Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 of 2 residents (Resident #3) reviewed for quality of care. Resident #3 exited the facility through an alarming secure unit exit door on 5/14/2025. CNA A turned off the alarm without looking for Resident #3. Resident #3 left the facility and went missing for over 1.75 hours. The police found Resident #3 in a parking lot near an interstate highway and highway access roads. The noncompliance was identified as PNC. The IJ began on 5/14/2025 and ended on 6/4/25. The facility had corrected the noncompliance before this investigation survey began. This failure could place residents at risk of injury or death due to lack of supervision. The findings were: Record review of Resident #3's face sheet, dated 7.29.25, and EMR (electronic medical record) revealed the resident was admitted on 4.18.25 with diagnoses that included: ALZHEIMER'S DISEASE WITH LATE ONSET, insomnia, dementia, depression, and anxiety. The RP (responsible party) was a family member. Record review of Resident #3's quarterly MDS assessment, dated 5.1.25, revealed,BIMS score was 4 (0-5=severe cognitive impairment)ADLs: B/B was frequently incontinent requiring substantial/maximal supervision. Transfer independent. Bed Mobility was independent. ROM showed no impairment.Section P - Restraints and Alarms, revealed that bed/chair/out of bed restraints and alarms were not in use. Record review of Resident #3's Care Plan, dated 5.19.25, revealed the resident was a high elopement risk/wanderer, disoriented to place, with a history of attempts to leave the facility unattended, and impaired safety awareness. The goals were: the resident's safety will be maintained through the review date and the resident will not leave facility unattended through the review date. Interventions included: Document wandering behavior and attempted diversional interventions in behavior. For night shift, resident is on 1:1 visual monitoring. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Room change away from back door. The resident's triggers for wandering/eloping are (early morning and sun downing hours). The resident's behavior was de-escalated by redirecting him away from door and offering pleasant diversions, structured activities, food, conversation, television, book, and magazines. Record review of Resident #3's Wandering Risk Scale showed a score of 13 (High Risk Wanderer) on 5.14.25, a score of 14 (High Risk Wanderer) on 4.21.25, and a score of 13 (High Risk Wanderer) on 4.18.25. Record review of Resident #3's orders revealed he had an order from 4.20.25 stating he should reside on the secure unit due to wandering and high risk of elopement. Record review of Resident #3's Nurse Note, dated 5.14.25 and created at 7:23 AM, authored by LVN B, revealed CNA A notified him that the C-back alarm was set off while she was on another unit and that Resident #3 could not be found. LVN B began searching all rooms with available CNA staff and initiated a code purple. DON assisted with the search, called emergency services, and notified the ADMIN. All available staff were searching possible areas. The DON notified the RP. Record review of Resident #3's Nurse Note, dated 5.14.25 and created at 11:55 AM, authored by the DON, revealed he was notified by charge nurse LVN B that floor staff has been unable to locate Resident #3 and all current members of staff on unit C continue to look for him. The DON assisted the search. After 5 minutes of looking for the resident, a code purple was called, and the entire team began looking for the resident on and off the property. The DON called the ADMIN and informed her of the elopement. The DON called 911 at 6:50 AM. A resident flyer with personal information was copied for police and staff members. Record review of Resident #3's Nurse Note, dated 5.14.25 and created at 12:02 AM, authored by DON, revealed Resident #3 was located and brought back to the facility by the police department. He received a full head to toe assessment. Skin noted to be intact with no bruises, scrapes, or bumps noted. A neurological assessment remains at baseline. DR G was informed of the elopement and safe return with no new orders obtained. Resident placed on line-of-site (sic) monitoring to prevent reoccurrence. Nursing staff received updates and in-service training. Record review of Resident #3's Nurse Note, dated 5.14.25 and created at 12:59 PM, authored by charge nurse LVN C, revealed Resident #3 was located and brought back to the facility by the police department. A full head to toe assessment was completed. Skin noted to be intact with no bruises, scrapes, or bumps noted. A neurological assessment remains at baseline. The resident denies pain or discomfort. The RP was notified of Resident #3's return and bed change to a room closer to the nurse's station. No new orders from the NP and per the DON, the resident was placed on line-of-site (sic) monitoring and neuro checks for 72 hours. Record review of Resident #3's Nurse Note, dated 5.15.25 and created at 6:48 AM, authored by LVN B, revealed staff was on 1-to-1 monitoring and 30-minute visual checks were in place. Resident #3 will continue to be monitored for exit-seeking behaviors. Record review of Resident #3's Nurse Note, dated 5.15.25 and created at 12:59 PM, authored by charge nurse LVN C, revealed staff continue to monitor Resident #3 for elopement behaviors on day 2/3. Resident #3 continues to wander through the MCU and expresses verbally that he wishes to go outside for a walk, was seen walking up to multiple exit doors but is easily redirected. Record review of Resident #3's Nurse Notes, dated 5.16.25 and created at 6:30 AM, authored by LVN B, and dated 5.16.25 and created at 2:11 PM, authored by LVN C, revealed 30-minute checks were in place as Resident #3 continues to wander, walk up to multiple exit doors, and voice if he can go outside. Record review of Resident #3's Nurse Note, dated 5.17.25 and created at 3:40 AM, authored by charge nurse LVN D, revealed staff continue to monitor Resident #3 for elopement behaviors on day 3/3. Resident #3 continues to wander through the MCU and expresses verbally that he wishes to go outside for a walk, was seen walking up to multiple exit doors but is easily redirected. Record review of elopement investigation report for Resident #3's, dated 5.14.25 authored by the ADMIN revealed, the resident eloped on 5.14.25 at around 5:45 AM. CNA A responded to the unit C-back door alarm after returning from another unit. CNA A turned the door alarm off and returned to assisting her coworker with rounding. CNA A noticed that Resident #3 was missing from the secured area and began to look for the resident. At 6:20 AM, CNA A notified LVN B that she cannot find the resident. At 6:25 AM, LVN B notified the DON that they cannot find Resident #3. At 6:30 AM, residents in the secured unit are counted and Resident #3 was the only one not accounted for. At 6:35 AM, the DON notified the ADMIN. At 6:40 AM, the ADMIN initiated a search for Resident #3 in the facility. At 6:50 AM, the DON called the police to report a missing resident as well as assigning available staff to search an extended zone. At 7:25 AM, the facility received a call from Resident #3s RP who stated that the resident was found by the police. At 7:40 AM, the resident was returned by the police. The ADMIN suspended CNA A and terminated her employment. Additional actions the facility took to correct the immediacy (prior to the surveyor entrance) included bi-weekly elopement drills, education was provided to the Admissions/Marketing team to ensure all residents were prescreened for wandering/elopement risk, and a 6-foot wooden fence with a keypad locked gate was constructed outside of the unit C-back secure exit door on 6.4.2025. Activation of the fire alarm system disables the lock. During an observation and interview on 7.27.25 at 4:41 AM with Resident #3, he stated the employees treat him good. He also revealed that other residents treat him good. He revealed that he did not need assistance with showers stating, no I can do it myself. Resident #3 was sitting at a table in the dining room on the secured unit, had on shoes, and was well-groomed. At 4:45 PM, Resident #3 got up and walked out of the dining room. During an observation and interview on 7.30.25 at 11:30 AM, Resident #3 was sitting in the dining area alone with a drink watching TV. He was groomed and calm. During an observation on 7.31.25 at 8:59 AM of Resident #3 revealed his room to be clean and call light on his bed. Resident was not in his room and was observed sitting in the dining room at a table with several other residents and appeared with a calm demeanor. During an interview on 7.30.25 at 5:45 PM, the ADMIN revealed that Resident #3 was residing in a secure unit and was an elopement risk. Regarding the elopement incident for Resident #3 that occurred on 5.14.25, the ADMIN stated, around 5:45 am the door alarm was sounding in the facility C wing back door end of hall and the aide CNA A told me that she put the code in and turned off the alarm and began helping her colleague with rounds. The ADMIN asked if she looked outside, and she said no. During the investigation, the church camera next door caught him going toward the front of the facility on the outside of the facility at 5:47 am. At 6:00 am CNA A realized he was missing because she went to his room and did not see him in the bed and started looking for him and in between that time she is looking for him around 6:10am he was seen at the (gas station) and asked the attendee for a soda and the attendee gave him a fountain drink and the attendee said he then went outside and was sitting outside for about 10 minutes. Around 6:20am he was seen leaving the (gas station) by the attendee and pointed toward the (bus station). Around 6:20am the CNA A told her nurse LVN B that Resident #3 was missing. At approximately 6:25am the nurse called the DON and notified him. He was the DON at that time. The DON was in facility, and she went to the unit and looked for the resident and then called me around 6:35am. At 6:40am I arrived, and I spoke with CNA A and LVN B about what happened and that is when she told me she heard the alarm and turned it off and went to help her fellow aide with rounding and I talked to LVN B who said he had just found out about it from CNA A. I directed staff and assigned staff to conduct a facility search internal and external. Around 6:50am the DON called the police to report a missing resident. The police arrived between 6:55-7:15 and during that time we developed flyers with his pictures and more staff arrived and I assigned them zones to look external around the area. Around 7:15am the church next door came over and showed me the video of Resident #3 walking by the front at 5:47am. At 7:25am the facility received a call from (police department) stating the police department found him. He was found at the renting vans location in front of the (bus station) which was about 4-minute walk from the (gas station) which is .4 miles from the facility. The police brought him back to the facility at 7:40am. When he returned, we completed a full head to toe assessment, and he had no bumps, scrapes, or bruises and was very pleasant spirits. The ADMIN revealed that two elopement in-services were conducted for staff prior to this incident. CNA A received in-servicing on elopement and door alarms on 3.12.2025 and signed the sign-in sheet. The ADMIN revealed exit doors will alarm for 15 seconds while the bar was being pushed before unlocking. Once unlocked, the alarm will continue to sound until reset by keypad. Staff has access to codes at each door. The ADMIN stated that the expectation of staff when a door alarm sounds, was that they react and look outside and look to see if anyone went out the door when a door alarm sounds. The ADMIN stated that the harm that could come to a resident when door alarms are silenced without investigating for