**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation for 1 of 11 residents (Resident #1) reviewed for resident abuse. The facility failed to ensure Resident #1 was free from physical abuse as evidence by on 08/05/2025, in the resident's room CNA A pushed Resident #1 onto the bed forcefully and held Resident #1 by pressing on the resident's chest when Resident #1 tried to get up. The noncompliance was identified as a PNC. The IJ began on 08/05/2025 and ended on 08/08/2025. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of serious injury, physical harm, serious impairment or death.The findings included: Record review of Resident #1's face sheet, dated 09/11/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included hepatic encephalopathy (the loss of brain function when a damaged liver does not remove toxins from the blood), dementia (loss of memory and thinking ability), anxiety disorder (a mental health disorder characterized by feelings of worry), and delusional disorder (A delusion is an unshakable belief in something that's untrue. The belief isn't a part of the person's culture or subculture, and almost everyone else knows this belief to be false). Resident #1 was discharged to another nursing home on [DATE] because of the resident's wandering behaviors. Record review of Resident #1's admission MDS assessment, dated 07/05/2025, revealed the resident's BIMS was 8 out of 15, which indicated the resident had moderate cognitive impairment, had verbal behavioral symptoms directed toward others, such as threatening others, screaming at others, and/or cursing at others, and required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to sit to stand, chair to bed, and toilet transfer. Record review of Resident #1's comprehensive care plan, dated 07/19/2025, revealed [Resident #1] resistive to care related to refuses medication, refuses care, refuses showers, becomes easily agitated and refused to be redirected. For intervention - 1:1 supervision, educate resident/family/caregivers of the possible outcomes of not complying with treatment or care, encourages as much participation/interaction by the resident as possible during are activities, give clear explanation of all care activities prior to an as they occur during each contact, and if resident resists with activities of daily livings, re-assure resident, leave and return 5 to 10 minutes later and try again. Record review of the facility's Provider Investigation Report, dated 08/08/2025, revealed On 08/05/2025, [Resident #1] was being transferred to bed by [CNA-A] used abrupt force to place resident in bed. Further record review of the Provider Investigation Report revealed the facility suspended CNA-A immediately, and the facility nurse assessed Resident #1 on 08/05/2025 at 6:15 p.m., and no injury was noted, and the facility immediately reported to Texas Health and Human Services the incident, contacted the local police and received a case number, physician and family were notified, staff educated on reporting abuse and neglect and resident rights and providing compassionate care to residents. Staff members and residents were interviewed. Record review of Resident #1's nurses notes, dated 08/05/2025, revealed At approximately 3:25 p.m., resident was observed by nurse ambulating in the hallway without wearing pants, and their brief was nearly falling down. Resident then entered another resident's room and stated, ‘I want to use the bathroom.' Resident was redirected appropriately. Staff attempted to explain and encourage the resident to return to their own room. During redirection, resident displayed aggressive behavior and attempted to physically strike the CNAs. Resident was safely guided back to their room by staff. Nurse attempted to administer Ativan as needed order for agitation; however, resident refused multiple times. CNAs assisted resident with hygiene, changing clothing, and ensuring resident's dignity and comfort were maintained. Will continue to monitor behavior closely and ensure safety of resident and others. Resident's family member was aware. Further record review of the resident's nurse note dated 08/05/2025 at 6:30 p.m. revealed The administrator along with the nurse manager notified this resident's family reported resident was being mishandled by a CNA. This nurse completed head to toe assessment. This nurse assessed pain level and asking the resident ‘Do you have any pain?' Resident denies any pain. Nurse observed that resident has no verbal/nonverbal indicated of pain. Resident family stay at the bed side while the nurse did head to toe assessment for resident. [CNA-A] removed from patient care. Medical doctor was notified. The resident denies pain at times and continues one on one due to wandering. Record review of Resident #1's incident report, dated 08/05/2025, revealed on 08/05/2025, [Resident #1] was being transferred to bed by [CNA-A] used abrupt force to place resident in bed, and [Resident #1]'s skin was dry and intact. No bruising was noted. Resident family was present when nurse do skin assessment for