**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview 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 (Resident #1) of 7 residents reviewed for abuse and/or neglect. The facility failed to prevent CNA A from physically and verbally abusing Resident #1 when she intentionally shoved and used derogatory language towards Resident # 1. The noncompliance was identified as PNC. The IJ noncompliance began on 10/7/23 and ended on 10/8/23. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of abuse and neglect. Findings included: Record review of Resident #1's face sheet, dated 07/17/2024, indicated she was admitted to the facility on [DATE] with diagnoses including, Hypertension (A condition in which the force of the blood against the artery walls is too high), Gastro-esophageal reflux disease without esophagitis (a common condition in which the stomach contents move up into the esophagus and inflammation of the esophagus), Gastrostomy infection (a surgical operation for making an opening in the stomach). Record review of Resident #1's Quarterly MDS assessment, dated 10/16/23, reflected Resident #1 usually made herself understood and usually understood others. Resident #1 had severe cognitive impairment with a (BIMS score of 0. Resident #1 had no physical or verbal behaviors symptoms directed towards herself or others. Resident #1 had no behavior of rejecting care. Resident #1 was dependent on staff for all activities of daily living and was always incontinent of bowel and bladder. Record review of Resident #1's care plan dated 4/24/24, reflected Resident #1 was incontinent of bowel and bladder. Staff were to provide incontinent care after each episode. The care plan reflected that Resident #1 was totally dependent on staff for all of her activities of daily living. Record review of the facility's provider investigation report dated 10/8/23, reflected CNA B reported she witnessed CNA A shove Resident # 1, tell Resident #1 to, Turn your ass over, don't touch me you be playing in your pussy, and shut the hell up. It was indicated that the police were notified. Record review of CNA A's signed statement, dated 10/8/2023, reflected, I CNA A was taking to the nurse and She was saying that milk was every were in Resident #1 and her roommate She ask who got them I said another CNA had them I was looking for them could not fine them so I got CNA B to help clean them up when I come out I said them to fat motherfucker got them so by ther another CNA and who are you taking to I did not say not me and another CNA going back and for and I told another CNA did you here me call any by name out she no but we the only to white girl her I apologize if they thank I was toke to them.(Sic) Record review of CNA B's signed statement, dated 10/9/23, reflected I CNA B is stating that on 10/7/2023 at approximately 9:45 p.m I witness CNA A actually go in to Resident #1's room and went to the left side of the bed while I was standing on the right side of the bed CNA A actually pushed Resident #1 and told her to turn her ass over as CNA A begin to clean Resident # 1 she reached out to touch CNA A she made a statement don't touch me you be playing in your pussy Resident #1 moaned and CNA A told Resident # 1 to shut the hell up. During an interview on 7/16/24 at 10:35 a.m., Resident #1 said she did not remember someone by the name of CNA A. She said that no one has been mean to her. She said that she cannot remember if anyone had harmed her or said disrespectful words to her. She said she cannot say if anyone has hurt her feeling here. During an interview on 7/16/24 at 11:15 p.m., with the DON she said CNA A came back after the incident and gave a statement, but it had nothing to do with the actual incident. She said CNA A would not talk about the allegations CNA B made. She said the former ADM was in charge during this incident and the current ADM is only acting ADM until one is hired. She said CNA A was terminated as it was confirmed this incident took place. She said CNA B notified her on 10/8/2023 at 1:15 p.m. that on 10/7/2023 at 9:50 p.m. she witnessed CNA A shove and use verbally abusive language to Resident # 1 . She said that she was the first person that the incident was reported to. During an interview on 7/16/24 at 1:34 p.m. with CNA B she said that she remembered the incident with Resident #1 and CNA A. She said she witnessed CNA A shove Resident # 1 hard when turning her over to do peri care. She said she heard CNA A tell Resident # 1 to turn her ass over. She said then Resident # 1 touched CNA A and she told Resident # 1 to not touch her because she plays with her pussy. She said she heard CNA A then tell Resident # 1 to shut the hell up after Resident # 1 made a groaning noise. She said she reported this incident to the DON. During an attempted interview on 7/16/2024 at 2:50 p.m. CNA A was contacted via telephone. A voicemail was not left as the number was disconnected. During an interview on 7/16/2024 at 3:02 p.m., LVN C said that any type of abuse was to be reported immediately to the abuse coordinator, charge nurse, or DON. She said that she has been in-serviced on this topic as well as their abuse policy multiple times including immediately after the incident with Resident #1. She said she would also need to ensure the resident that was allegedly abused was safe after the allegation and remove the alleged perpetrator for access to any resident. During an interview on 7/16/2024 at 3:04 p.m., CNA D said if a resident made an allegation that they were abused then she would need to ensure the resident was safe, report to the abuse coordinator and any other management that was working, keep the resident safe, and prevent the person who allegedly did the abuse away from other residents. She said she has been in-serviced on all these principals multiple times. During an interview on 7/16/2024 at 3:07 p.m., LVN E said that she has been in-services on the facility abuse