possible elopement could cause death if we don't find them. An interview with CMA E on 7.28.25 at 9:41 AM revealed Resident #3 always looked outside and would sometimes push on the doors to test them. An interview with LVN C on 7.28.25 at 4:10 PM revealed that she worked at the facility for 2.5 years and worked in the memory care unit. She revealed that Resident #3 always wanted to go outside and go for walks. When Resident #3 first entered the facility, staff would have to redirect him and find activities to keep him busy. An interview on 7.31.2025 at 9:45am with the Administrator revealed the fence on the outside of the unit C-back exit door was installed on 6.4.2025 and residents at risk for elopement on the unit started on 1-hour observation until the new fence was installed. The administrator stated elopement drills were ongoing with staff and there have been no further elopements. The administrator stated Resident #3 expressed wanting to leave at times and remains an elopement risk and continues to reside on the secure unit. Interviews on 7.31.2025 between 8:45 AM and 2 PM with 1 RN, 4 LVNs, 3 CNAs, and an Admissions/Marketing staff member from various shifts demonstrated that they were knowledgeable of what to do when a door alarm was activated, understood elopement precautions, and had received training on elopement procedures. Record review of the Ad Hoc QAPI held on 5.14.2025 regarding Resident #3's elopement from the memory care unit revealed the document was signed by the Administrator, DON, Medical Director, Regional Director of Operations and an RN. Record review of the facility's Elopement/Code Purple in-service dated 5.14.2025 defined elopement as A situation in which a resident leaves the premises without the facility's knowledge and supervision. It is the responsibility of ALL TEAM MEMBERS to direct residents away from exit doors for their safety. the facility's interior or exterior grounds. CNAs and nurses need to conduct one-hour visual checks on all When a resident is missing, staff are to notify the charge nurse immediately (if unable to locate the DON). Charge nurse is to initiate a Code Purple. Record review of facility in-service on the topic of Elopement/Code Purple conducted on 5.14.25 by the DON revealed 80 staff members received the training (100% of staff trained). Record review of doors and locks maintenance check logs dated 3.31.25 - 7.25.25 revealed exit doors with alarms were checked for operation and passed. Record review or facility's Wandering and Elopement Prevention policy, undated, read The facility will identify residents who are at risk of unsafe wandering and stive to prevent harm while maintaining the least restrictive environment for residents. During exit conference on 7.31.25 at 3:51 PM, Administrator was informed that evidence revealed a F689 past non-compliance IJ (immediate jeopardy) for elopement of Resident #3.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 1 of 6 residents (Resident #2) reviewed for abuse, in that: The facility did not properly monitor or put in place preventative measures for Resident #2, who had a severe cognitive impairment, to prevent an act of sexual abuse by Resident #1 on 02/13/25, when he kissed Resident #2, and 02/14/25, when he fondled Resident #2. An IJ was identified on 02/27/25. The IJ template was provided to the facility on [DATE] at 06:18 PM. While the IJ was removed on 03/01/25 at 05:00 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm. This failure could result in residents suffering injury, a diminished quality of life, and psychosocial harm. The findings were: Record review of Resident #1's admission Record reflected he was a [AGE] year-old male initially admitted [DATE] and re-admitted [DATE]. It further reflected he had diagnoses to include dementia (group of symptoms affecting memory, thinking and social abilities) and major depressive disorder. Record review of Resident #1's quarterly MDS assessment, dated 01/23/25, reflected a BIMS score of 14 out of 15, indicating intact cognition. Record review of Resident #1's care plan, reflected, The resident has a behavior problem [Resident #1] goes into other residents' room, and sits in there while the resident is not in the room r/t confusion . Resident masturbates in empty rooms and during showers and when staff is providing peri care often. Resident makes sexually inappropriate comments and attempting to inappropriately touch female staff . Sexually inappropriate behaviors with female resident touching females and private areas breast and peri are in common areas at times., initiated 05/16/24 and revised 02/24/25. With interventions to include if reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident, initiated 05/16/24 and Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed., initiated 05/16/24. 1:1 when out of bed and room, initiated 02/11/25. During an interview on 03/03/25 at 01:48 PM, MDS nurse Q revealed the intervention for 1:1 when out of bed and room, dated on 02/11/25, was entered on 02/14/25 and accidentally back dated for 02/11/25. Record review of Resident #2's admission Record reflected she was an [AGE] year-old female initially admitted [DATE] and re-admitted [DATE]. It further reflected she had diagnoses to include dementia (group of symptoms affecting memory, thinking and social abilities), cognitive communication deficit, restlessness and agitation, generalized anxiety disorder, and senile degeneration of brain. Record review of Resident #2's quarterly MDS assessment, dated 12/12/25, reflected a BIMS score of 99, indicating resident was unable to complete the interview. It further reflected Resident #2 had a short and long-term memory problem and was severely cognitively impaired (never/rarely made decisions). Record review of Resident #1's Nurse's Note on 08/09/24 at 02:18 PM, authored by ADON D, reflected, assigned CNA for 8/9/24 7-3 reported during resident's shower the resident fondle himself, grab her breast and attempted to kiss her neck. CNA expressed to the resident that his behavior was inappropriate, and she would stop the shower to get someone else. resident stated he liked the CNA and wanted to finish; shower was completed by this time. resident was quickly taken to room where [Resident #1's RP] was present, CNA informed [Resident #1's RP] of [Resident #1]'s inappropriate touching of CNA and fondling of himself. [Resident #1's RP] stated he does that all the time, it's ok. we pay people to please him sometimes. CNA informed [Resident #1's RP] that staff is not [Resident #1]'s privately paid employee, and that is inappropriate for this facility. [Resident #1's RP] stated she would remind [Resident #1]. Record review of Resident #1's Nurse's Note on 01/21/25 at 01:48 PM, authored by LVN N, reflected, [Resident #1] was found in empty room on back of b hall masturbating. Was alone and CNA were able to take him to is room, he did not want to go back to room . Explained to [Resident #1] that he cannot be in another room in dark he needed to be in his room or let staff know where he was. He also did this yesterday that is went to another room in back of [Activity Room] where we had to look for him. Record review of Resident #1's Nurse's Note on 01/22/25 at 04:00 PM, authored by ADON E, reflected, [Resident #1] was noted to be in empty room on crescendo masturbating, resident was also seen bent forward in wheelchair trying to clean the floor. Explained to resident that for safety reasons staff needs to be aware of whereabouts. Resident expressed understanding. Record review of Resident #1's Nurse's Note on 02/11/25 at 05:18 PM, authored by ADON D, reflected, [Resident #1] seen by this nurse, other staff, and several visitors sitting in main common area/foyer next to female resident from [room number and bed identifier] holding and rubbing her forearm while she groped/fondled his penis. this nurse informed both residents this was not allowed in the common/public area. The female resident removed her hand from the male resident's crouch/groin area but left it on his thigh. this resident nodded his head and stated yes, (he) understands, thank you. they continued to sit in the common area/foyer watching the television. Record review of Resident #1's Nurse's Note on 02/13/25 at 03:45 PM, authored by ADON E, reflected, this nurse was informed this resident was witnessed blowing kisses to and then kissing a female resident who is incapable of consent on the mouth in the common area/foyer. this resident was informed not to kiss or have physical contact with this resident because she is unaware and incapable of consenting to any physical or sexual advances. this resident nodded his head, and said yes, ok. this resident remained in the common area/foyer and the other resident was removed from the area. [Resident #1's RP] called and informed of this incident and of actions facility will be taking on this repetitive matter; also informed if resident persisted with inappropriate sexual behavior after unsuccessful md/np-psych consults, possible med adjustments that resident may be discharged . [Resident #1's RP] acknowledged understanding of information provided. [Resident #1's RP] stated she spoke with him about [Resident #1's] inappropriate behavior and thought he wasn't going do anything else. And [Resident #1's RP] wanted to talk with the social worker about getting in contact with the psych doctor. this nurse let the [Resident #1's RP] know that the nurse manager will reach out to the psych np with these concerns but if she wanted to speak with the psych np, her visiting days are Tuesdays and Wednesdays, as it is not protocol for staff to give out the numbers. [Resident #1's RP] voiced understanding. [Resident #1's RP] asked to have this resident contact her. Record review of Resident #1's Nurse's Note on 02/13/25 at 03:45 PM, authored by the DON, reflected, New orders obtained from [NP F] to refer to psych services and initiate Depakote 125mg BID due to inappropriate sexual behavior. [Resident #1's RP] informed and consented to treatment. Record review of Provider Investigation Report, dated 02/14/25, reflected the [DOR] witnessed [Resident #1] caressing [Resident #2's] breasts. on 02/14/25 at 10:30 AM. Record review of Record of In-Service for Abuse/Neglect for All Departments, dated 02/13/25, reflected Neglect: HHSC defines neglect as, the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. Abuse is also resident to resident contact. This document further reflected 8 out of 90 current facility staff had not signed this In-Service. Record review of a Psych note, dated 02/14/25, reflected [Resident #1] reports to I am fine. Staff report [Resident #1] is experiencing sexually inappropriate behaviors. This is first time he is having these behaviors since admission to this facility. He was observed by staff, blowing kisses to [Resident #2] and then he started kissing on her mouth without consent. [Resident #2] is A x O x 1, and incapable to make any decisions or consent. Staff witnessed this incident occurred in the common area/foyer. Redirections non effective, [Resident #1] still want to involved with [Resident #2] physically. [Resident #1's RP] made aware about incident happened by facility staff. [Resident #1] intending to go in the same room. Closed observation placed by PCP. We also reported to (local police). Although patient is A x O x 4, patient intentionally provided false information to police officer, and he was defending himself by accusing [Resident #2] and staff, when they came in the facility. Attempted interview with Resident #2 was on 02/24/25 at 08:29 AM. Resident #2 was unable to participate in interview due to confusion. During an interview on 02/25/25 at 11:30 AM, the SW revealed Resident #1 was alert and oriented with a BIMS of 15 and misread the situation. She revealed Resident #2 was not able to consent to this incident. The SW further revealed this was not typical behavior for Resident #1. She further revealed