there to grab her, and me and Resident #1 both fell to the ground. Record review of a Personal Action Form indicated CNA B was terminated with last day worked listed as 10/24/23. Record review of a Personal Action Form indicated CNA C was terminated with last day worked listed as 10/24/23. Record review of a Mechanical Lift Competency Skills Checklist dated 2/27/07 indicated When transferring from or to a wheelchair, shower chair or bed, make sure that wheelchair, shower chair or bed is locked . Record review of the hoyer service provider Certification of Calibration forms indicated visits were made on 10/10/23, and 1/2/24. Record review of a Quality Assurance and Performance Improvement Meeting Minutes form indicated a meeting was held on 10/24/23 at 4:30 p.m. with the following members were present; DON, activity director, care plan/MDS nurse, nutritional services director, HR, interim ED, unit manager, and financial manager. Report also indicated the incident was discussed with the Medical Director over the phone. The following interventions were put in place: Steps taken regarding the incident with completion dates included: Resident assessed immediately- completed 10/24/23 Physician contacted and orders received-completed 10/24/23 PRN pain medication administered-completed 10/24/23 In-services initiated on abuse/neglect- started 10/24/23, completed 10/26/23 In-services initiated on Hoyer transfers- started 10/24/23, completed 10/26/23 In-services initiated on stand-pivot transfers and gait belts- started 10/24/23, completed 10/26/23 In-services initiated on assessment- started 10/24/23, completed 10/26/23 100% audit conducted by maintenance on wheelchair brakes-completed 10/25/23 Audit of Hoyer pads-started 10/24/23, completed 10/25/23 Audit of Hoyers in the facility- started 10/24/23, completed 10/25/23 Grievance completed-completed 10/24/23 Reported to HHSC-completed 10/24/23 Ombudsman notified-completed 10/24/23(message left) spoke to her 10/25/23 Resident sent to hospital-completed 10/24/23 Both aides suspended pending investigation-completed 10/24/23-both terminated Safe surveys initiated-completed 10/25/23 Resident interviews initiated (part of safe surveys) Psychosocial assessment completed prior to resident leaving facility-completed 10/24/23 Inservice on daily care guide- started 10/24/23, completed 10/26/23 Record Review of In-service Training Reports indicated training was done on safe transfers, Abuse/Neglect, Assessment, Activities of Daily Living-Daily Care Guide, and Accidents/Incidents. Trainings were initiated on 10/24/23 and were completed on 10/26/23. A review of Mechanical Lift Competency Skills Checklist, and Transfer Skills Checklist indicated training was initiated on 10/25/23 and completed on 10/26/23. Training records indicated 50 employees received training. The noncompliance was identified as PNC. The Immediate Jeopardy began on 10/24/23 and ended on 10/26/23. The facility had corrected the noncompliance before the survey began.