resident. [Resident #1] denies any pain or discomfort at this time. Observation on 09/11/2025 at 1:18 p.m. of the video footage dated 08/05/2025 inside Resident #1's room revealed CNA-A held both of Resident #1's arms behind him and approached Resident #1's bed. CNA A pushed Resident #1 onto the bed forcefully and held Resident #1 by pressing on the resident's chest when Resident #1 tried to get up. During an interview on 09/11/2025 at 1:20 p.m. with Resident #1's family member revealed he saw the video footage on 08/05/2025 and he thought CNA-A pushed Resident #1 onto the bed, so he notified the administrator immediately. Further interview with Resident #1's family member revealed Resident #1 did not have any abuse or neglect before this incident and after this incident. This was only incident related to abuse. Resident #1's family member said he thought Resident #1 was a little bit scared of the staff after this incident because the resident refused more cares, and Resident #1 was unable to interview because he was confused. During an interview on 09/10/2025 at 12:25 p.m., CNA-A stated Resident #1 was very aggressive and tried to enter a female resident's room on 08/05/2025, so CNA-A re-directed and guided Resident #1 to the resident's room. CNA-A said when he guided Resident #1, he was behind the resident and approached the bed, the resident tripped, lost his balance, and was about to fall. To prevent the actual fall, CNA-A pushed Resident #1 a little bit onto the bed. That was it, but later the facility told CNA-A to go to home, and the facility finally terminated CNA-A. During an interview on 09/10/2025 at 11:14 a.m., Sitter-B stated she was doing one to one supervision inside Resident #1's room on 08/05/2025, and Sitter-B saw Resident #1 was very aggressive to staff by throwing the television remote control and tried to hit staff, so CNA-A tried to re-direct and guide Resident #1 to the bed. Sitter-B said she did not see CNA-A push Resident #1 onto the bed, and she did not see any abuse to the resident. During an interview on 09/10/2025 at 10:09 a.m., the DON stated she saw the video footage on 08/05/2025 because Resident #1's family member showed it, and per the video footage, CNA-A hugged Resident #1 from behind the resident and guided the resident to the bed, then forcefully pushed the resident onto the bed because the resident was trapped and about to fall, so CNA-A tried to prevent the fall, but the facility immediately suspended CNA-A and finally terminated the CNA because he hugged the resident and did not request help from other staff. The DON said the facility assessed Resident #1 and found no injury was noted, reported it to the family and doctor, and provided in-services to all staff regarding Rights, Compassionate Care, Abuse and Neglect, and how to take care of residents with aggressive behaviors. During an interview on 09/10/2025 at 10:44 a.m., the facility Administrator stated Resident #1's family member called and showed the video footage to the Administrator on 08/05/2025, and according to the scene on the video footage, CNA-A tried to guide Resident #1 to the bed and pushed the resident forcefully onto the bed to prevent a fall, but CNA-A did not request any help from other co-workers. That was why the administrator suspended CNA-A immediately and terminated the CNA on 08/08/2025. The Administrator said the facility assessed Resident #1 and found no injury was noted, reported it to the family and doctor, and provided in-services to all staff regarding Rights, Compassionate Care, Abuse and Neglect, and how to take care of residents with aggressive behaviors, and the Administrator said the facility did not have residents with wandering and aggressive behaviors. During interviews on 09/11/2025 from 2:00 p.m. to 2:43 p.m. with Residents #2, #3, #4, #5, #6, #7, #8, #9 and #10 revealed they felt very safe and did not have or see any abuse or neglect in the facility. During an interview on 09/12/2025 at 9:30 a.m., LVN-C stated LVN-C worked the evening shift (from 2 p.m. to 10 p.m.) and assessed Resident #1 on 08/05/2025 and noted the resident did not have any injury and denied any pain. Resident #1's behaviors after the incident occurred were not changed, and the resident never was scared of staff but still was aggressive sometimes. LVN-C said the facility staff received in-service trainings regarding Resident Rights, Compassionate Care, Abuse and Neglect, and how to take care of residents with aggressive behaviors, and the nurse said she learned that the resident had right for free from abuse, the definition of abuse, staff must report any abuse immediately to the abuse coordinator (The Administrator), and using therapeutic communication skills when taking care of resident with aggressive behaviors. During interview on 09/11/2025 from 1:24 p.m. to 1:59 p.m. with CNA-D, CNA-E, CMA-F, Housekeeper-G, CNA-H, LVN-I, CNA-J and LVN-K revealed they worked at morning shift (6 am to 2 pm) and sometimes evening shift (2 p.m. to 10 p.m.) at the facility and Resident #1's behaviors after this incident