Resident #1 was on a one to one when resident was not in his room. She revealed it was Resident #1's responsibility to let someone know when he came out of the room. During an interview on 02/25/25 at 03:37 PM, CNA A revealed she was not trained about any resident needing a one to one. She revealed Resident #1 had been more touchy last week (week of 02/17/25). She revealed Resident #1 can't come out of his room. She revealed Resident #2 tended to be around the facility by herself and was not able to make her own decisions. During an interview on 02/25/25 at 04:36PM, Resident #1's RP could not recall any incident in August 2024 or any incident before last week with inappropriate behavior. She revealed Resident #1 did not think about the consequences. The RP revealed it was disgusting they didn't contact her about any other incident because she would have gotten this resident some help. During an interview on 02/25/25 at 05:25 PM CNA B stated he was a new hire, had started a week and a half ago, and was not aware of any residents being on a 1:1. He further revealed he did not know who Resident #1 was and would not be able to recognize him if Resident #1 was in the hallway. During an interview and observation on 02/26/25 at 08:08 AM, Resident #1 was in his room alone. Resident #1 stated, I'd rather not in response to an attempted discussion on his recent resident to resident incidents. Resident #1 stated he was being treated OK. During an interview on 02/26/25 at 11:01 AM, CNA C revealed she worked last week, shadowing CNA B, and was not aware of any resident having a one to one. She revealed she was trained on ANE and how to handle behaviors, but nothing for any specific behaviors for specific residents at the facility. During an interview on 02/26/25 at 12:50 PM, ADON D revealed on 02/11/25, Resident #1 had a consensual act with Resident #3 but it was inappropriate because it was in public and the facility told both residents this could not happen in public. ADON D revealed on 02/13/25, Resident #1 and Resident #2 were facing each other in a common area. She revealed a visitor reported to ADON D that Resident #1 was kissing Resident #2 and Resident #1 was told to scoot back from Resident #2 as Resident #2 could not consent. She further revealed on 02/14/25 Resident #1 was found fondling Resident #2's breasts. She revealed Resident #1 had been going to empty rooms to masturbate. ADON D confirmed her note on 08/09/24 occurred and revealed when she showered Resident #1 he also did this to her. She further revealed she thought she documented when he did this to her and there should have been interventions created for these behaviors of Resident #1. She revealed it was important for ADON D to document this to prevent anything from happening with female residents. She revealed it was possible the facility had interventions after these incidents of inappropriate behavior by Resident #1, but she could not remember exactly what. She revealed these incidents were discussed in morning meetings. ADON D revealed after the 02/14/25 incident, she communicated with B wing nurses and a B wing CNA. She revealed she hoped this nursing staff passed on this information from shift to shift. She revealed they were responsible for reading the 24-hour report or verbally passing this information on for the next shifts. She revealed she did not think there was any oversight for this process, but it was common sense. She further revealed A wing CNAs should know about the 02/14/25 incident to make sure Resident #1 did not go back into Resident #2's room. She revealed there was a doctor's order to check on Resident #1 every hour, but after nurses checked if resident was in the room or not, there was not any follow up actions for the staff to follow and there should be. During an interview on 02/26/25 at 02:47 PM, ADON E revealed they had a one to one for Resident #1 over the weekend of 02/15/25, which was an initial intervention. She revealed this was documented in the MAR that they checked on Resident #1 every hour (constantly watching where he was at). She revealed someone had to keep an eye on him so Resident #1 did not go into any ladies' rooms or go close to other females. She revealed management only told staff that needed to know, like A wing nurses, about the 02/14/25 sexual abuse incident, but was unaware if A wing CNAs were told. She revealed she expected the nurses to educate the CNAs and was unsure if anyone was overseeing this process. ADON E revealed when Resident #1 was going down to other rooms to masturbate, they educated Resident #1 that he had privacy in his room and redirected him appropriately. ADON E revealed there was no history of Resident #1 wandering into female's rooms. She was not aware of Resident #2 being kissed by Resident #1 on 02/13/25. She revealed there was probably some intervention on 02/13/25, but she could not recall. She revealed she was not aware of the incident between Resident #1 and Resident #3, but that Resident #3 was alert and oriented. She revealed she was unaware of any August incidents with Resident #1. She revealed this was not a reoccurring behavior for resident that she was aware of. During an interview on 03/03/25 at 01:48 PM, MDS nurse W and MDS nurse Q revealed for Resident #1 the interventions for his masturbation incidents were to intervene as necessary and protecting rights of residents. MDS nurse Q revealed the intervention for 1:1 when out of bed and room, dated on 02/11/25, was entered on 02/14/25 and back dated for 02/11/25 accidentally. They further revealed interventions were put in Resident #1's care plan after the team met in the morning meeting and decided this intervention would be appropriate. They revealed the DON oversaw this. They revealed it was important for interventions to be followed because it was a part of the plan for what they have done for the resident. During an interview on 03/06/25 at 04:52 PM, Resident #2's RP revealed she did not feel like Resident #2 had been neglected by the facility. She revealed she thought the facility was doing their best to protect Resident #2. She revealed Resident #2 was not alert and oriented and could not make conscious decisions for daily tasks. During an observation on 02/25/25 at 3:00 PM, Resident #1 was in a private room with no roommate and the door was open. Resident #1 was observed seated with a walker in front of him. Resident #1 was alone and without any staff supervision. It was further observed that no staff were in the hallway. Record review of facility's policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, reflected, 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anything including, but not necessarily limited to: b. other residents . 7. Implement measures to address factors that may lead to abusive situations, for example: a. adequately prepare staff for caregiving responsibilities. The Administrator was notified on 02/27/25 at 06:18 PM an IJ was identified on 02/27/25 due to the above failures. The IJ template was provided to the facility on [DATE] at 06:18 PM and the POR was accepted on 02/28/25 at 03:26 PM. Date: 2/27/2025 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes. On 02/24/2025, a complaint survey was initiated at [The Facility]. On 02/27/2025, A surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: The facility failed to ensure that residents had the right to be free from abuse. The facility failed to provide necessary monitoring for Resident #1 to protect Resident #2 from sexual abuse. Identify residents who could be affected. All Residents have the potential to be affected. On 02/27/25, the resident census was 51. Identify responsible staff/ what action taken: Start date: 02/27/25. Completion date: 02/27/25 Responsible: Administrator/Designee Action: The Administrator/designee will place the male resident involved on 1:1 supervision immediately to ensure no sexually inappropriate behavior occurs. This 1:1 supervision will be provided until alternate placement for resident #1 is secured or he is cleared by the medical director or psychiatrist. Start date: 02/18/25. Completion Date: 02/27/25 Responsible: DON/Designee Action: Resident #2 was evaluated by the psychiatric nurse practitioner. The psychiatric nurse practitioner did not note a deviation of the resident's baseline behavior or mood. Resident #2 has an order for behavior monitoring that occurs every shift and is ongoing to monitor for mood changes. A review of this monitoring reveals no deviation of the resident's baseline behavior or mood. Start date: 02/27/25. Completion date: Ongoing Responsible: Administrator/Designee Action: The Administrator/Designee will interview all team members to determine if team members have knowledge of any inappropriate sexual behavior of male residents that may have occurred and has not been reported. If any are identified, an immediate assessment and a self-report will be completed. Start date: 02/27/25. Completion Date: 02/27/25 Responsible: Regional Director of Clinical Services Action: The Administrator and Director of Nursing will be educated by the Regional Director of Clinical Services on reportable sexually inappropriate behavior: 1. Residents must have the capacity to make decisions to give consent for sexual activity 2. Sexual activity without consent or cognitive ability to give consent is a reportable event 3. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, or mental abuse, including abuse facilitated or enabled using technology. 4. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. Staff should monitor for any behaviors that may provoke a reaction by residents or others, which include, but are not limited to, sexually aggressive behavior such as saying sexual things and inappropriate touching/grabbing. 5. Any resident displaying sexually inappropriate behaviors involving non-cognitive residents will be placed on 1:1 supervision until evaluated by the primary provider and/or psych provider and deemed safe to have 1:1 supervision discontinued. Start date: 02/26/25. Completion Date: 02/28/25 Responsible: DON/Designee Action: DON/Designee will provide training for all team members on reportable sexual inappropriate behavior to include: 1. Team members educated on male residents' 1:1 status and sexually inappropriate behavior (i.e., touching, inappropriate sexual touching, and kissing towards residents who are unable to consent. 2. Sexual activity without consent or cognitive ability to give consent is a reportable event. 3. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, or mental abuse, including abuse facilitated or enabled using technology. 4. Sexual Abuse: is defined as non-consensual sexual contact of any type with a resident. Staff should monitor for any behaviors that may provoke a reaction by residents or others, which include, but are not limited to, sexually aggressive behavior such as saying sexual things and inappropriate touching/grabbing. 5. Training will include reporting all sexually inappropriate behavior to the Admin/DON immediately and intervening to prevent any injury. This training will be provided upon hire, annually and as needed. Full-time staff will be educated by end of day 02/28/25. PRN will be educated before the beginning of their next scheduled shift. Initial education may occur verbally via telephone, and in-person education will be completed prior to the beginning of their next scheduled shift. Any staff that are on leave or unavailable will receive the education before the beginning of their next scheduled shift. 