policy several times. She said that if an allegation of abuse is made, they are to immediately report the allegation to the abuse coordinator. She said she can also report to the charge nurse and the DON as well as call the abuse coordinator. She said that she would also need to ensure that the person who did the abuse did not have access to any resident and have them leave the building. During an interview on 7/16/2024 at 3:09 p.m., LVN F said that the abuse coordinator should be notified immediately after an allegation of abuse is made. She said that she can tell the abuse coordinator in person or call them. She said that she can also tell other management of an allegation of abuse. She said that she has been trained in this topic multiple times. She said the abuse policy is a topic that is trained frequently. She said that when abuse allegedly occurs she would also need to ensure that the resident and other residents are kept safe from the person who allegedly did the abuse. During an interview on 7/16/2024 at 3:20 p.m., with the former ADM he said he vaguely remembers this incident. He said he immediately suspended CNA A on 10/8/2023 before she came back to work. He said he then investigated the incident. He said he doesn't recall any type of statement from CNA A other than what is in the PIR. He said he doesn't recall the resident needing any counseling or showing any type of emotional response to the incident. He said he doesn't remember what time this was reported by CNA B but it will be located on the PIR. He said these were typically reported immediately to himself or the DON. He said he does not recall when he got the self-report for this incident. During an interview on 7/17/24 at 12:53 p.m., the Administrator said CNA A was immediately upon learning of the incident on 10/8/2024 at 1:15 p.m. suspended pending the investigation results. He said CNA A was terminated when it was determined that the allegations made against CNA A were true. He said that all staff were in-serviced over abuse, neglect and exploitation. The Administrator said abuse of residents would not be tolerated at the facility. Record review of a facility in-service dated 10/8/2023 revealed that CNA B was in-services for the facilities abuse policy. Abuse policy educates staff on identifying abuse and neglect as well as timeframes associated with reporting abuse and neglect to the State Agency. Record review of CNA A's personnel file on 07/17/24 indicated hire date of 9/5/23. The facility had performed background check and employee misconduct search. No concerns were identified. Record review of CNA A's Employee Disciplinary Report, dated 10/10/23, indicated she was terminated on 10/10/2023 for misconduct regarding allegations of Abuse and was not eligible for rehire. The administrator was notified of IJ PNC on 07/16/2024 at 5:16 p.m. due to the above failures. The administrator was provided with the IJ template on 07/16/2024 at 5:17 p.m. The noncompliance was identified as PNC. The IJ noncompliance began on 10/7/23 and ended on 10/8/23 . The facility had corrected the noncompliance before the investigation began. The surveyor confirmed the following actions had been implemented sufficiently to remove the immediacy by: Facility notification of abuse incident to responsible party, MD, Ombudsman and HHSC on 10/8/2023. Completion of in-services on abuse. Abuse policy educates staff on identifying abuse and neglect as well as timeframes associated with reporting abuse and neglect to the State Agency. Termination of confirmed perpetrator on 10/10/2023. Residents of facility interviewed did not indicate that they had been abused and were safe. Safe surveys were conducted with residents and no resident reported feeling unsafe. Record review of the facility's policy and procedure dated January 10th, 2017, titled Abuse/Reportable Events All residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians . Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish . Mental Abuse: Includes, but is not limited to, humiliation, harassment, threats of punishment and deprivation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse of residents for 1 of 7 Residents (Resident #1) whose records were reviewed for abuse. CNA B failed to report an allegation of resident abuse within 2 hours after learning about the allegation per facility policy. The facility failed to conduct a thorough investigation when the DON completed only 4 safe surveys and did not interview the resident. The facility failed to prevent CNA A from physically and verbally abusing Resident #1 when she intentionally shoved and used derogatory language towards Resident # 1. The noncompliance was identified as PNC. The IJ noncompliance began on 10/7/23 and ended on 10/8/23. The facility had corrected the noncompliance before the investigation began. This deficient practice could affect any resident and contribute to further resident abuse. The findings were: Record review of the facility's policy and procedure dated January 10th, 2017, titled Abuse/Reportable Events All residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants, or volunteers, staff of other agencies serving the resident, family members or legal guardians . Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish . Mental Abuse: Includes, but is not limited to, humiliation, harassment, threats of punishment and deprivation . Reporting: Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC. If the allegations involve abuse or result in serious bodily Injury, the report Is to be made within 2 hours of the allegation. Record review of Resident #1's face sheet, dated 07/17/2024, indicated she was admitted to the facility on [DATE] with diagnoses including, Hypertension (A condition in which the force of the blood against the artery walls is too high), Gastro-esophageal reflux disease without esophagitis (a common condition in which the stomach contents move up into the esophagus), Gastrostomy infection (a surgical operation for making an opening in the stomach). Record review of the Resident #1's Quarterly MDS assessment, dated 10/16/23, reflected Resident #1 usually made herself understood and usually understood others. Resident #1 had severe cognitive impairment with a BIMS score of 0. Resident #1 had no physical or verbal behaviors symptoms directed towards herself or others. Resident #1 had no behavior of rejecting care. Resident #1 was dependent on staff for all activities of daily living and was always incontinent of bowel and bladder. Record review of Resident #1's care plan dated 4/24/24, reflected Resident #1 was incontinent of bowel and bladder. Staff were to provide incontinent care after each episode. The care plan reflected that Resident #1 was totally dependent on staff for all of her activities of daily living. Record review of the facility's provider investigation report dated 10/8/23, reflected CNA B reported she witnessed CNA A shove Resident # 1, tell Resident #1 to, Turn your ass over, don't touch me you be playing in your pussy, and shut the hell up. It was indicated that the police were notified. Record review of CNA B's signed statement, dated 10/9/23, reflected I CNA B is stating that on 10/7/2023 at approximately 9:45 p.m., I witness CNA A actually go in to Resident #1's room and went to the left side of the bed while I was standing on the right side of the bed CNA A actually pushed Resident #1 and told her to turn her ass over as CNA A begin to clean Resident # 1 she reached out to touch CNA A she made a statement don't touch me you be playing in your pussy Resident #1 moaned and CNA A told Resident # 1 to shut the hell up Record review of CNA A's signed statement, dated 10/8/2023, reflected, I CNA A was taking to the nurse and She was saying that milk was every were in Resident #1 and her roomate She ask who got them I said another CNA had them I was looking for them could not fine them so I got CNA B to help clean them up when I come out I said them to fat motherfucker got them so by ther another CNA and who are you taking to I did not say not me and another CNA going back and for and I told another CNA did you here me call any by name out she no but we the only to white girl her I apologize if they thank I was toke to them.(Sic) During an interview on 7/16/24 at 10:35 a.m., Resident #1 said she did not remember someone by the name of CNA A. She said that no one has been mean to her. She said that she cannot remember if anyone had harmed her or said disrespectful words to her. She said she cannot say if anyone has hurt her feeling here. During an interview on 7/16/24 at 11:15 p.m., with the DON she said CNA A came back after the incident and gave a statement, but it had nothing to do with the actual incident. She said CNA A would not talk about the allegations CNA B made. She said the former ADM was in charge during this incident and the current ADM is only acting ADM until one is hired. She said CNA A was terminated as it was confirmed this incident took place. She said CNA B notified her on 10/8/2023 at 1:15 p.m. that on 10/7/2023 at 9:50 p.m. she witnessed CNA A shove and use verbally abusive language to Resident # 1. She said that she was the first person that the incident was reported to. During an interview on 7/16/24 at 1:34 p.m. with CNA B she said that she remembered the incident with Resident #1 and CNA A. She said she witnessed CNA A shove Resident # 1 hard when turning her over to do peri care. She said she heard CNA A tell Resident # 1 to turn her ass over. She said then Resident # 1 touched CNA A and she told Resident # 1 to not touch her because she plays with her pussy. She said she heard CNA A then tell Resident # 1 to shut the hell up after Resident # 1 made a groaning noise. She said she reported this incident to the DON. During an interview on 7/16/2024 at 2:41 p.m., with the DON she said that all safe surveys were completed during the investigation of the allegations. She said that the safe surveys were also called psychosocial assessments. She said she was the first person the incident was reported to. She said that she thought 4 safe surveys was sufficient to determine if facility residents felt safe. She said that Resident # 1 was not interviewed after the incident, and she did not receive a safe survey. During an interview on 7/16/2024 at 3:02 p.m., LVN C said that any type of abuse was to be reported immediately to the abuse coordinator, charge nurse, or DON. She said that she has been in-serviced on this topic as well as their abuse policy multiple times including immediately after the incident with Resident #1. She said she would also need to ensure the resident that was allegedly abused was safe after the allegation and remove the alleged perpetrator for access to any resident. During an interview on 7/16/2024 at 3:04 p.m., CNA D said if a resident made an allegation that they were abused then she would need to ensure the resident was safe, report to the abuse coordinator and any other management that was working, keep the resident safe, and prevent the person who allegedly did the abuse away from other residents. She said she has been in-serviced on all these principals multiple times. During an interview on 7/16/2024 at 3:07 p.m., LVN E said that she has been in-services on the facility abuse policy several times. She said that if an allegation of abuse is made, they are to immediately report the allegation to the abuse coordinator. She said she can also report to the charge nurse and the DON as well as call the abuse coordinator. She said that she would also need to ensure that the person who did the abuse did not have access to any resident and have them leave the building. During an interview on 7/16/2024 at 3:09 p.m., LVN F said that the abuse coordinator should be notified immediately after an allegation of abuse is made. She said that she can tell the abuse