**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 out of 8 residents (Resident #12) reviewed for abuse/neglect as evidenced by:The facility failed to ensure Resident #12 was free from abuse when CNA A squirted Resident #12 with a water gun in her mouth while she slept on 5/24/25. The facility failed to ensure Resident #12 was free from abuse when Resident #12 made an allegation of abuse by CNA C. The allegation was reported to the Administrator on 05/31/2025 by CNA C and on 06/19/2025 by HHSC Surveyor L.An Immediate Jeopardy (IJ) was identified on 07/08/2025 at 4:40 p.m. The IJ template was provided to the facility on [DATE] at 5:06 p.m. While the IJ was removed on 07/10/2025 at 4:10 p.m., the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of its Plan of Removal (POR). This failure could place residents at risk of abuse, injury, and psychosocial harm. Findings included: 1). Record review of Resident #12's admission record, dated 6/18/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #12 had diagnoses which included: type 2 diabetes mellitus chronic kidney disease (disease that affects how the body uses blood sugar), seizures (sudden surge of abnormal electrical activity in the brain), COPD (chronic obstructive pulmonary disease is a lung condition caused by damage to the lungs), and dementia (loss of cognitive functioning). Record review of Resident #12's quarterly MDS, dated [DATE], revealed the resident had severely impaired cognition for daily decision-making skills with a BIMS score of 5.Record review of Resident #12's care plan, dated 06/18/2025, reflected Resident #12 had impaired cognitive function/dementia or impaired thought process, BIMS score severe cognitive impairment, and at times resident made statements that were far from reality or are nonsensical, with an initiated date of 01/16/2025, and revised on 06/06/2025. Record review of the facility's investigation report, dated 06/04/2025, stated On the afternoon of 05/28/2025, CNA [B] reported to Administrator's office with ., Business Office Manager/HR informing that resident [#12] stated that on Saturday, 5/23 [sic], CNA [A] had dropped the bed remote on her left arm. She reported that, when she told him not to do that again, he stated that he would do it as many times as he wanted. Later that day while she was taking a nap, [Resident #12] reported that [CNA A] entered her room and woke up her by shooting a water gun in her mouth .Record review of witness statement summaries: [CNA A] stated that he works weekends only. He denied ever dropping a remote on [Resident #12]'s arm or making statements about continuing to do so despite the protest. When asked if he had ever brought a water gun to work, he stated that he had only squirted residents with it in the kitchen area. He denied squirting [Resident #12] or having the water gun in her room.[Resident #33] a resident in the same section of hallway/CNA assignment as the alleged victim, was asked if she knew [CNA A]. She confirmed that he was her CNA .When asked if she had ever seen him with a water gun, she stated that he had brought one into her room recently and squirted her with it while she laid in bed. She reported that she was not bothered by this act but did think it bizarre behavior.[Resident #16] a resident on the same section of hallway/CNA assignment as the alleged victim, acknowledged that he knew [CNA A] as his weekend CNA. He confirmed that [CNA A] had brought a water gun to the facility and squirted him with it while in his room. He did not feel negatively toward this act and asked that [CNA A] not get in no trouble for this behavior . During an interview on 06/18/2025 at 11:44 a.m. Resident #12 stated she was terrified and scared when she awoke in her room to CNA A splashing water into her mouth with a pistol. Resident #12 stated CNA A had dropped a remote on her arm that caused her pain earlier that day and she told him not to do that again. Resident #12 stated CNA A told her he would do it as many times as he wanted. Resident #12 stated she reported the incident to CNA B on 05/28/2025. During an interview on 06/19/2025 at 12:08 p.m. CNA D stated she knew of an outdoor water activity where they threw water balloons but never saw or knew of any activities that involved water guns. CNA D stated no residents ever reported to her being squirted with a water gun. CNA D stated Resident #12 hallucinated before, but they did a UA (urine analysis), and she had a UTI. During an interview on 06/19/2025 at 1:01 p.m. CNA A stated there was an outdoor activity Resident #12 was never involved in and the water gun was left over from the facility activity. He stated he never sprayed any residents with a water gun only other staff in the dining room area. CNA A stated Resident #33 vouched for him that he never sprayed any residents with the water gun. He stated he was suspended pending the investigation around 05/29/2025 and terminated on 06/05/2025. CNA A stated if residents were squirted with a water gun and did not approve of it, it could make them mad and it would bother them. During an interview on 06/19/2025 at 1:24 p.m. Resident #33 stated she used to share a room with Resident #12, but she had since been moved due to her watching the TV loudly. Resident #33 stated Resident #12 had delusions of a man in the window or her family in the room that was not there. Resident #33 stated Resident #12 had a UTI that had caused her delusions and once treated she did not have any more. Resident #33 stated CNA A did squirt them with a water gun before, but she had fun and only wished she had a water gun to squirt him back. During an interview on 06/19/2025 at 3:06 p.m. the Administrator stated Resident #12 told her about the incident during her afternoon rounds . The Administrator stated Resident #12 told her about how the CNA A dropped the remote on her arm and the resident found it to be malicious. The Administrator stated Resident #12 told her about being squirted in the mouth by CNA A. The Administrator stated Resident #12 felt humiliated, embarrassed, and annoyed by CNA A's childish behavior. The Administrator stated Resident #12 had issues with clarity but after she interviewed a few other residents they also stated CNA A had squirted them with a water gun while they were in bed. The Administrator stated CNA A worked weekends only and was suspended during the investigation and later terminated after the investigation was completed. Record review of a facility incident summary for intake #1012723, dated 06/03/2025, revealed the immediate actions taken regarding CNA A and Resident #12 included: Nursing staff performed head to toe assessment on resident. CNA A was contacted