6. Education was provided to all staff regarding residents who do not have the cognitive ability to give consent. Start date: 02/26/25. Completion date: 02/27/25 Responsible: Administrator/Designee Action: The Administrator/Designee conducted safe surveys with all cognitively intact residents residing on the A and B wings. The following questions were asked: 1. Question 1. Has another resident ever touched you inappropriately or made unwelcome advances towards you? If yes, tell me what happened, when it happened, if you reported it and who you reported it to. 2. Question 2. Do you feel safe? No further incidences of sexually inappropriate behavior were identified. Start Date: 02/26/25. Completion Date: 02/27/25 Responsible: DON/Designee Action: DON/Designee completed full skin assessments for non-cognitively intact residents residing on A and B wings. No evidence of sexually inappropriate behavior, such as bruising of the genitals or inner thighs, bleeding, irritation, or pain of the anus or genitals, or bloody, stained, or tattered undergarments, was identified. No behavioral signs of sexual abuse, such as new increased agitation, anxiety, social withdrawal, or fear, were identified. Start Date: 02/27/25. Completion Date: 03/27/27 Responsible: DON/Designee Action: DON/Designee will monitor process compliance and understanding daily during the morning clinical process and room rounding observations. Start Date: 02/27/25. Completion Date: 02/27/25 Responsible: Administrator Action: An Ad Hoc QAPI committee meeting was held with the Medical Director, Dr. G, regarding the current IJ and plan of correction. Start Date: 02/27/25. Completion date: 02/27/25 Responsible: Administrator/Designee Action: Results of in-servicing and interviews will be reviewed during the monthly QA meeting scheduled on 03/26/25. POR verification reads as follows: Record review of the facility's POR Binder dated 2/25/2025 revealed 51 residents were identified as vulnerable for ANE. Record review of Resident #2's PHQ-9 assessment (standardized tool used for screening, diagnosing, and measuring the severity of depression) reflected a score of 0, indicating no depression. Record review of Resident #2's doctor's orders reflected, BEHAVIOR MONITORING FOR: mood changes, verbal aggression .for every shift, as of 06/01/21, . BEHAVIOR MONITORING FOR: anxiety/restlessness . for every shift, as of 02/10/25, [Psych] to eval and treat . as of 12/20/22. Record review of the facility's POR binder reflected statements from staff regarding question do you have knowledge of any inappropriate sexual behavior made by male residents towards other residents that has not been reported? If so, what happened? revealed staff responded in a negative for inappropriate sexual behaviors. Record review of the safe Survey Team Member Interview dated 02/27/25 revealed the Administrator documented no to the question. Record review of the safe Survey Team Member Interview dated 02/27/25 revealed the Activities Assistant documented no to the question. Record review of the safe Survey Team Member Interview dated 02/27/25 revealed LVN Q documented no to the question. Record review of the safe Survey Team Member Interview dated 02/27/25 revealed the Social Worker documented no to the question. Record review of the safe Survey Team Member Interview dated 02/27/25 revealed the Housekeeping Director documented no to the question. Record review of the safe Survey Team Member Interview dated 02/27/25 revealed LVN N documented no to the question. Record review of the facility's in-service record dated 02/27/25 revealed, residents must have the capacity to make decisions to give consent for sexual activity Further record review revealed the Administrator and the DON received the in-service. Record review of the facility employee roster, dated 02/24/25, reflected 94 employees which included all departments, Administration, Nursing, Dietary, Therapy, and Housekeeping. Record review of the facility's in-service titled Sexual Abuse dated 2/26/2025 revealed, sexual inappropriate behavior . sexual activity without consent is a reportable behavior . all reports of potential abuse / neglect must be verbally reported immediately no matter the time (24 / 7) day night weekends, holidays, vacations, etc., to the abuse coordinator (the Administrator). AND One to one in-service dated 2/26/2025 revealed Resident #1 is to remain on one-to-one observation at all times and monitored for inappropriate sexual behaviors. Team-member may sit outside his room in the hallway to provide privacy but once he leaves his room the team-member must escort him and continue to monitor him. Record review of the facility's in-service titled Sexual Abuse ANE and One-to One, dated 2/26/2025, revealed 94 of 94 employees received both in-services which included the following employees: CNA A, CNA B, CNA C, ADON D, ADON E, LVN H, CNA J, CNA K, LVN L, CNA M, LVN N, LVN O, LVN P, LVN Q, LVN R, CNA S, LVN T, CNA U, CNA V, CNA X, CNA Y, LVN Z, CNA AA, CNA AB, LVN AC, CNA AD, CNA AE, CNA AF, LVN AG, CNA AH, CNA AI. Record review of nursing schedules for the month of January 2025 reflected 3 nursing shifts which included 7AM to 3PM, 3PM to 11PM, and 11PM to 7AM. Further record review revealed the 7AM to 3PM shift comprised of 5 nurses and 7 CNAs, the 3PM to 11PM shift comprised of 5 nurses and 7 CNAs, and the 11PM to 7AM shift had 2 nurses and 3 CNAs. Observation on 02/28/25 at 03:35 PM revealed the BOM was sitting, in the hall across from Resident #1. During an interview and observation on 02/28/25 at 03:36 PM, the BOM stated she was on 1:1 monitoring for Resident #1 and kept a form (1:1 sheet) she wrote on. The BOM was observed writing what she observed while she conducted the 1:1 monitoring of Resident #1. The BOM stated she did receive the in-service training on Resident #1's sexually inappropriate behavior. The BOM stated if she saw Resident #1 with inappropriate sexual behavior, she would intervene and notify DON. During an interview on 03/01/25 at 11:57 AM, the DON stated Resident #2 was ordered to receive psychiatric follow up. During an interview on 03/01/25 at 11:30 AM, the Administrator stated she and her designee interviewed all the current staff and revealed no evidence of sexual abuse and stated if any staff were not interviewed, they would not be able to assume a duty. During an interview on 02/28/25 at 03:50 PM, LVN N (who worked 7AM-3 PM) stated if she saw a resident with inappropriate sexual behavior, she would intervene and notify DON. During an interview on 02/28/25 at 04:21 PM, LVN R (who worked weekends) stated they had not seen any inappropriate sexual behavior. LVN R stated if they saw a resident with inappropriate sexual behavior, she would intervene and notify DON. During an interview on 02/28/25 at 04:30 PM, ADON D stated she had not seen any inappropriate sexual behavior. ADON D stated if she saw a resident with inappropriate sexual behavior, she would intervene and notify DON. During an Interview on 02/28/25 at 04:58 PM, Receptionist S stated he had not seen any inappropriate sexual behavior. Receptionist S stated if he saw a resident with inappropriate sexual behavior, he would intervene and notify DON. During an interview on 02/28/25 at 05:29 PM, LVN T stated she had not seen any inappropriate sexual behavior. LVN T stated if she saw a resident with inappropriate sexual behavior, she would intervene and notify DON. During a joint interview with LVN L and Receptionist S on 02/28/25 at 05:30 PM, LVN L stated he had not seen any inappropriate sexual behavior. Receptionist S stated if he saw a resident with inappropriate sexual behavior, he would intervene and notify DON. During an interview with Laundry Aide AL on 2/28/2025 at 5:54 PM Laundry Aide AL stated she had not seen any inappropriate sexual behavior. During an interview on 2/28/2025 at 06:00 PM PT AK stated he had not seen any inappropriate sexual behavior. PT AK stated if he saw a resident with inappropriate sexual behavior, he would intervene and notify DON. During an interview on 03/01/25 at 11:33 AM, the Administrator stated she received ANE prevention and reporting training from the Reg[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 8 Residents (Resident #4) reviewed for neurological assessments after a fall. 1. On [DATE] at approximately 5:28 AM Resident #4 had an unwitnessed fall and was discovered on the floor in her bedroom, and LVN H failed to perform neurological assessments for Resident #4 at 6:45 AM, and at 7:15 AM, and failed to report to LVN I she had not assessed Resident #4 and at 8:00 AM Resident #4 and discovered deceased . 2. On [DATE] at approximately 7:40 AM LVN I assessed Resident #4 without performing a neurological assessment at 7:45 AM and did not document Resident #4's vital signs. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began on [DATE]. These failures could place residents at risk for harm by lack of interventions up and including death. The findings included: A record review of Resident #4's admission record revealed an admission date of [DATE] and a discharge date of [DATE] with diagnoses which included atrial fibrillation (an irregular heartbeat which can lead to blood clots in the heart, can increase the risk of stroke, heart failure and other heart-related complications), atherosclerotic heart disease (plaque buildup in artery walls, can cause a heart attack) and essential hypertension (high blood pressure.) A record review of Resident #4's quarterly MDS assessment dated [DATE] revealed Resident #4 was an [AGE] year-old female admitted for rehabilitation related to an implanted pacemaker (a device used to control an irregular heart rhythm) and was assessed with a BIMS score of 13 out of a possible 15 which indicated no cognitive impairment. A record review of Resident #4's care plan dated [DATE] revealed, The resident has an ADL self-care performance deficit r/t generalized weakness new pacemaker date Initiated: [DATE], . BEDFAST: The resident is bedfast all or most of the time. I have chosen DO NOT RESUSCITATE status Date Initiated: [DATE] . Signed DNR order is in my chart. The resident has a pacemaker Date Initiated: [DATE] . Monitor / document / report PRN any s/sx of altered cardiac output or pacemaker malfunction: dizziness, syncope (fainting), difficulty breathing (Dyspnea), pulse rate lower than programmed rate, lower than baseline B/P. The resident is at risk for falls r/t Confusion, Gait / balance problems, Incontinence, Narcotic use, Antihypertensive use, Recent Surgery, Oxygen Use. Date Initiated: [DATE] . A record review of Resident #4's nursing progress notes dated [DATE] revealed LVN H documented at 6:40 AM Resident #4 was discovered on the floor due to a fall, [DATE] 06:40 . Position: *Charge Nurse Created By: (LVN H) . Note Text: CNA was doing her rounds and this resident requested medication for pain. CNA told this nurse that resident wanted something for pain. This nurse retrieved pain med and went to residents' room to give to her and found her laying on the floor beside her bed. This nurse assessed resident and had CNA to go get the other nurse to help assist resident from the floor back into her bed. Resident alert and took pain medication, no apparent injuries noted at this time. Bed put in the lowest position and call light in reach. Neuro checks have been started. All parties have been notified. A record review of Resident #4's Neurological Assessment Flow Sheet dated [DATE] revealed LVN H began and continued 4 times with neuro-check assessments on [DATE] starting at 5:30 AM which included a level of consciousness, pupil response, hand grasp, motor functions, pain response, blood pressure, temperature, pulse, and respirations. Review revealed Resident #4's assessments were as follows: 10/16 at 05:30 AM alert, pupils equal reactive to light and accommodating = brisk, hand grasp = right greater than left, motor function = moves all extremities, pain response = appropriate, blood pressure = 106/56, temperature = 97.1, pulse = 60, respirations 16 (per minute). 10/16 at 05:45 AM alert, pupils equal reactive to light and accommodating = brisk, hand grasp = right greater than left, motor function = moves all extremities, pain response = appropriate, blood pressure = 104/60, temperature = 97.5, pulse = 62, respirations 16 (per minute). 