coordinator in person or call them. She said that she can also tell other management of an allegation of abuse. She said that she has been trained in this topic multiple times. She said the abuse policy is a topic that is trained frequently. She said that when abuse allegedly occurs she would also need to ensure that the resident and other residents are kept safe from the person who allegedly did the abuse. During an interview on 7/16/2024 at 3:20 p.m., with the former ADM he said he vaguely remembers this incident. He said he immediately suspended CNA A on 10/8/2023 before she came back to work. He said he then investigated the incident. He said he doesn't recall any type of statement from CNA A other than what is in the PIR. He said he doesn't recall the resident needing any counseling or showing any type of emotional response to the incident. He said he doesn't remember what time this was reported by CNA B but it will be located on the PIR. He said these were typically reported immediately to himself or the DON. He said he does not recall when he got the self-report for this incident. During an interview on 7/16/24 at 4:26 p.m., with the Administrator, he said that he was the acting Administrator until a new Administrator was hired. He said if he became aware of abuse, he would be required to report it within two hours to the state. He said that as soon as he found out there was an alleged perpetrator, he would suspend the alleged perpetrator and remove their access to residents. He said when he is called, he will ask the person who called him to ensure that the resident was safe, what they were currently doing to ensure the safety of the resident and he will then give guidance if additional measures were needed. He said if it was necessary, he would then call the police. He said that he would then ensure there was an assessment completed for the resident to identify any potential issues. He said if the resident can speak, they would be interviewed and safe surveys would be completed, he would talk to family, talk to the physician, and police if necessary. He said if the resident could not tell what occurred, they would then rely on safe surveys and witness statements. He said that the number of residents that they have complete safe surveys depend on what happened, and the residents would be picked at random. During an interview on 7/17/24 at 12:53 p.m., the Administrator said CNA A was immediately suspended pending the investigation results. He said CNA A was terminated when it was determined that the allegations made against CNA A were true. He said that all staff were in-serviced over abuse, neglect and exploitation. The Administrator said abuse of residents would not be tolerated at the facility. He said that all allegations of abuse are reported within two hours after the incident occurred. Record review of CNA A's personnel file on 07/17/24 indicated hire date of 9/5/23. The facility had performed background check and employee misconduct search. No concerns were identified. Record review of CNA A's Employee Disciplinary Report, dated 10/10/23, indicated she was terminated for misconduct regarding allegations of Abuse and was not eligible for rehire. The administrator was notified of IJ PNC on 07/16/2024 at 5:16 p.m. due to the above failures. The administrator was provided with the IJ template on 07/16/2024 at 5:17 p.m. The surveyor confirmed the following actions had been implemented sufficiently to remove the immediacy by: facility notification of abuse incident to responsible party, MD, Ombudsman and HHSC. Completion of in-services on abuse on 10/8/2023. Abuse policy educates staff on identifying abuse and neglect as well as timeframes associated with reporting abuse and neglect to the State Agency. Staff and management recognizing the steps to report abuse and neglect. ADM and DON being able to articulate the steps of an investigation on 7/17/2024. Termination of confirmed perpetrator. The noncompliance was identified as PNC. The IJ noncompliance began on 10/7/23 and ended on 10/8/23. The facility had corrected the noncompliance before the investigation began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right of the residents to be free from abuse for 6 of 7 residents reviewed for abuse and neglect. (Resident #2, Resident #3, Resident #5, Resident #6, Resident #7, Anonymous Resident) The facility failed to ensure Resident #7 and AR did not suffer physical pain when CNA B provided ADL care to them. The facility failed to ensure Resident #3, Resident #5, Resident #7, and an AR did not suffer verbal and mental abuse, and mistreatment when CNA B would cuss and say hurtful things towards them. The facility failed to ensure CNA B did not remove Resident #5's food from him so he would not have a bowel movement on her. The facility failed to ensure Resident #2 did not experience verbal aggressive behaviors from CNA B. The facility failed to ensure Resident #6 did not experience emotional distress when CNA B would refuse to change her or speak to her in an unprofessional manner. An Immediate Jeopardy (IJ) situation was identified on 02/23/24 at 3:10 p.m. while the IJ was removed on 02/24/24 at 3:45 p.m., the facility remained out of compliance at a potential for actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: 1. Record review of Resident #3's face sheet printed 02/15/24 indicated Resident #3 was a [AGE] year-old male and admitted on [DATE] with diagnoses including schizoaffective disorder (is a mental health condition), generalized anxiety disorder (is a condition of excessive worry about everyday issues and situations), cognitive communication (problems with communication that have an underlying cause in a cognitive deficit), and muscle wasting and atrophy (shortening). Record review of Resident #3's quarterly MDS assessment dated [DATE] indicated Resident #3 was understood and had the ability to understand others. The MDS indicated