occurred were not changed, and the resident was never scared of staff and was still aggressive sometimes, and they received in-service trainings regarding Resident Rights, Compassionate Care, Abuse and Neglect, and how to take care of residents with aggressive behaviors, and they answered they learned that the resident had right for free from abuse, the definition of abuse, staff must report any abuse immediately to the abuse coordinator (The Administrator), and using therapeutic communication skills when taking care of resident with aggressive behaviors, such as keep voice at a conversation level, maintain eye contact, ask a few questions, and maintain a safe distance from the resident. During interview on 09/12/2025 from 10:00 a.m. to 11:15 a.m. with CNA-L, CNA-M, and CNA-N stated they worked the night shift (10 pm to 6 am) at the facility and Resident #1's behaviors after this incident occurred were not changed, and the resident was never scared of staff and was still aggressive sometimes, and they received in-service trainings regarding Resident Rights, Compassionate Care, Abuse and Neglect, and how to take care of residents with aggressive behaviors, and they answered they learned that the resident had right for free from abuse, the definition of abuse, staff must report any abuse immediately to the abuse coordinator (The Administrator), and using therapeutic communication skills when taking care of resident with aggressive behaviors, such as keep voice at a conversation level, maintain eye contact, ask a few questions, and maintain a safe distance from the resident. Record review of CNA-A's employee profile revealed CNA-A was hired on 11/18/2024 and terminated on 08/08/2025 because of the incident of 08/05/2025. CNA-A's employee profiles revealed the facility conducted checking criminal background on 11/17/2024, and CNA-A completed in-services training regarding abuse and neglect on 11/25/2024 before he started working the floor. Record review of the facility's in-service training regarding Resident Rights related to residents to have right to live in safe condition, be free from abuse, and be free from any physical restraint, Compassionate Care related to take care care of not only physical well-being but also the emotional, social, and spiritual well-being, Abuse and Neglect related to types of abuse, how to prevent and screening procedures, and how to identify abuse, signs of abuse, and how to report abuse, and how to take care of residents with aggressive behaviors, such as keep voice at a conversation level, maintain eye contact, ask a few questions, and maintain a safe distance from the resident. revealed 98 Staff out of total 103 staff completed receiving these in-service trainings on 08/05/2025. Record review of the facility's policy, titled Abuse & Neglect Policy and Procedure, revised 08/10/2022, revealed The facility is charged with the safeguard of each resident and will follow a consecutive plan in the pursuit of maintaining a safe environment. Suspected actions or allegations of abuse including physical, mental, verbal, sexual, involuntary seclusion, neglect or misappropriation of property by any individual including resident to resident altercations with injury will be reported to local authorities, state, and federal agencies and other appropriate agencies as required by law. The noncompliance was identified as PNC. The IJ began on 08/05/2025 and ended on 08/08/2025. The facility had corrected the noncompliance before the investigation began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 2 residents (R#6 and R#5) reviewed for abuse. The facility did not properly monitor or put in place preventative measures for R #1 to prevent an act of sexual abuse on 09/27/23, when R#1 was found without a brief laying in the bed of R#6 without the consent of R#6. The facility did not properly monitor or put in place preventative measures for R #1 to prevent further acts of sexual abuse on 10/14/23, when R#1 was found on top of R#5, in her bed, without the consent of R#5. An IJ was identified on 10/26/23. The IJ template was provided to the facility on [DATE] at 3:50 PM. While the IJ was removed on 10/27/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy because of facility's need to monitor the implementation and effectiveness of its corrective systems. Failure to put in place supervision measures and training on abuse measures could result in residents denied the right to be free from sexual abuse. Findings included: Record review of facility's Abuse and Neglect Policy dated 8/10/22 read: The facility is charged with the safeguard of each resident and will follow a consecutive plan in the pursuit of maintaining a safe environment. Suspected actions or allegations of abuse including physical, mental, verbal, sexual, [involuntary] seclusion, neglect or misappropriation of property by any individual including resident to resident altercations with injury will be reported to local authorities, state and federal agencies, and other appropriate agencies as required by law . Sexual abuse-is