10/16 at 06:00 AM alert, pupils equal reactive to light and accommodating = brisk, hand grasp = right greater than left, motor function = moves all extremities, pain response = appropriate, blood pressure = 100/58, temperature = 97.0, pulse = 60, respirations 16 (per minute). 10/16 at 06:15 AM alert, pupils equal reactive to light and accommodating = brisk, hand grasp = right greater than left, motor function = moves all extremities, pain response = appropriate, blood pressure = 100/61, temperature = 97, pulse = 58, respirations 16 (per minute). Further review of Resident #4's Neurological Assessment Flow Sheet revealed no further assessments for the scheduled 6:45 AM, 7:15 AM, the 7:45 AM, nor the 8:15 AM assessments. During an interview on [DATE] at 9:02 AM LVN H stated she works the 11:00 PM to 7:00 AM shift and on [DATE] she discovered Resident #4 on the floor next to her bed. LVN H stated she assessed Resident #4 with the assistance of CNA K and LVN L. LVN H stated she assessed Resident #4 with no injuries and Resident #4 was a/o x 3 (alert and oriented to self, time, and place) and could state she was attempting to toilet without using the call light and fell. LVN H stated she began neuro-checks and gave a report to the on-call physician and Resident #4's family. LVN H stated she began neuro-checks at 5:30 AM and per the neuro-check protocol she checked Resident #4 every 15 minutes for the first 4 assessments, then planned to check on Resident #4 every 30 minutes for the next 4 assessments, and then every hour for the next neuro-check assessments. LVN H stated she gave report to the next nurse, and could not recall her name, to include a report on Resident #4. LVN H Stated this nurse-to-nurse report usually takes from 7:00 AM to 7:20 AM. LVN H stated she left at 7:30 AM and stated before she left a CNA reported to the next nurse Resident #4 needed to be assessed. LVN H received information that a record review of Resident #4's neuro-check worksheet document dated [DATE] revealed documentation that Resident #4 was assessed for neuro checks every 15 minutes for the first four neuro checks which began at 5:30 AM and continued at 5:45 AM, 6:00 AM, and at 6:15 AM without any documentation for 6:45 AM and no further documentation. LVN H stated she could not recall why there was no assessment for the 6:45 AM assessment and the 7:15 AM assessment was the duty of the oncoming nurse. LVN H stated she may have been busy administering medications for other residents during her end of shift. A record review of LVN H's timecard dated [DATE] through [DATE] revealed LVN H clocked out at 7:50 AM on [DATE]. During an interview on [DATE] at 3:50 PM LVN I stated she was the nurse for Resident #4 on [DATE] from 7:00 AM to 3:00 PM. LVN I stated on [DATE] she was running late and arrived for her scheduled 7:00 AM to 3:00 PM shift approximately 30 minutes late, 7:30 AM. LVN I stated LVN H was irritated because many nursing interventions had been moved to her shift (11:00 PM to 7:00 AM) and she was behind in care. LVN I stated during the nurse-to-nurse report LVN H had reported Resident #4 had a fall and was followed with neuro-checks but had not reported when the next neuro check was due nor how many she had done. LVN I stated during the nurse to nurse report a CNA interrupted and asked for LVN I to assess Resident #4. LVN I stated she stopped the nurse-to-nurse report and assessed Resident #4 as sleepy with vital signs (VS) with in normal limits. LVN I stated she had not assessed Resident #4 with a neuro-check assessment, nor documented the actual numbers of the VS, nor the actual time but did state the time must have been around 7:45 AM. LVN I stated at the completion of the nurse-to-nurse report, around 8:00 AM, she returned to assess Resident #4 and discovered her unresponsive, without respirations nor a pulse. LVN I stated Resident #4 was a do-not-resuscitate (DNR) and she reported the death to the DON. A record review of Resident #4's nursing progress notes dated [DATE] revealed the DON received a report from LVN I that Resident #4 was deceased . The DON documented her assessment, 0818 (8:18 AM) this nurse was called into residents' room being informed by charge nurse that she was unable to obtain vital signs. Confirmed in medical record that resident had DNR in place. On entering resident room resident was noted to be in bed with HOB elevated above 30 degrees, oxygen in place via nasal canula, and sling in place to left upper extremity, on assessment resident was not responsive to verbal or tactile stimuli including pain with sternal rub. No rise and fall of chest noted. No pulse present. Unable to obtain blood pressure. Once again confirmed in medical record active DNR. During a joint interview on [DATE] at 12:30 PM with the Administrator and the DON, the DON stated on the morning of [DATE] she received a report from LVN I that Resident #4 was deceased , a DNR, unresponsive without respirations, and without a pulse. The DON stated she assessed and documented her assessment. The DON stated she reported Resident #4's death to the Administrator. The Administrator stated she reported the death to the state agency and directed the DON to investigate the death, assess peer residents who may be on neuro-checks for safety, and to in-service the nursing staff on neuro-check protocols. The DON stated LVN H had not reported she had not assessed Resident #4 for the 6:45 AM nor the 7:15 AM neuro-checks and LVN I had not reported she had not assessed Resident #4 with neuro-checks at 7:45 AM nor did she document the VS for that 7:45 assessment. The Administrator and the DON stated LVN H was suspended during the investigation and received an in-service for following neuro-check protocols and reporting the assessments before returning to work aafter the investigation. The Administrator and the DON stated the expectation for nursing staff was to have a Resident first plan of care to include an immediate full assessment to include neuro-checks for all residents who had an unwitnessed fall and or head strike, to immediately SBAR a physician and to continue neuro checks and follow any additional physicians' orders. The DON stated staff were also to contact family / representatives, and document in the residents' medical record and to initiate an incident report. During an interview on [DATE] at 1:20 PM Dr. G stated he was familiar with Resident #4 and his expectation for neurological assessments was for the facility to follow their protocol. Dr. G stated it would have been ideal if the nursing staff had done the assessments to include the 3 scheduled proposed assessments prior to Resident #4's discovery of being deceased . A record review of the facility's in-service titled Neuro checks dated [DATE] revealed, neurological assessments flow sheet must be initiated immediately after each unwitnessed fall or head injury. Each check should include a full set of vital signs and a head-to-toe assessment to ensure no neurological changes have occurred. IF there are changes from the baseline noted call 911 and update MD, DON, and family. Frequency of neuro-checks 15 minutes x 4; 30 minutes x4; 1-hour x4; 4 hours x4; 8 hours x3. Further review revealed 44 of 44 nursing staff signed the in-service. PNC Verification A record review of the facility's incident reports from [DATE] through [DATE] revealed no residents with lack of neuro-check assessments. A record review of the facility's in-service titled Neuro checks dated [DATE] revealed, neurological assessments flow sheet must be initiated immediately after each unwitnessed fall or head injury. Each check should include a full set of vital signs and a head-to-toe assessment to ensure no neurological changes have occurred. IF there are changes from the baseline noted call 911 and update MD, DON, and family. Frequency of neuro checks 15 minutes x 4; 30 minutes x4; 1-hour x4; 4 hours x4; 8 hours x3. Further review revealed 44 of 44 nursing staff signed the in-service. A record review of nursing schedules for the month of [DATE] revealed 3 nursing shifts which included 7:00 AM to 3:00 PM; 3 PM to 11:00 PM; and 11:00 PM to 7:00 AM. Further review revealed the 7AM to 3PM shift comprised of 5 nurses and 7 CNAs, the 3PM to 11PM shift comprised 5 nurses and 7 CNAs, and the 11PM to 7AM shift had 2 nurses and 3 CNAs. 7AM-3PM Nurses = 5 1. During an interview on [DATE] at 3:40 PM LVN P stated she works days and evenings and usually worked the 7AM to 3PM shift in the MCU. LVN P stated she had received the ANE and the neuro check in-service a couple of times to include the October in-service which included the fall protocol - if the fall was unwitnessed and or the Resident had a head injury nursing would immediately initiate neuro checks which would be done over 3 days beginning with 4 checks every 15 minutes followed by 4 checks every 30 minutes; 4 checks every hour, 4 checks every 4 hours and then 4 checks every 8 hours. 2. During an interview on [DATE] at 3:10 PM LVN N stated she had received the ANE and the neuro check in-service which was universal everywhere to include neuro checks every 15 minutes then every 30 minutes followed by every hour to include pupil reactions and to document the findings on the worksheet. 3. During an Interview on [DATE] at 3:50 PM Agency LVN I stated she had received the ANE and the neuro check in-service in [DATE] which included to initiate neuro check assessments for any Resident who had an unwitnessed fall and or a head strike. LVN I stated neuro checks included a full set of VS and Pupillary reactions. LVN I stated the neuro check worksheet would serve as documentation. LVN I stated, If it was not documented - it was not done. 4. During an interview on [DATE] at 11:20 AM ADON D stated she had received the ANE and the Neuro-check in-service in [DATE] and again in 2025 which included the fall protocol which called for initiation of neuro-checks for any unwitnessed fall and or head strike. ADON D stated the expectation was for nurses to immediately start the checks with a full set of VS 4 times every 15 minutes, 4 times every 30 minutes, 4 times every hour, and so on for 3 days or until the MD gives an order to end the checks. 5. During an interview on [DATE] at 9:10 AM LVN Z stated he worked weekend days and evenings. LVN Z stated he had received the ANE and the neuro check in-service a couple of times to include the October in-service which included the fall protocol - if the fall was unwitnessed and or the Resident had a head injury nursing would immediately initiate neuro checks which would be done over 3 days beginning with 4 checks every 15 minutes followed by 4 checks every 30 minutes; 4 checks every hour, 4 checks every 4 hours and then 4 checks every 8 hours. 6. During an interview on [DATE] at 1:02 PM ADON E stated she had received the ANE and the neuro-check in-service in [DATE] and again in 2025 which included the fall protocol which called for initiation of neuro-checks for any unwitnessed fall and or head strike, ADON E stated the expectation was for nurses to immediately start the checks with a full set of VS 4 times every 15 minutes, 4 times every 30 minutes, 4 times every hour, and so on for 3 days or until the MD gives an order to end the checks. CNAs = 7 1. During an interview on [DATE] at 2:10 PM CNA J stated she worked the 7AM -3PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA J stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 2. During an interview on [DATE] at 6:05 PM CNA V stated she worked the 7AM -3PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA V stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 3. During an interview on [DATE] at 9:12 AM CNA Y stated she worked the 7AM -3PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA Y stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 4. During an interview on [DATE] at 9:05 AM CNA AA stated she worked the 7AM -3PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA AA stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 5. During an interview on [DATE] at 9:06 AM CNA BB stated she worked the 7AM -3PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA BB stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 6. During an interview on [DATE] at 6:13 PM CNA FF stated she worked the 7AM -3PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA FF stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 7. During an interview on [DATE] at 9:53 AM CNA HH stated she worked the 7AM -3PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA HH stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 3PM - 11PM Nurses = 3 1. During an interview on [DATE] at 3:28 PM LVN O stated she had received the ANE and the neuro check in-service which was universal everywhere to include neuro checks every 15 minutes then every 30 minutes followed by every hour to include pupil reactions and to document the findings on the worksheet. 