Resident #3 had unclear speech, adequate hearing, and adequate vision. The MDS indicated Resident #3 had a BIMS score of 13 which indicated intact cognition. The MDS indicated Resident #3 did not have psychosis, behavioral symptoms, or rejection of care. The MDS indicated Resident #3 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, shower/bathe self, lower body dressing, personal hygiene, and partial/moderate assistance (helper does less than half the effort) for oral hygiene, upper body dressing and toilet transfer. The MDS indicated Resident #3 was occasionally incontinent for urine and frequently incontinent for bowel. Record review of Resident #3's care plan dated 06/12/22, edited on 01/11/24 indicated Resident #3 had potential for injury related to falls due to history of previous fall. Intervention included remind/encourage resident to use call light to gain assistance. During an interview on 02/15/24 at 12:04 p.m., Resident #3 said CNA B acted like she was better than him. He said CNA B said mean stuff to him all the time. He said CNA B did cuss at him and recently cussed him out after she helped him in the shower. He said CNA B made him feel like an outcast. 2. Record review of Resident #5's face sheet printed 02/15/24 indicated Resident #5 was a [AGE] year-old male and admitted on [DATE] with diagnoses including hemiplegia (is paralysis that affects only one side of your body) and hemiparesis (is weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction affecting non dominant side, cerebral infarction (stroke), acquired absence of right leg below knee, and end stage renal disease (is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Record review of Resident #5's quarterly MDS assessment dated [DATE] indicated Resident #5 was understood and had the ability to understand others. The MDS indicated Resident #5 had adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #5 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #5 had functional limitation range of motion to lower extremities to one side. The MDS indicated Resident #5 required partial/moderate assistance (helper does less than half the effort) for oral and toileting hygiene, shower/bathe self, dressing, and personal hygiene, and substantial/maximal assistance for sit to stand, chair/bed-to-chair, toilet, and tub/shower transfer. The MDS indicated Resident #5 had frequent incontinence for urine and bowel. Record review of Resident #5's care plan dated 01/20/24 indicated Resident #5 had an ADL self-care performance deficit and limited physical mobility. Intervention included the resident required extensive assistance for bed mobility, toilet use and transfer. During an interview on 02/15/24 at 12:00 p.m., Resident #5 said CNA B was not easy to work with. He said the facility wanted CNA B to use the mechanical lift to transfer him, but she did not which made her pick him up from the wheelchair and push him on the bed. He said she sometimes acted like she was afraid to transfer him because she thought he would put poop on her. He said sometimes she put his coat in his wheelchair to sit on so he could poop on it instead of the facility's linen. He said CNA B did not want him eating his snacks because it made him have loose bowels. He said CNA B talked rough to him and kind of turned and cleaned him rough. He said he was not afraid of her. He said sometimes she tells him, Don't talk to me! He said CNA B did not know how to talk to people. He said CNA B put him in hospital gowns instead of shirts, which he would ask for, but was always told gowns were easier. He said CNA B was not very nice to Resident #3, his roommate. He said she throws his clothes in the trash and talked rough to him. 3. Record review of Resident #7's face sheet printed on 02/15/24 indicated Resident #7 was a [AGE] year-old female and admitted on [DATE] and latest return on 02/15/24 with diagnoses including nontraumatic intracranial hemorrhage (brain bleed), flaccid hemiplegia affecting left side non dominant (the affected extremity exhibits decreased muscle tone and cannot be actively moved by the patient), legal blindness, muscle weakness, muscle wasting and atrophy (shortening), body mass index 50.0-59.9 (morbidly obese), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of Resident #7's quarterly MDS assessment dated [DATE] indicated Resident #7 was understood and had the ability to understand others. The MDS indicated Resident #7 had adequate hearing, clear speech, and severely impaired vision. The MDS indicated Resident #7 had a BIMS score of 14 which indicated intact cognition. The MDS indicated Resident #7 had functional limitation in range of motion to her upper and lower extremities on one side. The MDS indicated Resident #7 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, shower/bathe self, dressing, personal hygiene, roll left and right and dependent for chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. The MDS indicated Resident #7 was always incontinent for urine and bowel. Record review of Resident #7's care plan dated 06/10/22, edited 02/14/24 indicated Resident #7 had an ADL self-care performance deficit and limited physical mobility. Intervention included bed mobility, bathing and toilet use required extensive assistance and total assistance required for transfers. Record review of Resident #7's care plan dated 08/02/22, edited 02/14/24 indicated Resident #7 had demonstrated demanding behaviors towards others, yelling out for assistance when request for assistance is not answered immediately, desiring one on one constant help/assist from staff. Intervention included offer an outlet for resident to express feelings, wishes and frustrations. During an interview on 02/14/24 at 10:35 a.m., Resident #7 said she did not get along CNA B. She said CNA B jerked her arm and caused her pain when she got her up and called her fat. She said CNA B said things like I'm [CNA B] a buck 75 and you're [Resident #7] 300 pounds, so you need to help me or You [Resident #7] don't even try to help me [CNA B]. She said her left arm was bad so she could not help from that side. She said when CNA B said mean things to her, it made her sad. During an interview on 02/14/24 at 11:00 a.m., Resident #7's family member #1 said around December 2023, AE #1 called her at home and told her she needed to check on Resident #7 because CNA B was mistreating her. She said AE #1 told her she reported CNA B's mistreatment to the DON. She said when she filed the complaint on 12/26/23, she told the DON that CNA B said rude and hurtful things to her family member. She said she told the DON, CNA B always commented on Resident #7's weight. She said CNA B also told Resident #7, nobody cared if she told her family about things because if her family really cared about Resident #7, they would not have put her in nursing home. She said CNA B also said things like I don't have time to be doing this or I'm busy, so I ain't doing that. During an interview on 02/15/24 at 10:20 a.m., Resident #7's family member #2 said Resident #7 told her CNA B was rough, mean, and talked to her in a demeaning way. She said CNA B's behavior upset Resident #7 and when CNA B was not working, Resident #7 was happy and relieved. During an interview on 02/15/24 at 11:00 a.m., Resident #7's family member #3 said Resident #7 complained CNA B was rude to her and does not treat her right. He said Resident #7 complained CNA B commented on her weight and told him I can't stand her! He said CNA B even mentioned private family matters to Resident #7 causing her to become upset. 4. Record review of Resident #2's face sheet printed 02/15/24, indicated Resident #2 was an [AGE] year-old, female and admitted on [DATE] and 04/22/22 with diagnoses including unilateral primary osteoarthritis (is a chronic condition affecting the joints), depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized anxiety disorder (is a condition of excessive worry about everyday issues and situations). Record review of Resident #2's annual MDS assessment dated [DATE], indicated Resident #2 was understood and had the ability to understand others. The MDS indicated Resident #2 had adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #2 had a BIMS score of 14 which indicated intact cognition. The MDS indicated Resident #2 required set-up or clean-up assistance for oral and toilet hygiene, shower/bathe self, and upper body dressing and supervision or touching assistance for lower body dressing, putting on/taking off footwear, transfers, and personal hygiene. The MDS indicated Resident #2 was occasionally incontinent of urine and bowel. Record review of Resident #2's care plan dated 03/01/22, edited on 01/30/24, indicated Resident #2 had potential for injury related to falls due to unsteady gait, attempted to stand unassisted, and lost balance easily. Intervention included resident educated on importance of using call light to gain assistance. During an interview on 02/14/24 at 12:45 p.m., Resident #2 said CNA B was verbally aggressive to her and other residents. She said the few times CNA B was verbally aggressive to her, it made her mad. 5. Record review of Resident #6's face sheet printed 02/15/24 indicated Resident #6 was an [AGE] year-old, female and admitted on [DATE] with diagnoses including age related cognitive decline (overall slowness in thinking and difficulties sustaining attention, multitasking, holding information in mind and word-finding), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), and chronic kidney disease, stage 3 (is a type of kidney disease in which a gradual loss of kidney function occurs over a period of months to years). Record review of Resident #6's quarterly MDS assessment dated [DATE] indicated Resident #6 was understood and had the ability to understand others. The MDS indicated Resident #6 had adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #6 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #6 required partial/moderate assistance for oral hygiene, upper body dressing, and personal hygiene and substantial/maximal assistance for toilet hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident #6 was always incontinent of urine and bowel. During an interview on 02/15/24 at 10:03 a.m., Resident #6 said CNA B spoke to you a nasty way. She said when you asked CNA B for something, she would say, What you want? or Well, I [CNA B} ain't got no time for that! She said CNA B did not say those things in a joking manner. She said CNA B had smarted off at her and a bunch of folks. She said CNA B refused to change her and would get someone else to do it. She said CNA B's actions hurt her feelings and made her feel like she did something wrong. 6. Record review of Resident #4's face sheet printed 02/15/24 indicated Resident #4 was a [AGE] year-old, male and admitted on [DATE] and 03/28/23 with diagnoses including multiple sclerosis (is a potentially disabling disease of the brain and spinal cord (central nervous system)), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and muscle wasting and atrophy (shortening). Record review of Resident #4's quarterly MDS assessment dated [DATE] indicated Resident #4 was understood and had the ability to understand others. The MDS indicated Resident #4 had adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #4 had a BIMS score of 14 which indicated intact cognition. The MDS indicated Resident #4 required partial/moderate assistance for toileting hygiene, shower/bath self, and dressing. The MDS indicated Resident #4 was occasionally incontinent of urine and frequently incontinent of bowel. Record review of Resident #4's care plan dated 12/26/23, edited on 01/09/24 indicated Resident #4 had potential for injury related to falls due to history of previous falls. Intervention included encourage resident to participate in activities program that encourages exercise and physical activity for strengthening and improved mobility. During an interview on 02/14/24 at 1:15 p.m., Resident # 4 said CNA B intimated the poor, old ladies on her hall. He said CNA B was so mean to AR sometimes, AR would start shaking. He said about 1-2 weeks ago, he heard CNA B tell Resident #3, Now, take your a** back to your room after she helped him take a shower. He said LVN G was standing by the shower door, so he did not know how LVN G did not hear CNA B cussing at Resident #3. 