and suspended. Trauma informed PRN assessment was completed with the resident. A report was filed with [city] police department. Messaged were left to inform family of alleged incident. RP [name] returned call and was notified on 06/02/2025. The conclusion revealed, The allegation that [CNA A] dropped a bed remote on resident's arm and stated that he would ‘do it as many times as he wanted' despite her protest is UNCONFIRMED. Findings: [CNA A] denies the allegation. There were no eyewitnesses to the alleged incident. No physical injury consistent with the event was documented during the head-to-toe assessment. No corroborating witness statements exist. The document also revealed, The allegation that, later the same day, [CNA A] entered [Resident #12]'s room while she was sleeping and squirted a water gun in her mouth is PARTIALLY CONFIRMED. The use of a water gun on residents was confirmed by multiple witnesses, which lends credibility to [Resident #12]'s claim. However, the specific act of squirting water into her mouth while asleep could not be directly verified. The overall behavior pattern was confirmed, though the specific incident remains UNCONFIRMED. Findings: [CNA A] denies this specific incident but admits to having used a water gun on residents in common areas. Two other residents [#33, #16] independently confirmed that [CNA A] had brought a water gun into their rooms and squirted them with it. While those residents did not find the behavior harmful, they substantiated the pattern of bringing and using a water gun in resident areas. Staff members interviewed had no witnessed the behavior but also did not directly contradict the claims. The Administrator completed the summary. 2) During an interview on 6/18/25 at 11:44 a.m., Resident #12 stated CNA A's family member, CNA C after the incident, delivered a food tray to her room and put it down so hard she thought the food was going to fall off the tray. Resident #12 stated CNA C stated she would not come into the resident's room alone because the resident may tell people she hit her. The resident stated this made her feel guilty and a little afraid because she does not like to argue with people. During an interview on 07/08/2025 at 12:52 p.m., the Administrator stated she did not recall being informed on 06/19/2025 by HHSC Surveyor L that Resident #12 reported to the HHSC Surveyor L that CNA C had put Resident #12's food down so hard she thought the food would fall off the tray, CNA C told Resident #12 she could not take care of Resident #12 alone because Resident #12 may tell people CNA C hit her and Resident #12 reported feeling guilty and afraid after the interaction. The Administrator stated if she had been notified, she would have suspended CNA C and started an investigation into the allegation. During an interview on 07/08/2025 at 1:30 p.m., Resident #12 stated she remembered a female CNA going into her room and stated, she slammed my tray down really hard, and she had an angry look on her face. Resident #12 stated CNA C said, I just cannot be in here I have to have someone else with me because I don't want you to say I hit you. Resident #12 stated it scared her when the incident occurred and stated, she doesn't take care of she and she doesn't like to take care of me. Someone else brings me my meals. Resident #12 stated she told someone about the incident but did not remember who she told. During an interview on 07/08/2025 at 1:50 p.m., CNA C stated she had received training on abuse and neglect and reporting abuse and neglect to the Abuse Prevention Coordinator that CNA C identified as the Administrator. CNA C stated she was notified by RN K on 05/31/2025 that Resident #12 reported to RN K that CNA C was being mean to her. CNA C stated she immediately called the Administrator to report the allegation Resident #12 made against her and the Administrator told CNA C that she could not refuse to provide care to Resident #12. CNA C stated she also called and reported the allegation to the DON. CNA C stated she had the phone call logs to prove that she contacted the Administrator and the DON to report the allegation. CNA C stated she was never interviewed or suspended related to the allegation. During an interview on 07/08/2025 at 2:15 p.m., the Administrator stated she was presented an IJ template on 06/20/2025 and stated she signed the template without reading the information on the template that included the allegation against CNA C. The Administrator stated, after reading the template on 07/08/2025, the Administrator acknowledged that the allegation toward CNA C was on the template and stated she was suspending CNA C on 07/08/2025 and initiated an investigation into the allegation. The Administrator stated she recalled having a conversation with CNA C around the time of the investigation into CNA A but did not recall CNA C reporting to the Administrator that Resident #12 was alleging that CNA C was mean to Resident #12. During an interview on, 07/08/2025 at 2:39 p.m., the DON stated staff had received training on abuse and neglect and all abuse allegations should be reported immediately to the Abuse Prevention Coordinator who was the Administrator. The DON stated she did not recall receiving a call from CNA C regarding an allegation made by Resident #12 on 05/31/2025. The DON stated intimidation was a form of abuse and should have been investigated immediately. During an interview, 07/08/2025 at 2:54 p.m., HHSC Surveyor L stated she met with the Administrator on 06/19/2025 at 3:06 p.m. and notified the Administrator of the allegation Resident #12 was making toward CNA C. HHSC Surveyor L stated she discussed retaliation with the Administrator due to the incident with CNA C occurring after CNA A was suspended and the fact that CNA C and CNA A were in a relationship. Record review of a facility IJ Template, dated 06/19/2025 at 11:06 a.m., revealed, Resident #12 stated CNA A's [family member], CNA C after the incident, delivered a food tray to her room and put it down so hard she thought the food was going to fall off the tray. Resident #12 stated CNA C stated she would not come into the resident's room alone because the resident may tell people she hit her. The resident stated this made her feel guilty and a little afraid because she does not like to argue with people. The template revealed, The Administrator stated CNA A was terminate and CNA C had called in for most of her shifts since the incident and has not worked with the resident. The template revealed, Resident #12 was terrified and scared. She also felt guilty and afraid from CNA C's visit. The template was signed by the Administrator and HHSC Surveyor L on 06/20.2025. Record