2. During an interview on [DATE] at 4:49 PM LVN R stated he worked weekend days and evenings. LVN R stated he had received the ANE and the neuro check in-service a couple of times to include the October in-service which included the fall protocol - if the fall was unwitnessed and or the Resident had a head injury nursing would immediately initiate neuro checks which would be done over 3 days beginning with 4 checks every 15 minutes followed by 4 checks every 30 minutes; 4 checks every hour, 4 checks every 4 hours and then 4 checks every 8 hours. 3. During an interview on [DATE] at 11:46 AM LVN T stated she works evenings and usually worked the 3PM - 11PM shift. LVN T stated she had received the ANE and the neuro check in-service a couple of times to include the October in-service which included the fall protocol - if the fall was unwitnessed and or the Resident had a head injury nursing would immediately initiate neuro checks which would be done over 3 days beginning with 4 checks every 15 minutes followed by 4 checks every 30 minutes; 4 checks every hour, 4 checks every 4 hours and then 4 checks every 8 hours. 4. During an interview on [DATE] at 3:03 PM LVN Q stated she works days and could work some evenings and usually worked the 7AM to 3PM as the MDS nurse. LVN Q stated she had received the ANE and the Neuro check in-service a couple of times to include the October in-service which included the fall protocol - if the fall was unwitnessed and or the Resident had a head injury nursing would immediately initiate neuro checks which would be done over 3 days beginning with 4 checks every 15 minutes followed by 4 checks every 30 minutes; 4 checks every hour, 4 checks every 4 hours and then 4 checks every 8 hours. 5. During an interview on [DATE] at 9:09 AM LVN CC stated she had received the ANE and the neuro check in-service in [DATE] and again in 2025 which included the fall protocol which called for initiation of neuro-checks for any unwitnessed fall and or head strike, LVN CC stated the expectation was for nurses to immediately start the checks with a full set of VS 4 times every 15 minutes, 4 times every 30 minutes, 4 times every hour, and so on for 3 days or until the MD gives an order to end the checks. 6. During an interview on [DATE] at 9:34 AM LVN GG stated she had received the ANE and the neuro check in-service in [DATE] and again in 2025 which included the fall protocol which called for initiation of neuro-checks for any unwitnessed fall and or head strike, LVN GG stated the expectation was for nurses to immediately start the checks with a full set of VS 4 times every 15 minutes, 4 times every 30 minutes, 4 times every hour, and so on for 3 days or until the MD gives an order to end the checks. CNAs = 7* 1. During an interview on [DATE] at 6:00 PM CNA B stated she worked the 3PM -11PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA B stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 2. During an interview on [DATE] at 4:20 PM CNA K stated she worked the 3PM - 11PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA K stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 3. During an interview on [DATE] at 6:01 PM CNA C stated she worked the 3PM - 11PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA C stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 4. During an interview on [DATE] at 6:03 PM CNA U stated she worked the 3PM - 11PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA U stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 5. During an interview on [DATE] at 9:10 AM CNA DD stated she worked the 3PM - 11PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA DD stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 6. During an interview on [DATE] at 9:33 AM CNA EE stated she worked the 3PM - 11PM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA EE stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 7. During an interview on [DATE] at 6:02 PM CNA W stated she worked the 3P - 11P shift and had received the ANE and the neuro check in service which included the fall protocol. CNA W stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 11PM - 7AM Nurses = 2 1. During an interview on [DATE] at 10:23 PM LVN H stated she had received the ANE and the neuro check in-service in [DATE] and again in 2025 which included the fall protocol which called for initiation of neuro-checks for any unwitnessed fall and or head strike. LVN H stated the expectation was for nurses to immediately start the checks with a full set of VS 4 times every 15 minutes, 4 times every 30 minutes, 4 times every hour, and so on for 3 days or until the MD gives an order to end the checks. 2. During an interview on [DATE] at 5:30 PM LVN L stated she had received the ANE and the neuro check in-service in [DATE] and again in 2025 which included the fall protocol which called for initiation of neuro-checks for any unwitnessed fall and or head strike. LVN L stated the expectation was for nurses to immediately start the checks with a full set of VS 4 times every 15 minutes, 4 times every 30 minutes, 4 times every hour, and so on for 3 days or until the MD gives an order to end the checks. 3. During an interview on [DATE] at 11:46 PM LVN T stated she had received the ANE and the neuro check in-service in [DATE] and again in 2025 which included the fall protocol which called for initiation of neuro-checks for any unwitnessed fall and or head strike. LVN T stated the expectation was for nurses to immediately start the checks with a full set of VS 4 times every 15 minutes, 4 times every 30 minutes, 4 times every hour, and so on for 3 days or until the MD gives an order to end the checks. CNAs = 3 1. During an interview on [DATE] at 9:46 PM CNA S stated she worked the 11PM - 7AM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA S stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. 2. During an interview on [DATE] at 1:46 AM CNA X stated she worked the 11PM - 7AM shift and had received the ANE and the neuro check in service which included the fall protocol. CNA X stated if a Resident had an unwitnessed fall and or a head strike to immediately report to the nurse and to expect the nurse would perform neuro checks every 15 minutes and then every 30 minutes, and then every hour. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 21 residents (Resident #1) reviewed for abuse. The facility failed to ensure CNA B reported when HA A allegedly abused Resident #1 on [DATE]. The facility failed to ensure HA A was not working after this alleged abuse and had access to residents for her overnight shift. The facility failed to ensure all staff members were properly educated on abuse, neglect, and exploitation after this incident. On [DATE] at 03:52 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed prior to exit on [DATE], the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Record Review of Resident #1's admission record, dated [DATE], revealed a female initially admitted [DATE] and expired [DATE] with diagnosis to include dementia (loss of thinking, remembering, and reasoning skills), and major depressive disorder. Record Review of Resident #1's care plan, closed date [DATE], reflected [Resident #1] has a mood problem . with an intervention of Behavioral health consults as needed (psycho-geriatric team, psychiatrist, etc.), initiated [DATE]. [Resident #1] has behavior problems . with an intervention of Monitor behavior episodes and attempt to determine underlying cause., initiated [DATE]. [Resident #1] has a terminal prognosis r/t family has elected hospice services with [NAME] hospice. With an intervention of Refer to Psychiatric/Psychogeriatric consult if indicated, initiated [DATE]. Record Review of Resident #1's annual MDS assessment, dated [DATE], reflected Resident #1 had a BIMS score of 99, indicating the resident was unable to complete the interview. It also reflected Resident #1 exhibited rejection of care 1 to 3 days per week in comparison to: Record Review of Resident #1's quarterly MDS assessment, dated [DATE], resident did not exhibit rejection of care. Record Review of the Provider Investigation Report, dated [DATE] and authored by the ADM reflected, Date/Time you first learned of incident: [DATE], 11:00AM Date/Time the incident occurred: [DATE], 10:45PM Brief narrative summary of the reportable incident: [CNA B] called this administrator to report physical abuse to [resident #1] by [HA A]. [CNA B] witnessed [HA A] slap [Resident #1] on the shoulder twice. .On [DATE], this administrator initiated resident questionnaires, which residents expressed to have been treated with respect, dignity, and no one has hurt them. On [DATE], [HA A] is terminated . I have concluded this allegation is confirmed because new injuries shown in new skin assessment completed on [DATE]. Record review of Nurse's Note, dated [DATE] at 11:27 AM and authored by the DON, reflected Resident skin noted to be clean dry and intact. Three small circular bruises noted to left posterior forearm. #1 2.5 x 2.0 cm, #2 0.3 x 0.3 cm, and #3 0.4x 0.3 cm. During an interview on [DATE] at 02:48 PM, the Administrator confirmed there were missing signatures on the in-services for this incident. During an interview on [DATE] at 03:13 PM, HA A could not recall Resident #1. During an interview on [DATE] at 11:01 AM, CNA B revealed she heard a loud thump when she was in the hallway 2 rooms away from Resident #1's room. She revealed she saw the AP in the process of hitting Resident #1 on the shoulder. CNA B witnessed the AP holding Resident #1's forearm while hitting Resident #1 once on the shoulder. She further revealed the AP hit Resident #1 hard enough to produce a loud sound. CNA B described Resident #1 as so small, fragile, and nonverbal. CNA B further revealed a red mark was visible on Resident #1's shoulder because her shirt was hanging off. CNA B could not see any other marks on her body. Resident #1 was not crying but Resident #1 flinched and looked at the AP in shock as if Resident #1 knew something happened to her. CNA B described the incident as an uncomfortable situation. CNA B revealed she told the AP to leave. CNA B stated she told Resident #1 that she would be okay. CNA B revealed the roommate was present in the room, but the curtain was closed. CNA B further revealed Resident #1's roommate was bedbound and had to have heard these thumps, but the roommate was observed sleeping. The administrator revealed in an email correspondence, dated [DATE] at 01:32 PM, Resident #1 never received psych services in the months of November and [DATE], after this incident of alleged abuse. During an interview on [DATE] at 02:11 PM, the Administrator revealed she educated all the staff the next 2 days after the incident, and she knew she educated everyone even though the [DATE] in-service was missing signatures. During an interview on [DATE] at 05:21 PM, the [Medical Doctor] revealed he was contacted when he heard about this incident of abuse. He did not contact or order psych services because he did not think the resident would need or benefit from these services because resident was nonverbal and was not responding to other care. When told about the MDS assessment findings of Resident #1 exhibiting behaviors of rejection of care after this incident of abuse, the [Medical Doctor] revealed he did not know about Resident #1 having new behaviors of rejection of care and would have wanted to know this. He further revealed if he was made aware of this, he would assess the situation, and prodder psychiatric services accordingly. Record Review of HA A's personnel file revealed her employee misconduct registry was clean. Record review of the [DATE] in-service titled Abuse/Neglect/Misappropriation/Reporting reflected 39 out of 104 (37.5%) did not sign that they received this training. Out of the staff members present during this shift 6 out of 12 (50%) did not sign this training. (At the time of this template the Administrator was verifying names.) Record review of facility's policy Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised [DATE], 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. 