7. During an interview and observation on 02/14/24 at 1:30 p.m., AR said he/she had been putting up with CNA B's behaviors for a while. AR said CNA B got a better attitude for a while then she went back to being bad. AR said she never hit her/him or anything, but CNA tells you to hurry up! AR said CNA B was always in a hurry and rough with cares. AR said she/he had pain in her/his arms and CNA B, who knew she/he had pain in the arms, would pull the arm up and yank her/his clothes off or pull on the hurt arm. AR said CNA B pushes you or throws you in the bed when she's transferring you. AR said she/he was afraid of CNA B. AR's body was shaking in the chair and increased as she/he talked. During an interview on 02/14/24 at 11:22 a.m., AE #1 said CNA B was mean and aggressive with cares. AE #1 said CNA B picked on Resident #7 all the time. AE #1 said CNA B made Resident #7 cry sometimes because of how bad she [CNA B] talked about her [Resident #7]. AE #1 said Resident #7 had behaviors of throwing herself out of the bed or wheelchair, but it was because she [Resident #7] was so mad and frustrated with CNA B picking on her all day long. AE #1 said she/he heard CNA B say things like, wipe your own a**! AE #1 said CNA B took Resident # 5's food away from him after he got back from dialysis, because sometimes he would be hungry and eat a lot of food since he did not eat at dialysis. AE #1 said she complained in front of Resident #5 if he ate too much, he was going to sh** everywhere. AE #1 said another resident [AR] complained CNA B was rude and rough with her/him, but the resident was too scared to report it because of retaliation. During an interview on 02/14/24 at 4:07 p.m., LVN G said she had worked at the facility for 22 years. She said she had never been told by a resident or staff CNA B was rough or rude to residents. She said she did not hear CNA B say cuss words to Resident #3. During an interview on 02/14/24 at 4:14 p.m., CNA E said she had worked at the facility for 5 years on the 2pm-10pm shift. She said she had heard residents being yelled at or staff refusing the resident care which she considered verbal abuse. She said it took the choices away from the resident making them feel helpless. She said she never saw who was verbally abusing the resident, just heard it. She said it happened on the 6am-2pm and 2pm-10pm shift. During an interview on 02/14/24 at 4:15 p.m., CNA B said she had been employed at the facility for a year. She said she normally worked the 2pm-10pm shift. She said she did not abuse any residents or was rough with cares. She said she did not have any issues with any of the residents. She said she did not have any issues with Resident #3, but she did try to take another person with her when she dealt with him. During an interview on 02/15/24 at 10:30 a.m., CNA J said she had been working for the facility since June 2022 but had previously worked at the facility for 4 years. She said she worked all shifts at the facility. She said she worked the middle hall (Rooms 201-216) and sometimes the B long hall (room [ROOM NUMBER]-228). She said several residents had complained about CNA B to her. She said Resident #3, Resident #5, Resident #7, and AR had complained about how CNA B talked to and treated them. She said CNA B's treatment of the residents made them feel like she did not like them. She said another resident told her CNA B cussed out Resident #3 and LVN G was there. She said when CNA B treats Resident #3 bad, he always says, I'm not putting with this sh**! During an interview on 02/15/24 at 11:22 a.m., CNA F said she had worked at the facility for 10 years on the 6am-2pm shift. She said she normally worked B long hall which were rooms 216-228. She said verbal and mental abuse was happening at the facility by CNA B. She said Resident #5 told her CNA B was too rough during cares and he was afraid of her. She said Resident #5 always asked the 6a-2pm shift to put him back to bed before they left because he did not want CNA B doing it. She said another resident reported to her CNA B was rough, talked harsh, and made them go to bed when she wanted them to. She said Resident #3 told her CNA B cussed at him and was ugly to him. She said the residents being abused probably felt sad, disgusted, or isolated themselves. During an interview on 02/15/24 at 1:20 p.m., the DON said she had known CNA B for a while and sometimes her tone was taken the wrong way. She said sometimes CNA B's tone and demeanor was aggressive. She said CNA B's aggressive tone or demeanor was not directed at the residents. She said it was just how CNA B was. She said she had done an in-service to all staff about their tone in November 2023. She said she had never done a 1:1 with CNA B about her tone and demeanor. She said CNA B had previous allegation of abuse last June (2023). She said staff had not recently told her of any residents complaining about CNA B's care or demeanor. She said recently Resident #3 told her CNA B and him had verbally got into, but he had called her a bit**. She said no formal disciplinary actions or report had been done on CNA B. During an interview on 02/15/24 at 2:09 p.m., the ADM said he was the abuse coordinator. He said CNA B had been verbally counseled a few times regarding how she spoke to residents. He said CNA B had been accused of abuse in June 2023. He said CNA B had employee disciplinary reports on file. He said CNA B had been monitored due to the