review of the facility's Abuse/Neglect policy, dated 3/29/18, reflected The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility . This was determined to be an Immediate Jeopardy on 07/08/2025 at 4:40 p.m. The Administrator was notified of the IJ and provided the IJ Template 07/08/2025 at 5:06 p.m.On 07/08/2025 the facility provided a plan of removal titled: Plan of Removal F600. The plan of removal was accepted on 07/09/2025 at 2:18 p.m. It was documented as follows: Plan of Removal F600Problem: FREE FROM ABUSE AND NEGLECTInterventions:One on One in-service on Abuse Investigation with the Administrator/DON was conducted by the Regional Compliance Nurse on 7/8/2025. This in-service included reviewing and conducting timely investigations for allegations. Staff working with Alleged perpetrators (CNA A and CNA C) have been interviewed on 7/8/2025.The alleged perpetrator, CNA C, was suspended on 7/8/25.Resident safe surveys were completed on 7/8/25.Un-interviewable residents had a head-to-toe assessment completed on 7/8/25.The following in-services were initiated on 7/8/25 and any staff member not present or in-serviced on 7/8/25, will not be allowed to assume their duties until in-services have been completed. Any new employees or agency staff if utilized will receive the following in-services before first shift to be worked.All StaffAbuse/NeglectAbuse/Neglect ReportingWho to Report Abuse/Neglect toInservice included reporting timelines and abuse and neglect coordinator notification. The medical director was notified of the immediate jeopardy situation on 7/8/25 at 4:40 pm. Followed by a text message notification to him on 7/8/2025 notifying him of the active IJ issuance. On 5/28/2025, CNA A was presented with suspension via telephone. On 6/2/25 CNA A was terminated from employment. On 5/29/2025, a police report was filed regarding allegation of abuse from CNA A. Report Case Number: [case number] was taken by [Officer Name]. On 5/29/2025, a trauma informed assessment was completed for Resident #12 which was negative for findings that required follow up interventions. On 7/8/25 a second Trauma Informed Assessment was completed for resident #12.CNA C was interviewed by the Administrator and refused to comment or give a statement on 7/8/25.7/8/25 Staff that worked with perpetrator were interviewed and asked if they had noted any abuse by the alleged perpetrator.ADHOC QAPI discussed with IDT on 7/8/25. MonitoringDON/Admin/Designee will interview 5-10 staff weekly x 6-week situational abuse scenarios had how to address effective 7/8/25.DON/Admin/Designee will interview 5 residents how staff treat them weekly x 6 weeks effective 7/8/25.ADO/Regional Compliance Nurse will monitor weekly x 6 weeks monitoring tools for staff and resident interviews effective 7/8/25.The QA committee will review the findings monthly x 3 months and makes changes as needed. The Administrator will resolve once no further issues have been identified. Effective 7/8/25 The facility's POR verification was as follows: Record review of a facility in-service training attendance record, dated 07/08/2025 revealed it was conducted by RCN and was signed by the Administrator and DON. The topic was abuse and neglect to include timely reporting. Record review revealed 13 staff members were interviewed between 07/08/2025 -07/09/2025 regarding witnessing abuse or neglect by a staff member and all responses were no. Record review revealed 13 staff interviews were conducted, and no additional findings were identified with the staff interviews. Record review of an Employee Disciplinary Report, dated 07/08/2025 listed CNA C as the employee and revealed that CNA C was placed on an investigatory suspension. Record review of facility safe survey questions revealed 27 resident interviews were conducted. Resident # 45, 30, 47 and 46 voiced allegations toward staff members. All other interviews revealed no identified allegations of abuse or neglect. Record review revealed 13 residents had skin assessments completed on 07/08/2025 and 07/09/2025 and no concerns were identified. Record review of a facility in-service, dated 07/08/2025, instructed by the DON, listed the topic of the in-service Abuse and Neglect, and included the Administrator as the Abuse Coordinator and to report any and all abuse to the Administrator. The in-service contained 54 staff signatures. Record review of CNA A's employee disciplinary report revealed CNA A received an investigatory suspension on 05/28/2025. Record review of CNA A's payroll/personnel action form revealed CNA A was terminated from the facility with an effective date of 05/26/2025. Record review of a [city] police report revealed an Officer provided an intake [case number] on 05/29/2025. Type of offense was described as assault. Record review of Resident #12's trauma informed prn assessment, dated 05/29/2025 at 7:52pm revealed resident #12 voiced no trauma concerns. Record review of Resident #12's trauma informed prn assessment, dated 07/08/2025 revealed Resident #12 and Resident #12 ‘s RP identified childhood trauma. Record review of Resident #12 progress note, dated 07/08/2025, by the DON revealed [behavioral health company] and [psychiatry company] were called to follow up on recent allegations, behavioral changes and follow up on Resident #12's trauma informed assessment from 07/08/2025. Record review of a statement by the Administrator, dated 07/08/2025, revealed when CNA C was brought into the office to discuss the allegation against her on 07/08/2025, CNA C got upset and stated it was the Administrator's fault because the resident is making false accusations against staff, CNA C declined to sign the suspension paperwork and left the facility stating I need to get out of here before I say something I regret. Record review of an email from CNA C to the DON, dated 07/08/2025 at 10:18 p.m. revealed CNA C reported an incident with Resident #12 on 05/31/2025 to the DON and the Administrator in which Resident #12 was reporting to staff that CNA C was being mean to her. Record review revealed an Ad Hoc QAPI sign in sheet dated 07/08/2025 and listed 10 names that included the Administrator, DON, Medical Director via phone, Dietary, Activity Director, MDS, Housekeeping, Regional Compliance Nurse, other and BOM/HR. Record review of the facility document revealed a weekly monitoring sheet for staff where it would be tracked for 6 weeks regarding abuse and neglect. The document revealed 3 staff members were interviewed on 07/09/2025 and indicated staff responded correctly to interview questions. Record review of a facility document revealed a weekly monitoring sheet where it would be tracked for 6 weeks which