8. Investigate and report any allegations within timeframes required by federal requirements. Record review of the facility's policy, revised [DATE], titled Abuse and Neglect-Clinical Protocol reflected: The physician will order measures required to address the consequences of an abuse situation, such as psychological evaluation . Record review of the Texas HHSC Long-Term Care Regulatory Provider Letter, issues [DATE], reflected for an abuse incident the facility was to report immediately, but not later than two hours after the incident occurs or is suspected. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 03:52 PM. The Administrator was notified. The following Plan of Removal submitted by the facility was accepted on [DATE] at 05:02 PM. Date: [DATE] PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes: On [DATE], an abbreviated survey was initiated at [Facility]. On [DATE] at 03:52PM, A surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F600 The facility failed to keep Resident #1 free from abuse and neglect by employees not reporting abuse to the abuse coordinator when abuse occurred. This administrator did not report abuse within the two-hour requirement and in-services were not 100% signed. Identify residents who could be affected: All Residents have the potential to be affected. The Facility census on [DATE] was 88. Identify responsible staff/ what action taken: . DON, ADONS and MDS nurses will conduct 100% skin assessments to all residents by [DATE]. Skin assessments completed. Social Worker, MDS nurses, Activities Director, admission Coordinator and Human Resources Director will conduct resident questionnaires to all cognitive residents by [DATE]. In-Service conducted: On [DATE], abuse, neglect and notification of abuse and neglect to the abuse coordinator to all current team members prior to their shift by [DATE]. The in-services indicate verbal notification to the abuse coordinator. The in-service specifically states allegations need to be verbally and immediate, which includes day, nights, weekends, holidays, vacation, and the abuse coordinator is available 24/7. If the abuse coordinator is not available, staff are directed to call the DON. This administrator and DON will be responsible for ensuring staff receive in-service. A current staff roster is printed, and staff will sign off next to their name. Any PRN or Agency staff will be trained in abuse, neglect and notification of Abuse and Neglect prior to their shift and they will sign next to their name or add their name and sign. Implementation of Changes Conduct daily rounds prior to morning meetings, which includes speaking to residents regarding any of their concerns. For non-verbal residents, residents will be monitored for changes in demeanor, changes to their baseline and communicate with family for any noticeable changes. The daily rounds will begin [DATE] (Monday through Friday), manager on duty will round on the weekends and will continue with no end date. Department managers will complete rounds in their assigned resident rooms to rule out abuse and neglect. If any concerns arise it will be addressed immediately per HHSC guidelines. The manager on duty will round on the weekends and will notify this administrator of any concerns of abuse and neglect. The administrator will follow HHSC guidelines. The round of excellence sheet will be completed by department managers and the manager on duty. The administrator will request to be part of resident council to be made aware of any current concerns. If this administrator is not approved to join resident council then the activity director will document any concerns on a grievance form and will provide document to this administrator. Abuse, neglect and reporting protocol to be given during orientation process. This will confirm all staff members will be aware of the Abuse, Neglect and notification of Abuse and Neglect protocol. Any staff member who is an alleged perpetrator for any ANE allegation will be suspended pending investigation and will be advised to leave the premises at that time. The residents who are identified as experiencing abuse or neglect will be referred to psych services by the social worker. Any potential concern of weekly skin observations will be reviewed in morning meetings to ensure residents are not at risk of any type of abuse. Monitoring Administrator/DON/Designee will monitor this process. Any negative outcomes will be reported to QAPI Committee. Involvement of Medical Director The [Medical Director] was notified about the immediate Jeopardy on [DATE]. Involvement of QA Any issues will be brought to the QA meeting. This plan will be added to QAPI. Who is responsible for implementation of process? [Administrator] The POR verification was accepted on [DATE] at 09:15 PM as follows: Record review reflected the Facility Census on [DATE] was 88 residents. Record review reflected daily care round forms were completed for 88 of 88 residents. Record review reflected skin assessments were completed for 86 of 88 residents (one resident declined to be assessed; one resident was in the hospital) on [DATE]. Record review of resident questionnaires reflected 28 of 28 cognitive residents received interviews by staff [DATE]. In an interview on [DATE] at 7:30 PM, the Regional RN stated all cognitive residents received safe surveys interviews, with no findings that required follow-up. In-Service conducted: Record review reflected In-Services on Abuse/Neglect, Reporting time constraints, and protocols to protect to residents, completed on [DATE], included all staff, on duty, with a plan to in-service all PRN and staff on leave prior to working with any residents. Interviews conducted between [DATE] and [DATE], with staff who worked 7-3p, 3-11p, 11-7a, along with 8-5 shift, and 6-2pm shift; 28 interdisciplinary staff (RNs, LVNs, CNAs, MAs, PTA, Dietary Aides, Social Services/Activity Aides, Maintenance, Administrative). [The facility currently has 105 staff]. Interviews indicated in-servicing topics included Abuse/Neglect that included definitions and examples; immediate interventions; reporting time constraints; and reporting entity requirements. Record review reflected In-Services on Abuse/Neglect, Reporting time constraints, protocols to protect to residents, completed on [DATE] included all agency staff on duty, with a plan to in-service all future agency staff prior to working with residents. Implementation of Changes Record review reflected daily care round forms were completed for 88 of 88 residents on [DATE]. Record review reflected daily care round forms were completed for 90 of 90 (current census) residents on [DATE]. Record review reflect Morning Meeting- Stand Up process template now includes agenda item to include discussion of daily care rounds, which are completed prior to the Morning Meeting. Record review of email dated [DATE] reflected the ADM requested invitation to future resident council meetings; with the caveat that if invitation request is declined, the activities director will document any concerns and provide the resulting grievance form to the administrator. Record review of the Facility Orientation Outline reflected a checklist that included: policy manual review of resident rights and resident abuse. Record review of facility Orientation In Service document with the topic of Abuse/Neglect, included definitions, examples, and reporting guidelines. Record review of sample personnel file revealed blank forms that required new employee signatures related to receipt and adherence to employee handbook with details related to resident rights including abuse and neglect prohibition. Record review of sample personnel file revealed new employee signature requirements for Senate [NAME] 9 Acknowledgement related to staff liabilities and penalties related to resident rights impingement specific to abuse/neglect. Record review of facility Orientation In-Service document with the topic of Abuse/Neglect, included statement that Nurses were to direct the alleged perpetrator to clock out and leave the premises. In an interview on [DATE] at 6:28 PM, the Regional RN stated that residents experiencing abuse or neglect would be identified in the Daily Care Rounds. The Regional RN stated this information was included in the new Morning Meeting process template. The SW would then make the psychological services referrals as necessary. Record review of Clinical Alerts Skin Observation reflected 13 observations discussed in morning meeting on [DATE]. Record review of Clinical Alerts Skin Observation reflected 13 observations discussed in morning meeting on [DATE]. Monitoring In an interview on [DATE] at 6:36 PM, the Regional RN stated that any negative outcomes would be identified in the Daily Care Rounds. The Regional RN stated this information was included in the new Morning Meeting process template. The ADM/DON/Designee would then update the pending QAPI agenda template at each instance. In an interview on [DATE] at 6:40 PM, the Regional RN stated that the MD was notified via telephone on [DATE] at approximately 6:00 PM regarding the Immediate Jeopardy being called on [DATE]. In an interview on [DATE] at 6:40 PM, the Regional RN stated that any issues would be identified in the Daily Care Rounds. The Regional RN stated this information was included in the new Morning Meeting process template. The ADM/DON/Designee would then update the pending QAPI agenda template at each instance for follow up at the next regularly scheduled QAPI meeting. In an interview on [DATE] at 6:46 PM, the Regional RN stated that the ADM of the facility is responsible for implementation of process. On [DATE] at 03:52 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed prior to exit on [DATE], the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 (Resident #3) reviewed for quality of care. Resident #3 had signs and symptoms of a stroke and was not sent to the hospital for evaluation for approximately 6 hours after a change of condition was reported. The non-compliance was identified as past non-compliance. The immediate jeopardy began on 2/23/2024 and ended on 2/28/2024. The facility corrected the non-compliance before the investigation began. This deficient practice placed all residents at risk of experiencing a delay in treatment that could have resulted in harm or potentially death. The findings included: Record review of the admission record revealed Resident #3 was a [AGE] year-old male, originally admitted on [DATE]. Diagnosis information revealed positive for gastrostomy status with an onset date of 3/04/2024 [date of return from hospitalization after stroke like symptoms reported on 2/23/2024]. Record review of comprehensive MDS assessment dated [DATE], revealed Resident #3 had a BIMS summary score of 15, indicative of intact cognition. Resident #3 had active diagnoses that included heart failure, hypertension [high blood