defined as non-consensual contact of any type with a resident . Record review of Resident#1's face sheet, dated 10/17/23, and EMR revealed, the resident was admitted on [DATE] and discharged [DATE] (inappropriate behaviors with another resident) with diagnoses that included: Parkinson's disease ( a form of dementia), mood disorder, and anxiety disorder. Resident was a male; age [AGE]. RP (responsible party) was listed as: the resident. Record review of Resident#1's MDS assessment, dated 8/24/23, revealed: o BIMS Score was 12 (moderate impairment) o ADLs : Transfer was listed as partial assistance. Bed Mobility was listed partial assistance. R#1's ROM was listed as no impairment. [R#1 assistive device was a wheelchair. The resident could maneuver the wheelchair, and lift himself out of the wheelchair and engaged in limited locomotion and difficult walking distance without assistance. The Resident had a diagnosis of Parkinson's Disease] Record review of R#1's CP revealed: goal of behavioral management and interventions included: 9/27/23 incident: move to another room, monitoring, and administer medications.[interventions did not include contacting law enforcement] Record review of R#6's face sheet, dated 10/17/23, and EMR revealed, the resident was admitted on [DATE] with diagnoses that included: hemiplegia and hemiparesis ( paralysis of one side of the body) , dementia, and cerebral infarction (stroke). Resident was a male; age [AGE]. RP was listed as: family member. BIMS score was a zero (severely impaired). The resident was total care for ADLs. Record review of R#6's CP revealed: total care for ADLs and required assistance with his paralysis. Record review of R#5's face sheet, dated 10/17/23, and EMR revealed, the resident was admitted on [DATE] with diagnoses that included: dementia, Parkinson's Disease, and poor vision. Resident was a female; age [AGE]. RP was listed as: family member. Record review of R#5's Quarterly MDS dated 2023 revealed, the resident had a BIMS score was a 10 (moderate impairment). The resident required moderate supervision and assistance for her ADLs. Record review of R#5's CP dated 10/14/23 revealed she was at risk for psychosocial harms due to R#1 entering her room and found on top of her. Record review of R#1's Behavioral note dated 09/27/23 at 11:55 PM, authored by LVN A, read: .This Nurse was making rounds on patients when this patient was noted to be lying in his roommates bed with no brief on. Resident [R#1] was lying face down with one leg on top of his roommates [R#6] leg. This Nurse immediately called for staff assistance. CNA [name not documented] arrived in the room and this Nurse and CNA immediately placed this patient [R#1] in his wheelchair and removed him from the room. Resident was taken off unit and moved to unit on the other side of the building in room . in a room by himself. Nurse and CNA's on that unit given report on patients behavior. DON immediately called, and Administrator made aware. Record review of R#1's Nurse Note dated 10/14/23 at 3:51 PM, authored by LVN B, read: .Upon answering call light ., this nurse witnessed this patient [R#1] on top of patient [R#5] in [who ]was lying supine (lying with face upward) in her bed with eyes closed. Upon entering room this nurse immediately question this PT [R#1]why he on top of patient in room ., this Pt states, ' were just talking' Both PT were fully dressed and Pt [R#5] in room . had her blanket on. This nurse immediately removed this PT [R#1] and call Administrator and R(N) Supervisor. This Pt was transferred out of room .and currently on 1:1 care (physically monitor by a staff member) with Male CNA [name not documented]. [family member] was called and this PT is to be discharged home . During an interview on 10/17/23 at 4:40 PM, LVN A stated: on 9/27/23, R#1 was found with no brief on in the bed of R#6 without the consent of R# 6. LVN A stated, R#1 was moved to another hall and room; and 15 minutes checks for 72 hours were started. LVN A stated, both families (R#1 and R#6) and MD were notified. In-service on abuse/neglect was initiated by the facility. LVN A stated, there was no psychosocial harm to R#6. Another intervention included Psych services (referral to a mental health clinic) for both residents. LVN A stated, on 10/14/23, R#1 was found fully clothed on top of R#5 who was in bed covered in a blanket. LVN A stated Interventions included: notified families and MD, in-service on abuse/neglect; exploring immediate discharge. R#1 was sent to ER for a psychological evaluation; and 1:1 monitoring was initiated. LVN A stated, R#1 was discharged [DATE] to a personal care home under hospice care. No psychosocial harm occurred to R#5. LVN A stated she received in-service on abuse/neglect after the incident. During a interview on 10/17/23 at 5:08 PM, the Administrator confirmed that R#6 did not consent to R#1 being in his bed; nor did R#5. During an observation and interview on 10/18/23 at 9:19 AM, R#6 was in a tilted wheelchair, alert and not oriented. Resident was cleaned and groomed; skin tears to the