residents were monitored for abuse and neglect. The starting date was 07/09/2025 and listed 2 interviews conducted with no negative response and no incidents reviewed in stand up on 07/09/2025 or identified on facility rounds on 07/09/2025. During an interview with the Administrator on, 07/09/2025 at 3:27 p.m., the Administrator stated she and the DON were in-serviced by the Regional Compliance Nurse on 07/08/2025 regarding reviewing and conducting timely observations. The Administrator stated staff who worked with the alleged perpetrators CNA A and CNA C were interviewed on 07/08/2025 regarding observing or witnessing any abuse or neglect in relation to CNA A and CNA C. No additional allegations were identified or voiced. The Administrator stated the interviews were conducted with 13 employees. The Administrator stated CNA C was suspended on 07/08/2025 pending an investigation into the allegation. The Administrator stated safe surveys were conducted with 27 residents and 3 allegations of abuse were identified and reported to HHSC on 07/08/2025 and 07/09/2025 that included Resident #30, 45, 46 and 47. The identified employees were suspended, and an investigation was initiated. The Administrator said non-interviewable residents received a head-to-toe assessment that was completed on 7/8/25 and no issues or concerns were identified. The Administrator stated staff in-servicing began on 07/08/2025 and included all staff members. The Administrator verified there were 52 staff members, and all staff also received training on the [alert system notification] that was sent by text and email to all staff and included a PDF of the abuse policy. The Administrator stated there were 54 wet signatures on the in-services. The in-services topics included reporting on abuse and neglect, reporting protocols, who to report to and definitions of abuse and neglect. The Administrator stated the Medical Director was notified of the immediate jeopardy on 7/8/2025 at 4:40pm. The Administrator stated CNA A was suspended by telephone on 5/28/2025 and was terminated from employment on 6/2/2025 after the investigation. The Administrator stated a police report was filed on 5/29/2025 regarding an allegation of abuse by CNA A. The Administrator stated a case number was provided, and the resident declined to press charges. The Administrator stated a trauma informed assessment was completed on 5/29/2025 for Resident #12 and was negative for any findings at that time. The Administrator stated a second trauma informed assessment was completed for Resident #12 on 7/8/25 and the findings included mention of childhood trauma and resident was seen by an LPC on 07/08/2025 and 07/09/2025. The Administrator stated she attempted to interview CNA C on 07/08/2025 and CNA C refused to provide a statement. The Administrator stated she received a statement from CNA C on 07/08/2025 at 10:18 p.m. that was emailed to the DON. Staff members who had worked with CNA C were interviewed regarding observations of abuse or neglect and no allegations were identified from staff interviews. An Ad Hoc QAPI meeting was held on 07/08/2025 and staff in attendance included the MD by phone, Administrator, DON, Dietary Manager, Activity Director, Regional Compliance Nurse, Maintenance Director, MDS Coordinator, Housekeeping Supervisor and HR Director. The Administrator stated the Administrator or DON would interview 5-10 staff members weekly for 6 weeks. The interviews would consist of situational abuse scenarios and how to address abuse scenarios. The finding would be brought to the monthly QAPI meeting to review for 3 months. The Administrator stated the Administrator or DON would interview 5 residents weekly for 6 weeks related to staff treatment and the finding would be brought to the monthly QAPI meeting for review for 3 months. The Administrator stated the Regional Compliance Nurse or ADO would monitor the monitoring tools weekly for 6 weeks to ensure compliance. The Administrator stated the QA committee would be reviewing findings from the monitoring tools monthly for 3 months and will make changes to the plan as needed. During interviews on 07/10/2025 from 9:04 a.m. to 1:05 p.m., with 10 employees (2 CNAs , 1 MA, 2 LVNs, 2 housekeeping staff, 1 cook, 1 Dietary Aide, 1 Hospitality Aide) from the day shift (6 AM to 2 PM) and 4 employees (1 CNA, 2 LVNs and 1 RN) from 2pm -10 pm, and 2 employees (1 LVN and 1 CNA) who work double weekend shifts from 6a-10pm and 1 CNA from the night shift (10 PM to 6 AM) revealed staff had received in-service education on Abuse and Neglect, identified the Abuse Coordinator, how and when to contact the Abuse Coordinator. The staff members were able to identify and define types of abuse and neglect. During an interview, 07/10/2025 at 10:11 a.m., the RCN stated the Administrator and DON were reeducated on abuse and neglect on 07/08/2025. The RCN stated the education included the importance of the Administrator and DON ensuring facility staff were reporting abuse to them timely and reviewed the timeline they had to report. The RCN stated the Administrator and DON were told they had 2 hours to report abuse or neglect, and they were to report first and then investigate the allegations. The RCN stated she notified the Medical Director of IJ on 07/08/2025 and stated an Ad Hoc QAPI meeting was held at that time with the Medical Director. The RCN stated RCN and/or the ADO would review the facility monitoring tools weekly and would verify the monitoring tools by interviewing a random sample of residents and staff to validate the interviews are occurring weekly. The RCN and/or ADO would sign the weekly template to validate their review of the tools. During an interview on 07/10/2025 at 10:40 a.m., the Medical Director stated he was notified by the DON and RCN on 07/08/2025 about the IJ and discussed the plan of action and training conducted to address the IJ concerns. During an interview on 07/10/2025 at 11:37 a.m., CNA C stated she was suspended on 07/08/2025. CNA C stated she wrote a statement and sent it by email to the DON and CNA C stated her statement included information on CNA C reporting Resident #12's allegation on 05/31/2025 to the DON and the Administrator on that date. CNA C stated she provided the DON phone records to prove that CNA C called and spoke to the Administrator and DON on 05/31/2025. CNA C stated the phone records revealed CNA C called the Administrator on 05/31/2025 at 11:56 a.m. and there was no answer. The Administrator returned CNA C's call at 1:58 p.m. and the length of the call was 21 minutes. During an interview on 07/10/2025 at 1:55 p.m., the Administrator stated the training she received on 07/08/2025 by