pressure], and high cholesterol [diagnoses indicative of higher risk for stroke or heart attack]. Record review of an email from COTA K dated 2/26/2024 at 12:26 PM, reflected that COTA K observed on 2/23/2024 at approximately 12:50 PM, Resident #3 was unable to use his left side as per his normal. COTA K informed RN M, who stated the resident was fine. COTA K and PTA L returned to Resident #3 at approximately 2:45 PM, and observed continued left sided weakness, incontinence of bowel and bladder, and reported findings to the DOR . Record review of an email from PTA L dated 2/23/2024 at 8:09 PM, revealed PTA L observed Resident #3 on 2/23/2024 after COTA K had informed PTA L of Resident #3's condition some time shortly after 12:00 PM. PTA L observed Resident #3 being unable to move his left arm and slurring speech. Further record review reflected that PTA L informed RN M of the resident's condition. When PTA L informed RN M of his findings, PTA L was told RN M had assessed Resident #3 and he seemed fine. PTA L returned to Resident #3's room around 3:00 PM, to provide incontinence care, and noticed Resident #3 was more pronounced in being unable to effectively use his left arm, and his voice was weaker than his normal self. PTA L reported the findings to the DOR. Record review of a typed note signed by the DOR revealed the DOR informed RN N on 2/23/2024 at approximately 3:30 PM of the changes in Resident #3 as slurred speech, having to repeat sentences multiple times, unable to lift LUE [left upper extremity], unable to grasp or make a fist with LUE, and overall fatigue. Record review of Nurses Note, authored by RN N on 2/23/2024 at 6:33 PM, reflected that Resident #3 was leaving via contracted service company for transport to ER for further evaluation. The hospital record revealed Resident #3 had an MRI done at the hospital, which found a stroke. The resident was also assessed for dysphagia that resulted in the placement of a gastrostomy tube for hydration, nutrition, and medications. Record review of the Care Plan revealed, Resident #3 .wears a Life Vest [wearable defibrillator for those at risk of sudden cardiac arrest], with a date initiated of 3/05/2024 [day after Resident #3 returned from hospital after stroke like symptoms on 2/23/2024]; additional problem area, .new feeding tube . with a date initiated 3/04/2024. In an observation on 5/20/2024 at 12:46 PM, Resident #3 was laying supine in bed, with the head of bed elevated approximately 60 degrees. Resident #3 had the over head lights off, but the television was playing softly. Resident #3 had his eyes closed but opened them when spoken to. Resident #3 declined to be interviewed stating that he was tired right now. In an interview on 5/24/2024 at 2:35 PM, RN M stated she was not very familiar with any of the residents at the time of the incident with Resident #3 (2/23/2024), as she had only worked at the facility for about a month. RN M stated she was informed by a member of the therapy staff that Resident #3 was not acting his usual self, by declining to attend his therapy session, and had complaints of shoulder pain. RN M stated this occurred just before or during lunch that day [approximately 11:30 AM-12:00 PM]. RN M stated she assessed the resident and recalled that his blood sugar was 77, and therefore he did not require a sliding scale dose of insulin before he could eat the lunch tray that had been delivered. RN M stated that Resident #3 did complain of his shoulder bothering him, and she administered Tylenol in response. RN M stated she felt that many other staff did not like Resident #3 due to him sometimes being mean spirited, and staff avoided taking the time to work with him. RN M stated she felt she had a good rapport with Resident #3, as they had similar back grounds and were jovial with each other in their conversations. RN M stated she did not document the findings of her informal assessment of him, because she, just did not see anything wrong with him. RN M stated at shift change the oncoming nurse (RN N) was running late and was flustered and out of breath when she arrived. RN M stated she reported to RN N about the new admissions they had received, the condition of another resident who had fallen earlier in the day. RN M stated that the unit was notorious for having a lot of stuff going on. RN M explained that the unit where this incident occurred was typically very busy. RN M stated that when the incident occurred the ADON, and the DON were both out. RN M stated no staff ever revisited their concerns that day about Resident #3 to her. RN M stated she observed him throughout the remaining afternoon before the end of her shift. RN M stated she never did see any thing that would have said possible stroke symptoms. RN M stated that looking back on the situation, that she really wished those staff that knew him better than she had at the time, had escalated the issue with her. RN M stated she was devastated by the whole thing. RN M stated that if she had run in to him as a stranger on the street, she would not have thought anything was wrong with Resident #3. RN M stated she was surprised and saddened to hear that Resident #3 had a stroke that day . In an interview on 5/24/2024 at 2:56 PM, NP O stated he was notified just after 3:00 PM by RN N, regarding a change in condition for Resident #3 with stroke like symptoms. NP O stated he was informed by RN N that it had been an ongoing concern since around lunch time. NP O stated he gave orders to send Resident #3 to the ER for further evaluation and treatment. NP O stated he felt that any resident with new onset stroke like symptoms should be sent immediately to the ER via 911/EMS before any further decline. In an interview on 5/24/2024 at 3:15 PM, RN N stated she did not receive any concerning information from RN M regarding Resident #3 during shift change report the day of the incident (2/23/2024). RN N stated she was not told that staff had raised concerns earlier in the day, or that Tylenol had been administered to Resident #3 for shoulder pain by RN M. RN N stated that the DOR came to her at about 3:15 PM, requesting an assessment of Resident #3 due to changes in his condition. RN N stated she was told the changes had been on-going since before lunch. RN N stated she recognized Resident #3 was not his normal self, he appeared fatigued, had some slurred speech, and one-sided weakness. RN N stated the most concerning symptom was that he was really slow to form words and really slow to respond to questions. RN N immediately notified the physician services group and received orders to send Resident #3 to the emergency room. RN N contacted the facility's contracted transportation and Resident #3 was picked up around 6:30 PM to be taken to the emergency room. [approximately 3 hours after she first assessed him for change in condition, and approximately 6 hours after the changes were first reported .] RN N stated she did not send him via EMS because her understanding was that the symptoms had been on-going since early morning, and by the time she assessed Resident #3, it would have been outside the window for the typical treatment associated with stroke. In an interview on 5/24/2024 at 3:32 PM, the DOR stated that two of her staff, COTA K and PTA L reported to her at approximately 2:45 PM on 2/23/2024, that they had concerns regarding Resident #3. The DOR assessed him and noted, slurred speech, unable to reach across his body. The DOR stated Resident #3 reported a headache to her. The DOR stated she requested the oncoming nurse assess Resident #3 right away . In an interview on 5/24/2024 at 3:43 PM, PTA L stated that his co-worker [COTA K] reported to him that she did not like the response the nurse gave when she reported a possible change in condition in Resident #3. PTA L stated he assessed Resident #3 before lunch on 2/23/2024 and then again near shift change [approximately 3:00 PM]. PTA L stated he observed the same changes his co-worker [COTA K] reported: different from his normal self, something off. PTA L stated that closer to shift change, around 2:45 PM, he took the issue to his DOR to escalate the findings. PTA L stated there were no significant changes from what he saw in Resident #3 before lunch and then again near shift change at 2:45 PM. PTA L stated Resident #3 was not any better, but not really any worse either. In an interview on 5/24/2024 at 5:15 PM, the DON stated her expectation was that assessments [NAME] documented as soon as completed, change of conditions were reported to the primary care provider, and that when the primary care provider issued new orders to send a resident with stroke like symptoms to the emergency room for further evaluation and treatment, that was done so via 911 and EMS transportation. The DON stated that in-servicing was initiated immediately in the wake of this event that included the signs and symptoms of a stroke, documenting, and reporting change of conditions. The DON stated Nurse M was suspended and ultimately terminated from employment at the facility upon completion of the internal investigation . The DON stated Resident #3 returned from the hospital with a PEG tube and was in therapy to see if he could return to intake by mouth. The DON stated Resident #3 was not as talkative now after the stroke as he used to be. Record review of In-Service topic, 911 Transfers, dated 2/23/2024, reflected that medical emergencies are any acute onset of a life-threating medical problems that cannot be managed in house. Further, signs and symptoms of a stroke include facial drooping, arm weakness, and speech difficulty. Record review of In-Service topic, Change in Condition, undated, reflected includes major decline, unknown injuries, and change in mental status. Anything out of the ordinary with the resident's baseline. Record review of Change in Residents Condition or Status policy, revised February 2021, reflected policy statement of promptly notifies the resident, attending physician, resident representative of changes in the residents medical or mental condition or status. Further review reflected a significant change in the residents physical .condition is a major decline .that a.) will not normally resolve itself without intervention; the nurse will record in the resident's medical record information relative to changes in the residents' condition or status. Record review of in-service topic, Stroke Signs and Symptoms, dated 2/23/2024, listed as: numbness or weakness in the face, arm, or leg, especially on one side of the body. Confusion or trouble speaking or understanding speech and severe headache with no known cause. Record review of in-service topic, Change in Condition Reporting, dated 2/23/2024, reflected change of conditions needs to be reported as soon as change is notice. If you report a change of condition or status to a charge nurse and nothing is done, the individual reporting needs to report the change to the DON or Administrator. The facility required immediate action to ensure that changes in condition and emergencies were recognized as such and an appropriate response was initiated. The facility initiated the following training with 100% compliance: Topic - 911 Transfers; target audience: RN and LVNs; started 2/23/2024; no dates next to signatures. Topic - Abuse/Neglect; target audience: all team members; started 2/23/2024; last signature dated 2/26/2024. Topic - Change of Condition; target audience: all team members; started 2/23/2024; last signature dated 2/26/2024. Topic - Change in Conditions: Stroke signs & symptoms; target audience: nursing; started 2/23/2024; no dates next to signatures. Topic - Change of Condition Reporting; target audience: all team members; started 2/23/2024; last signature dated 2/28/2024. Interviews included 20 staff members, across all shifts, confirming they received and understood the topics during the in-servicing (LVNs, RNs, CNAs, SW, PTAs, DOR, ADON/Infection Preventionist, Dietary Mgr, and [NAME] ).