head. Contracture to the right hand. No signs of anxiety, fear, or sadness. The resident could not answer any direct questions. [RP was not interviewed because of the sensitive nature of the investigation.] During an interview on 10/18/23 at 9:22 AM, LVN D stated: R#6 tended to scratch himself in the head because of agitation. The resident could be anxious because of his co-morbidity (multiple diagnoses). The resident had not revealed signs of being afraid or not feeling safe. The resident received medication for the anxiety. LVN D stated she was trained and abuse and neglect after the 10/14/23. LVN D stated that the abuse coordinator was the administrator and suspicion of abuse needed to be reported immediately. LVN D stated that sexual contact between residents required consent and the assessment of the residents. During an observation and interview on 10/18/23 at 9:29 AM, R#5 was in bed watching TV; alert and oriented to person and place. The resident was cleaned and groomed; no signs of bruises, wounds, or skin tears. The resident was anxious. The resident stated: this is a nursing home .a man came into my room and tried to rape me .he got on my bed .he tried to touch me .I told him to stop .he told me ugly words in Spanish I do not know how long he was in my room .thank God staff came in .he would have hurt me .the nurse pulled him off me I feel safe today .no other man has come into my room .the door is opened .the nurse checks .the call light works .[resident scratched her nose and it started bleeding; some old scratches were present on top of the forehead from her history of anxiety. Surveyor ended the interview because of the resident's anxiety]. During a telephone interview on 10/18/23 at 10:03 AM, LVN B stated: I found (10/14/23 around 3-4 PM) [R#1] on top of [R#5] and both residents were clothed; and [R #5] had a blanket covering her. [R #5] had triggered the call light. LVN B stated, R #5 was saying help. LVN B got R#1 off R#5 and called for help. R #1 was placed in his wheelchair and moved out of the room, Skin assessments on both residents were negative. LVN B called the family members. LVN B stated, R#1 was put on one of one monitoring; R#5 was not anxious and felt safe. LVN B stated he was trained on abuse/neglect after the incident on 10/14/23. Part of the training involved reporting immediately to nursing management and/or administrator any incident or suspicion of sexual abuse. During a telephone interview on 10/18/23 at 10:14 AM, LVN E stated: on 9/27/23 at night she found R#1 in R#6's bed without a brief on and R#6 had his brief on. LVN E stated, R #1 was naked from the torso down. R#1 had his leg over on R#6. I requested assistance and we separated the residents .he was placed in another room vitals and skin assessments were done and negative for [R#6] .other safety measures included 15 minute checks and door opened .[R#1] was put on 15 minute checks .the MD was notified and the administrator notified the family because of the delicate situation . LVN E stated she was trained on abuse and neglect after the incident on 09/27/23. Part of her training involved notifying the administrator or nurse management when abuse was suspected; to include sexual abuse. During an interview on 10/18/23 at 10:25 AM, RN C stated: on 10/14/23 the charge nurse (LVN B) requested assistance involving R#1 and R#5. RN C went with LVN F to the room and R#1 was sitting on the floor mat, and R#1 was transferred to his wheelchair and moved him to another room. RN C stated, R#5 said she was okay. R#1 was put on 1:1. Both families were contacted. I contacted (R#1's) family and requested whether they could take the resident home because of inappropriate behaviors .the family refused because they did not have the resources .I informed the Administrator of the situation .I have been trained on abuse and neglect .not sure whether the MD was notified .this was an emergency discharge .there was a previous incident with him (R#1) [09/27/23] . RN C stated she was trained on abuse and neglect after the incident on 10/14/23. During a telephone interview on 10/18/23 at 10:55 AM, R#1 stated: I am safe in my new home .I agreed to the placement .I am under hospice care I agreed with the placement because this is a good place I did not like the nursing home .I went to the hospital but did not want to stay .I do not remember whether I got [psych services] at the nursing home .I do not remember lying in other residents' beds .