RCN included how to conduct investigations of abuse and neglect and the steps that needed to be included when conducting investigations. The Administrator stated 13 residents had head to toe assessments completed and no concerns were identified. The Administrator and DON were informed the Immediate Jeopardy was removed on 07/10/2025 at 4:10 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the environment was as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 of 1 resident (Resident #1) reviewed for accidents and hazards, in that: Resident #1 was able to leave the front porch of the facility on 09/09/2024 without staff's knowledge and go to a grocery store 1.7 miles away, then became confused when leaving the grocery store as to where he resided. Resident was found at the homeless shelter where he had previously lived. Resident #1 had a cognitive decline and that although staff were concerned about letting the resident sit out on the front porch, they continued to do so prior to his elopement. An IJ was identified on 02/27/2025. The IJ template was provided to the facility on [DATE] at 2:12 PM. While the IJ was removed on 02/28/2024, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because the facility needed to evaluate the effectiveness of their corrective actions. This failure could place residents at risk of accidents that could result in serious injury, harm, impairment, or death. Findings were: Record review of Resident #1's admission record, dated 02/25/2025, reflected a [AGE] year-old resident with an admission date of 07/15/2024, and diagnoses of unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance (a mental health condition characterized by a loss of contact with reality), mood disturbance, and anxiety, alcohol abuse, uncomplicated, hypertensive crisis (severely elevated blood pressure), unspecified, unspecified dementia, unspecified, severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, essential (primary) hypertension (high blood pressure that develops gradually over time and has no clear cause), disorientation, unspecified. Resident #1's Quarterly MDS assessment with a completion date of 09/02/2024 reflected a male with a BIMS of 08, which indicated moderate cognitive impairment, and had exhibited behaviors of wandering type occurred daily. Further review of Resident #1's MDS reflected he required supervision or touch assistance with mobility. Record review of Resident #1's Comprehensive Person-Centered Care Plan, dated 08/21/2024, reflected nothing related to do with wandering or being an elopement risk. Record review of Resident #1's Comprehensive Person-Centered Care Plan, dated 09/09/2024, reflected Focus: Resident has had an actual elopement. The incident: During an interview on 02/25/2025 at 1: 31 PM, the DON stated Resident #1 went out on 09/09/2024 to sit on the front patio the day of the incident with another resident (Resident #1 now resides at a memory care facility. The other resident has been discharged .) and was observed to be gone from the front porch by the receptionist. DON stated the staff looked for Resident #1 everywhere, called the police, called the homeless community where he had been prior informing them, he was missing in case he went there, and when they received a call from the police and the homeless community, he had returned to the homeless community they went and picked up the resident. DON further stated Resident #1 had left the front patio to go to the store and reported he did not know where to go when he came out of the store. During an interview on 02/25/2025 at 2:21 PM LVN P stated he had been working for the facility for about a month. LVN P further stated he had not received training during his orientation on elopements, however then stated he was to notify the administrator, look for the resident and figure out what was going on. LVN P stated to determine if a resident should be out on the front patio would be based on the resident's cognition and if they were an elopement risk. LVN P stated they had a list at the nurses' station with names of residents who were an elopement risk and he had 2 residents on his unit. During an interview on 02/25/2025 at 3:19 PM CNA J stated the facility did not really have elopements too often, stating the receptionist during the day watched the residents when they were outside. CNA J further stated prior to letting residents sit on the front porch they would ask the nurse. He stated if they felt a resident would wander off, they would have to sit with the resident. CNA J stated he believed there was a list of residents at risk of eloping. During an interview on 02/26/2025 at 1:06 PM the corporate nurse revealed all residents were assessed after the incident for elopement risk, elopement risk was to be conducted on admission, quarterly and when incidents occurred. She stated a sign had been placed on the door alerting staff and families to speak with nurse prior to assisting residents outside. Staff had been in-serviced on elopement prevention, elopement response, and elopement codes. The corporate nurse stated the Kardex informed staff of residents who were an elopement risk and there haven't been any issues since this was put in place. During an interview on 02/27/2025 at 5:39 AM CNA Q stated if she was not able to find a resident, she would tell the nurse and look for the resident. She stated they would look everywhere for the resident. CNA Q stated residents who were more focused and not confused were able to go outside to the front, however the courtyard was safer and fenced in. She stated she would ask the nurse prior to assisting and if a resident was more alert, they were able to go out. During an interview on 02/27/2025 at 9:20 AM with the MDS Coordinator revealed the BIMS for Resident #1 changed from an 11 in July 2024 to an 8 in September 2024 and it was not a significant change in cognition. Stating depending on the time of day a person's BIMS could vary on score if done in morning or the afternoon. Stating he (Resident #1) liked to go outside and sit with his pal, and this would occur several times a day. Stated Resident #1 had not been showing signs of wanting to leave. During an interview on 02/27/2025 at 10:01 AM the ADON stated a resident who was an elopement risk would be someone who actually was exit seeking, states they want to leave and attempts. The ADON stated cognitive issues would affect the residents being able to go out on the front porch. The ADON further stated the nurses knew to review the elopement assessment. The ADON stated Resident #1 was smart and intact in the mornings, but in the evenings, he could have some confusion on time, regarding if he had coffee or if he had eaten. During an interview on 02/27/2025 at 10:35 AM LVN A stated the determination on whether a resident was able to go out on the front porch was based on the elopement risk, assessments, and nursing judgement at the time depending on the actions of the resident. LVN A further stated she had access to the residents' assessments and care plans on the computer. During an interview on 02/27/2025 at 10:42 AM interview with DON revealed she did not feel Resident #1 was able to be out on the porch alone. The DON stated he had become friends with another resident who he would sit outside with. The DON described Resident #1 as forgetful and would basically walk back and forth around the facility, she would not have considered his behavior wandering he was just walking. The DON stated the determination on if a resident was able to sit on the front porch would be by looking at the BIMS, looking at the assessments and what was going on in the moment. The DON further stated if the individual was not making sense, she would not recommend them sitting on the front porch. The DON further stated staff were made aware of changes through the UDAs (user defined assessment) under the assessment section of PCC (point click care). The DON stated the BIMS can always change throughout the day depending on when you ask the resident. The DON stated she always encouraged the nurses to check the assessment and listen to the resident/observe the resident before making a decision. During an interview on 02/27/2025 at 10:58 AM with MA B revealed she didn't feel Resident #1 was safe to be out front alone. The MA B stated Resident # 1 would ask to go outside every couple of minutes and staff would redirect him. The MA B stated Resident #1 would talk about before he came to the facility how he went everywhere, and he did not like to be told what to do. MA B stated she knew if an individual was able to go out front through her nurse. She stated the nurse would let them know along with the administrative staff. MA B further stated they had in-services and would talk about this quite often. MA B stated everything went through the charge nurse. During an interview on 02/27/2025 at 11:05 CNA I stated to prevent elopements the staff received updates through a group chat and verbally letting them know if they had a new resident if they were on elopement protocol. CNA I stated the nurses would let them know who was able to sit on the front porch. During an interview on 02/27/2025 at 11:20 AM the Dietary Supervisor stated Resident #1 was always moving around and would move a lot through the facility. The Dietary Supervisor stated he would notify the nurse if someone wanted to go outside, and they would tell him if they could. He further stated the nurse would look at assessments and see who could or could not. During an interview on 02/27/2025 at 11:30 AM with CNA C further stated Resident #1 was not safe to go out on the front porch alone and the nurse would go out on the front porch with him. CNA C stated Resident #1 always had to be redirected and would ask people to let him outside. CNA C stated before opening the doors she would notify the nurse and ask who was allowed to go outside. Record review of the Provider Investigation Report dated 9/12/2024 revealed Resident #1 was last seen at 1:50 p.m. He was found at a local homeless shelter at 3:55 p.m. and returned to the facility at 4:45 p.m. Record review of google maps reflected the local store was 1.7 miles from the facility. Record review of facility in-service training named Elopement Prevention dated 09/09/2025, revealed 63 staff had signed the in-service. Record review of facility in-service training named Emergency Codes, dated 09/09/2025, revealed 62 staff had signed the in-service. Record review of facility in-service training named Elopement Response, dated 09/09/2025 revealed 63 staff had signed the in-service. Record review of facility's employee roster revealed the facility had 63 employees. During an interview on 02/27/2025 at 11:48 AM the Administrator revealed Resident #1 had a different cognitive level at different times of the day without an assessment it would not have been safe for him to be out at that time. The Administrator further stated one of the changes they had made was people were to be assessed prior to being outside unattended. This was determined to be an Immediate Jeopardy (IJ) on 02/27/2025 at 2:12 PM. Administrator was provided with the IJ template on 02/27/2025. The following Plan of Removals was accepted on 02/27/2025 at 7:32 PM. Plan of Removal: River City Care Center 2/27/25 POR-Elopement (Incident Date 9/9/24) Problem: On 9/9/24 at approximately. 1:50 pm resident [resident initials] was seen sitting out front right in the front walkway area, at approximately. 2:05 pm the receptionist noticed that resident [resident initials] was no longer sitting there. Interventions: On 2/27/25 100% of residents in facility assessed for any active exit seeking behaviors or any active wandering behaviors by DON or designee, none noted. On 2/27/25 Elopement assessments completed for 100% of residents in facility, By DON or Designee- Any resident at risk for elopement has interventions in place to include risk for elopement on residents Kardex and care plan. On 2/27/25 100 % of resident current BIMS assessments reviewed to determine Cognitive status by MDS nurse. On 2/27/25 Medical Director [Directors Name] Notified of Immediate Jeopardy Situation on by RCN. On 2/27/25 ADHOC QA completed with IDT team on Regarding Immediate Jeopardy Situation. Inservice's: in services initiated on 2/27/25 with an anticipated completion date of 2/27/25, staff will receive in servicing either in person or via phone by DON or Designee. If staff is in serviced via phone, they will sign in-services prior to their next working shift. No staff will be allowed to work until they receive the in-services- (Includes any agency staff or new hires) - Elopement policy - Elopement prevention - How to identify a resident at risk for Elopement in PCC Via POC task (Non licensed nursing staff) - How to identify a resident bims score in pcc via POC task, BIMS Assessment score ( 0-7 Severe cognitive impairment or 8-12 Moderate cognitive impairment) Will utilize the back courtyard to sit outside upon their request or staff supervision. - (Non-Licensed nursing staff) - All other non-licensed staff will inquire with licensed nurses for questions regarding resident bims score. - How to Identify a resident at risk for Elopement in PCC Via Elopement assessment, POC task and Care plan (Licensed Nurses) - How to identify resident BIMS assessment score located in special instructions tab