[either in September or October 2023]. During a telephone interview on 10/16/23 at 9:30 AM, the NP said she was made aware by the facility that R#1 was found in the bed of his roommate R#6. The NP stated: the facility addressed R#1's behavior by moving him to another room. R#1 was also referred to psychological services for behavior management. The NP stated no medication adjustment was made to R#1's physician's orders. The NP stated she arrived at the facility and assessed R#6 and there were no residual effects from the incident. The NP did not answer the question as to whether R#1's behavior of being found in his roommates bed with brief removed constituted sexual abuse. During a telephone interview on 10/18/23 at 9:45 AM, The MD stated: R#1 engaged in erratic behavior and possible criminal behavior and he, as the physician, was notified by the facility of the incidents on 09/27/23 and 10/14/23. The MD stated: his main recommendation after the 09/27/27 incident was to transfer the resident (R#1) to a locked secured unit and to closely monitor pending a discharge. According to the MD the facility was unsuccessful in finding a nursing facility that would accept the resident (R#1). The MD did not consider a psychotropic medication adjustment because it could be used as a chemical restraint. On the question of whether R #1's behavior constituted sexual abuse; the MD stated: the facts are in front of you . During an interview on 10/26/23 at 10:00 AM, LVN F stated: regarding the 09/27/23 she was informed by LVN E that R#1 was found in R#6's bed with no brief on. R#1 was moved from hall 100 to hall 400 to a private room. LVN F stated that she kept a close eye on him and my staff was made aware to track his movements . LVN F stated, the inappropriate behavior by R#1 did not repeat itself until 10/14/23. I was upset to hear about the incident on 10/14/23 since we closely monitored him . LVN F stated, R#1 was found in R#5's bed; and it was a potential sexual assault. LVN F stated she was trained on abuse and neglect. During an interview on 10/26/23 at 10:22 AM, LVN D stated: she had no direct knowledge of the 09/27/23 incident involving R#1 and R#6. LVN D, stated: R#1 was moved to another hall (400). LVN D stated: sexual abuse could constitute a sexual behavior between residents without consent. During an interview on 10/26/23 at 10:37 AM, LVN A stated: the interventions put in place to address R#1's behaviors after the 09/27/23 incident included: R#1 was moved to another hall and put on a Q15 for 72 hour regimen (15 minutes every hour, 30 minutes every hour, and then hourly up to 72 hours). LVN A stated, by nursing practice every two hours check were made on residents to include R#1. LVN A stated: R#1 did not show any inappropriate behaviors after 09/27/23; but had another episode of inappropriate sexual behavior on 10/14/23. LVN A stated: she was not sure how the resident got into R#5's room on the day of the incident on 10/14/23. LVN A stated: sexual abuse was inappropriate behavior without consent. During an interview on 10/26/23 at 10:56 PM, the DON stated: the interventions put in place after the 09/27/23 incident included: R#1 was moved to a private room; Q15 for 72 hours[record review of CP dated 09/28/23 contained the intervention to check on resident q shift for wellness]then routine monitoring for 72 hours. The DON stated: between the period of 09/27/23 to 10/14/23 there were no other inappropriate incidents involving R#1 with other residents. The DON stated: R#1 could self-propel his wheelchair; not observed by staff when he entered R#5's room on 10/14/23 between 3:00-4:00 PM. The DON stated: the facility tried to discharge R#1 but no other nursing home wanted the resident. The DON stated she was trained on abuse and neglect; sexual abuse was when the parties did not give consent. The DON stated: all the residents had dementia and the residents could not consent to inappropriate behaviors .therefore it did not meet the definition of sexual abuse The DON stated that there were no adverse effects to the residents. During an interview on 10/26/23 at 11:15 AM, the Administrator stated: the actions put in place involving the 09/27/23 incident included: R#1 was moved to another hall; Q15 checks for 72 hours; and nursing practice to monitor every 2 hours after the 72 hours ended. The administrator stated: the facility pursued a discharge plan and involved the family and the ombudsman; but no other facility wanted the resident. R#1 was referred to psych services and was being monitored by the MD, NP and mental health facility. The administrator stated: abuse/neglect training was given to staff from 09/27/23 to 10/18/23. The administrator stated: R#1 got into R#5's room during the time he was not monitored; the resident was not on 1:1 after the 72-hour monitoring had ended. The administrator stated, sexual abuse by policy is nonconsensual sexual contact .by policy the incidents involving the residents (09/27/23) and 10/14/23 did not constitute sexual abuse .all the residents had dementia. Record review of facility's sign-in sheets from 09/27/23 to 10/17/23 (surveyor entrance) revealed : on 09/28/23 the facility conducted abuse/neglect training for 31 staff members ( 60% of 52 paid staff). On 10/16/23 the facility conducted abuse/ neglect training for 43 staff members (83% of 52 paid staff members). The Administrator was given the IJ template and was notified of the Immediate Jeopardy {IJ} on 10/26/23 at 3:50 PM; and a plan of removal was requested. On 10/27/23 at 11:00 AM, the facility provided a plan of removal and it was accepted on 10/27/23 At 2:00 PM. It was documented as follows: Date: 10-27-2023 Subject: Plan of Removal PLAN OF REMOVAL Preparation and/or execution of his plan of removal does not constitute admission or agreement by the provider of the truth of the facts alleged, or conclusions set forth on the template that was provided by state surveyor. This plan of removal is prepared and/or executed solely because it is required by the provisions of Federal and State law. The following immediate actions were implemented as follows: ¢ On 10-14-23, resident #1 was sent out for a psych eval and returned to facility the same day. Resident was placed on 1:1 until alternate placement could be established. Resident was discharged on 10-16-2023. ¢ Resident #6 has a dx of dementia and does not communicate. Resident was assessed for signs and symptoms of distress after the initial incident occurred on 9-27-23 and again on 9-28-2023 with no signs present. Resident will be re-evaluated again on 10-27-2023, by [local mental health facility]. Additionally, this resident was evaluated on 9-28-23 and 10-6-23 by [local mental health facility]. Family visited resident on 9-28-2023 and was happy with the care being provided and did not notice any behavioral concerns. ¢ Resident #5 has a dx of dementia and verbally communicates. Resident was assessed on 10-14-2023 for signs and symptoms of distress from alleged incident and no signs present. Resident family made aware of the incident and were comfortable with the actions taken. Resident was also evaluated by [local mental health facility] 10-16-2023 and routinely thereafter. ¢ Social Services and designee will be conducting interviews with all residents to determine if they feel safe from abuse at this facility. These interviews will be completed on 10-27-2023 and any negative findings will be addressed immediately. ¢ The facility completed a 100% audit of all staff and residents against the Sexual Abuse Registry for the state of Texas, without any findings on 10/27/2023. ¢ The administrator and DON were in-serviced on abuse and neglect on 10-16-2023 and again on 10-26-2023. These in-services were conducted by Corporate Nurse Consultant and COO, LNFA. ¢ The facility started in-servicing on abuse and neglect, to include reporting requirements, for all full-time staff on 10-16-2023 until completion was accomplished on 10-18-2023. The facility initiated the following training on 10-26-2023: o Full-Time Staff All staff received training on 10-26-2023. o PRN Staff Training has been completed on all staff but 1. This staff member has been removed from the schedule until training has been completed. o New Employees Each new employee will be trained in abuse and neglect during orientation. ¢ The facility will conduct a QAPI meeting on 10-27-2023 to discuss the findings noted on the IJ Template. This will include a review of our current abuse and neglect policy. ¢ The Medical Director was notified of the immediate jeopardy on 10-27-2023. Please let me know if more additional information is needed. Thank you for considering this Plan of Removal. [ LNFA] On 10/27/23, the surveyor confirmed the facility implemented their Plan of Removal sufficiently to remove the IJ by: Interviews: During a telephone interview on 10/27/23 at 2: 05 PM, the COO, LNFA stated: the DON and Administrator were in-serviced on abuse and neglect. The highlight of the training was to report to HHS and law enforcement incidents of suspected sexual abuse. During a joint interview on 10/27/23 at 2:10 PM, the Administrator and DON stated they received the abuse/neglect training and the highlights were: report to HHS and law enforcement if sexual abuse was suspected. Also, they received information on the definition of sexual abuse from the facility's policy of abuse/neglect. 1. During an interview on 10/27/23 at 2:26 PM, CNA G (6A-2P) stated: you need to report to the nurse suspicion of abuse and sexual abuse. The abuse coordinator was the administrator. 2. During an interview on 10/27/23 at 2:30 PM, CNA H (6A-2P) stated: if something happens to report to the administrator and after that the DON .because someone needs to do something . 3. During an interview on 10/27/23 at 2:34 PM, CNA I(6A-2P): there were several types of abuse and neglect. If abuse was suspected to inform the DON and Administrator; and in emergency call 911 for sexual assault. 4. During an interview on 10/27/23 at 2:38 PM, CNA J(6A-2P) a staff needed to be observant and report any suspicion of abuse. The abuse coordinator was the administrator. 5. During an interview on 10/27/23 at 2:41 PM, LVN D stated: incidents needed to be immediately to the administrator. Consent needed to be given for any sexual contact between residents; even consent was present to report and allow the administrator. 6. During an interview on 10/27/23 at 2:51 PM, LVN K (2P-10P) stated: to report abuse and neglect to the administrator immediately. Sexual abuse needed to be reported immediately. Check behaviors or change of condition when there was a suspicion of sexual abuse. 7. During an interview on 10/27/23 at 2:55 PM, LVN L(2P-10P) stated: to be aware of the most vulnerable victim and to report any suspicion of abuse or neglect to the administrator. 