in residents' chart in pcc. (Licensed Nurse) - All non-licensed staff to notify licensed nurses prior to letting any resident go outside of facility. (Non-licensed staff) - - Resident who have been identified as cognitively impaired via BIMS Assessment score (0-7 Severe cognitive impairment or 8-12 Moderate cognitive impairment) Will utilize the back courtyard to sit outside upon their request or staff supervision. - Inservice completed with DON/ADON and MDS nurse regarding entering BIMS score in special instruction tab in pcc by RCN on. - BIMS assessment score will be located in the special instructions tab in each patient's chart. (licensed nurses.) *** Facility patio/ back courtyard is located on facility premises within a secure gate not considered leaving facility property*** Monitoring: All monitoring will be maintained on a monitoring log. Monitoring will begin on 2/27/25. DON and or Designee will review all elopement assessments weekly to ensure any residents at risk for elopement have proper interventions in place. (Includes new admissions) x 4 weeks and periodically thereafter to ensure compliance. DON and or Designee will review all residents BIMS assessments to ensure residents identified with cognitive impairment have interventions in place (Special instructions in place in pcc) weekly x 4 weeks and periodically thereafter to ensure compliance (Includes new admissions) DON or Designee will be responsible to update special instructions tab in pcc if a change in BIMS score is identified, weekly x 4 weeks and periodically thereafter to ensure compliance. DON/Designee will notify staff if any BIMS score change is noted upon review of assessments and on an as needed basis via communication board in pcc. DON/Designee will ask 4 non licensed nursing staff situational questions related to elopement (How to identify a resident at risk for elopement in pcc, what to do if a resident elopes) x 4 weeks and periodically thereafter to ensure compliance. DON/Designee will ask 4 licensed nurses situational questions regarding elopement and cognition (How to identify a resident at risk for elopement in pcc, how to identify a resident with a cognitive deficit in pcc) x 4 weeks and periodically thereafter to ensure compliance. DON/Designee will Monitor once a day 3xs a week to ensure there is no evidence of facility staff or visitors allowing residents to go outside without notifying nurse x 4 weeks and periodically thereafter to ensure compliance. All findings will be reviewed in monthly QA and changes will be made to the plan if needed. Verification: Interview with the Corporate Nurse Liaison on 02/28/2025 at 9:00 AM revealed the facility started in-services on 02/27/2025. Corporate Nurse Liaison stated all staff had been in-serviced in person and via phone. She stated staff who were in-serviced via phone were to sign the in-services prior to starting their shifts. Observations of the facility front porch and courtyard on 02/28/2025 at 11:30 AM, 2:00 PM and 6:00 PM revealed no one sitting on the front porch or in the courtyard of the facility. Interview with MA D on 02/28/2025 at 10:21 AM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, Elopement Prevention, and how to identify a resident BIMS Score in PCC via POC task. MA D was able to demonstrate an understanding of the in-service materials. Interview with LVN E on 02/28/2025 at 11:04 AM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, how to identify a resident at risk for elopement in PCC via elopement assessment, POC task and care plan, Elopement Prevention, BIMS assessment score will be located in the special instructions tab, how to identify resident BIMS assessment score located in special instructions tab, how to identify a resident BIMS Score in PCC via POC task, and DON/Designee will notify staff if any BIMS score change is noted upon review of assessment and on as needed basis via communication board in PCC. LVN E was able to demonstrate an understanding of the in-service materials. Interview with Housekeeping Supervisor on 02/28/2025 at 1:25 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, Elopement Prevention, and all other non-licensed staff will inquire with licensed nurse for questions regarding resident BIMS score. The Housekeeping Supervisor was able to demonstrate an understanding of the in-service materials. Interview with Housekeeper F on 02/28/2025 at 1:30 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, Elopement Prevention, and all other non-licensed staff will inquire with licensed nurse for questions regarding resident BIMS score. Housekeeper F was able to demonstrate an understanding of the in-service materials. Interview with Laundry G on 02/28/2025 at 1:35 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, Elopement Prevention, and all other non-licensed staff will inquire with licensed nurse for questions regarding resident BIMS score. Laundry G was able to demonstrate an understanding of the in-service materials. Interview with DA H on 02/28/2025 at 1:40 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, Elopement Prevention, and all other non-licensed staff will inquire with licensed nurse for questions regarding resident BIMS score. DA H was able to demonstrate an understanding of the in-service materials. Interview with LVN A on 02/28/2025 at 1:55 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, how to identify a resident at risk for elopement in PCC via elopement assessment, POC task and care plan, Elopement Prevention, BIMS assessment score will be located in the special instructions tab, how to identify resident BIMS assessment score located in special instructions tab, how to identify a resident BIMS Score in PCC via POC task, and DON/Designee will notify staff if any BIMS score change is noted upon review of assessment and on as needed basis via communication board in PCC. LVN A was able to demonstrate an understanding of the in-service materials. Interview with CNA I on 02/28/2025 at 2:00 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, Elopement Prevention, and how to identify a resident BIMS Score in PCC via POC task. CNA I was able to demonstrate an understanding of the in-service materials. Interview with MA B on 02/28/2025 at 2:05 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, Elopement Prevention, and how to identify a resident BIMS Score in PCC via POC task. MA B was able to demonstrate an understanding of the in-service materials. Interview with Medical Records on 02/28/2025 at 2:10 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, Elopement Prevention, and how to identify a resident BIMS Score in PCC via POC task. Medical Records was able to