8. During an interview on 10/27/23 at 3:09 PM, CNA M (2P-10P) stated: to report immediately to the DON, administrator; and in an emergency the Police. Signs and symptoms of sexual abuse are many; for instance inappropriate touching of a resident or a resident having sexual contact with another resident without consent . Believe any outcry of sexual abuse. 9. During an interview on 10/27/23 at 3:10 PM, CNA N (2P-10P) stated: anyone can be an abuser; report all suspicions to the administrator. Be aware of the vulnerable residents who are bedbound and cannot speak. if you see something, say it to the administrator. 10. During an interview on 10/27/23 at 3:30 PM, CNA O (2P-10P) stated: she attended training and the highlight was to report to the administrator. Also, she learned about some of the signs and symptoms of sexual abuse; for example, resident to resident sexual contact without consent. 11. During an interview on 10/27/23 at 3:35 PM, (10P-6A), CNA P stated: if you see it .or hear it .report to the administrator and an emergency call 911. Signs of sexual abuse include resident behaviors and skin changed and injuries, and bruises and skin tears. 12. During interview on 10/27/23 at 3:35 PM, CNA Q(10P-6A), stated: check the resident's behaviors. Check on signs and symptoms of sexual abuse and report immediately to the nurse or the administrator the abuse coordinator. 13. During telephone interview on 10/27/23 at 3:42 PM, (10P-6A), LVN R stated: report to the administrator. Signs and symptoms of sexual abuse appear in skin assessments and interactions with the resident. Prevention by monitoring. Report any suspicion. 14. telephone interview on 10/27/23 at 3:46 PM, CNA S(10P-6A), stated: report it; call the administrator anytime; let the charge know. Signs and symptoms of sexual abuse could include injuries, bruises and skin tears. 15. During telephone interview on 10/27/23 at 3:54 PM, CNA T(10P-6A), stated: report any abuse to the administrator immediately. Signs and symptoms of sexual abuse could involve non-consensual; injuries and bruises can be discovered during peri-care and bathing. During an interview on 10/27/23 at 3:04 PM, the HR Manager stated she conducted a 100% audit of all staff and residents against the Sexual Abuse Registry for the state of Texas, without any findings on 10/27/2023. During an interview on 10/27/23 at 3:25 PM, SW stated: he conducted interviews with all residents to determine if they felt safe from abuse at the facility; and there were no negative findings. During a joint interview on 10/27/23 at 4:50 PM, the DON and Administrator stated a local mental health provider assessed R#6 who had a BIMS of zero and there were no concerns. Record Reviews: Record review of R#1's Nurse Note dated: 10/14/23 authored by LVN B: revealed: On 10-14-23, resident #1 was sent out for a psych eval and returned to facility the same day. Resident was placed on 1:1 until alternate placement could be established. Resident was discharged on 10-16-2023. Record review of facility's discharge list for November 2023 revealed: R#1 was discharged on 10/16/23 at 5:15 PM to .to home or self-care. Record review of R#6 skin assessment dated [DATE] revealed no new injuries, bruises or skin tears. Record review of R#6's mental health documents dated 09/28/23 and 10/06/23 revealed resident was assessed with no adverse effects. Record review of R#6's general notes dated 10/14/23 revealed: administrator spoke to the family; and the family had no concerns. Resident was not in distress. Record review of R#5's skin assessment on 10/14/23 revealed: no new skin issues after the incident on 10/14/23. Record review of R#5's mental health assessment by local mental health provider on 10/16/23 revealed: chronic history of anxiety. No anxiety due to sexual encounter on 10/14/23. Record review of facility Social Work binder dated 10/27/23 revealed: 72 contact sheets with entries made that the resident felt safe and free from abuse and neglect. Of the 72 residents, all were contacted or the RP except for one resident with a request for a return call. Record review of corporate sign in sheet dated 10/18/23 revealed the DON and Administrator received training on abuse and neglect. Record review of facility's sign-in sheets on abuse and neglect training from 10/18/23 to 10/26/23 revealed the signatures for 52 staff (100% completion rate). Record review of facility's QAPI meeting on 10-27-2023 revealed the required attendees were: administrator, DON, and Medical Director. Six other staff members attended the meeting. Topic of abuse/neglect was part of the agenda. Record review of facility's text message to Medical Director on 10/27/23 at 4:17 PM revealed, he was contacted on the IJ. On 10/27/23 at 5:00 PM , the administrator was informed that the IJ was removed. However, the facility remained out of compliance at a severity of actual harm that is not immediate and a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its corrective systems.