demonstrate an understanding of the in-service materials. Interview with MDS Coordinator on 02/28/2025 at 2:20 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, how to identify a resident at risk for elopement in PCC via elopement assessment, POC task and care plan, Elopement Prevention, BIMS assessment score will be located in the special instructions tab, how to identify resident BIMS assessment score located in special instructions tab, how to identify a resident BIMS Score in PCC via POC task, DON/Designee will notify staff if any BIMS score change is noted upon review of assessment and on as needed basis via communication board in PCC and the DON/ADON and or MDS nurse will be responsible for entering BIMS score in special instruction tab in PCC. The MDS coordinator was able to demonstrate an understanding of the in-service materials. Interview with CNA J on 02/28/2025 at 2:30 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, Elopement Prevention, and how to identify a resident BIMS Score in PCC via POC task. CNA J was able to demonstrate an understanding of the in-service materials. Interview with LVN K on 02/28/2025 at 3:00 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, how to identify a resident at risk for elopement in PCC via elopement assessment, POC task and care plan, Elopement Prevention, BIMS assessment score will be located in the special instructions tab, how to identify resident BIMS assessment score located in special instructions tab, how to identify a resident BIMS Score in PCC via POC task, and DON/Designee will notify staff if any BIMS score change is noted upon review of assessment and on as needed basis via communication board in PCC. LVN K was able to demonstrate an understanding of the in-service materials. Interview with CNA L on 02/28/2025 at 3:15 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, Elopement Prevention, and how to identify a resident BIMS Score in PCC via POC task. CNA L was able to demonstrate an understanding of the in-service materials. Interview with CNA M on 02/28/2025 at 3:36 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, Elopement Prevention, and how to identify a resident BIMS Score in PCC via POC task. CNA M was able to demonstrate an understanding of the in-service materials. Interview with CNA N on 02/28/2025 at 3:49 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, Elopement Prevention, and how to identify a resident BIMS Score in PCC via POC task. CNA N was able to demonstrate an understanding of the in-service materials. Interview with the DON on 02/28/2025 at 4:00 PM revealed the monitoring logs had been started on 02/27/2025, all residents had been reassessed for elopement, BIMS and care plans had been updated. The DON further stated the Medical Director had been notified of the current IJ. She stated PCC and POC had been updated on all residents with special instructions along with the task had been updated. Interview with LVN O on 02/28/2025 at 4:30 PM revealed they receive training after the IJ was identified on 02/27/2025. In-services were on staff to notify licensed nurses prior to letting any resident go outside of the facility, residents who have been identified as cognitively impaired via BIMS assessment score, Elopement Policy, how to identify a resident at risk for elopement in PCC via POC task, how to identify a resident at risk for elopement in PCC via elopement assessment, POC task and care plan, Elopement Prevention, BIMS assessment score will be located in the special instructions tab, how to identify resident BIMS assessment score located in special instructions tab, how to identify a resident BIMS Score in PCC via POC task, and DON/Designee will notify staff if any BIMS score change is noted upon review of assessment and on as needed basis via communication board in PCC. LVN O was able to demonstrate an understanding of the in-service materials. Record review of all residents' Elopement Risk assessments on 02/28/2025 revealed the facility completed the re-assessments of all residents on 02/27/2025. Record review of all residents' Special Instructions in PCC on 02/28/2025 revealed the facility had updated the Special Instructions with BIMS and Elopement Risk of all residents on 02/27/2025. Record review of all residents' BIMS Assessments in PCC on 02/28/2025 revealed the facility had completed re-assessments of all residents' BIMS on 02/27/2025. Record review of in-service training on Staff to notify licensed nurses prior to letting any resident go outside of facility, dated 02/27/2025, on 02/28/2025 revealed 40 of 56 staff had signed the in-service training and 16 staff members had been notified by phone. Record review of in-service training on Resident who have been identified as cognitively impaired via BIMS Assessment score (0-7 Severe cognitive impairment or 8-12 Moderate cognitive impairment) Will utilize the back courtyard to sit outside upon their request or staff supervision, dated 02/27/2025, on 02/28/2025 revealed 40 of 56 staff had signed the in-service training and 16 staff members had been notified by phone. Record review of in-service training on Elopement Policy dated 02/27/2025, on 02/28/2025 revealed 40 of 56 staff had signed the in-service training and 16 staff members had been notified by phone. Record review of in-service training on How to identify a resident at risk for Elopement in PCC via POC task (non-licensed nursing staff), dated 02/27/2025, on 02/28/2025 revealed 11 of 17 non-licensed nursing staff had signed the in-service training and 6 staff members had been notified by phone. Record review of in-service training on How to identify a resident at risk for Elopement in PCC via Elopement assessment, POC task and Care plan (Licensed Nurses), dated 02/27/2025, on 02/28/2025 revealed 11 of 17 licensed nurses had signed the in-service training and 6 staff members had been notified by phone. Record review of in-service training on Elopement Prevention, dated 02/27/2025, on 02/28/2025 revealed 40 of 56 staff had signed the in-service training and 16 staff members had been notified by phone. Record review of in-service training on BIMS assessment score will be located in the special instructions tab in each patients chart (licensed nurses), dated 02/27/2025, on 02/28/2025 revealed 11 of 17 licensed nurses had signed the in-service training and 6 staff members had been notified by phone. Record review of in-service training on How to identify a resident BIMS assessment core located in special instructions tab in residents' chart in PCC. (Licensed Nurses), dated 02/27/2025, on 02/28/2025 revealed 11 of 17 licensed nurses had signed the in-service [NAME][TRUNCATED]