previous abuse allegations by doing rounds. CNA B's employee disciplinary reports were requested during the interview and not received before exit. CNA B's employee disciplinary reports were received 6 days after exit. Record review of CNA B's proficiency dated 04/11/23 indicated .knowledge of abuse/neglect protocol .satisfactory .communication skills (respect/dignity) .satisfactory . Record review of CNA B's employee disciplinary report dated 02/02/24, indicated .CNA B .verbal counseling .Resident #3 complained that CNA B talked to him disrespectfully while attempting to provide care .reminded CNA B that this was the 2nd complaint regarding her tone with Resident #3 .another complaint would result in her suspension and/or termination .CNA B reported that she was only trying to get Resident #3 to get up and take a shower .Resident #3 needed to be cleaned up and was refusing .signature of supervisor presenting EDR:ADM .employee refused to sign .ADM (supervisor initial) .to be retained in employee's personnel file . The employee disciplinary report did not reveal CNA B's signature or date received and a witness initials of CNA B's refusal to sign. Record review of the facility's 12/23 staff sign in sheet indicated CNA B worked 24 days, 2pm-10pm shift on the hall where Resident #3, Resident #5, and Resident #7 resided. Record review of a facility's Be mindful of your tone and how you say things to and around the residents in-service dated 11/14/23 reflected CNA B's signature was noted on the attendance roster. Record review of a facility's Abuse, Neglect, and reportable events in-service dated 01/30/24 indicated .all resident have the right to be free from abuse, neglect .residents should not be subjected to abuse by anyone .it is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect .and situations that may constitute abuse or neglect to any resident in the facility . CMA L, LVN G, LVN H, CNA E, CNA F signature was noted on the attendance roster. CNA B signature was not noted on the attendance roster. Record review of a facility's Abuse/Reportable Events policy dated 01/17 indicated .all residents have the right to be free from abuse, neglect .residents should not be subjected to abuse by anyone .it is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect .and situations that may constitute abuse or neglect to any resident in the facility .abuse: the willful infliction of injury .intimidation .pain or mental anguish .it included verbal abuse, sexual abuse, physical abuse, and mental abuse .mental abuse .includes, but not limited to humiliation, harassment, threats of punishment or deprivation .verbal abuse .any use of oral, written or gestured language that willfully disparaging and derogatory terms to resident . This was determined to be an Immediate Jeopardy (IJ) on 02/23/24 at 3:10 p.m. The facility Administrator, and DON were notified. The Administrator was provided with the IJ template on 02/23/24 at 3:10 p.m. 2/24/2024 Plan of Removal - F 600 Immediate Action Taken Resident Specific CNA B was suspended pending investigation on 2/15/2024 at 3:30pm. CNA B was terminated on 2/21/2024 at 2:21pm. CNA B did not work in the facility after allegations of verbal abuse were brought to the Administrator, by the HHSC surveyor on 2/15/2024. Residents #3, #5, and #7 were interviewed by the Administrator on 2/15/2024. Residents #3, #5, and #7's Responsible Parties notified of the verbal abuse allegation on 2/15/2024. Residents #3, #5, and #7 had head to toe assessments performed by the Treatment Nurse on 2/15/2024. MD notified of the IJ on 2/23/2024 at 4:48pm by Administrator, no new orders received. System Changes All interviewable residents were interviewed by Administrator regarding abuse, safety, who to report concerns to, and complaint resolution on 2/23/2024. All non-interviewable residents received a head-to-toe skin assessment, to assess for any injuries or evidence of abuse, by Charge Nurses, Director of Nursing and Treatment Nurse on 2/23/2024. All residents in the facility received head to toe skin assessments, to assess for any injuries or evidence of abuse, by Charge Nurses, Director of Nursing and Treatment Nurse on 2/23/2024. Direct care staff interviewed on 2/24/2024 by Administrator regarding abuse and whether they have witnessed any abuse. All resident care plans revised to include being at risk for mental/emotional distress on 2/23/2024 by Regional Reimbursement Consultant. Abuse/Reportable Event policy reviewed on 2/23/2024 at 5:15pm by Administrator, Regional Nurse, and Director of Nursing. No changes made to policy at this time. Education Director of Nursing provided education to all staff regarding the Abuse/Reportable Event Policy, including types of abuse, definition of verbal and mental abuse, reporting requirements. All staff present in the facility were educated on 2/23/2024, at 6pm. Staff not present for the education will receive the education prior to their next shift. Director of Nursing provided education to all staff regarding the Grievance Policy, including how to file a grievance, timely resolution, and that residents are able to voice grievances without fear of reprisal or discrimination. All staff present in the facility were educated on 2/23/2024, at 6pm. Staff not present for the education will receive the education prior to their next shift. Regional Clinical Consultant provided education to Administrator and Director of Nursing regarding the Abuse/Reportable Event Policy on 2/23/2024 at 5:45pm. Regional Clinical Consultant provided education to Administrator and Director of Nursing regarding the Grievance Policy on 2/23/2024 at 5:45pm. On 02/24/24 a surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of CNA B's termination letter. CNA B was suspended immediately and was officially terminated by telephone on 02/21/24. Record review of an Abuse Pre/Post test. The administrator said this was the test used for educational purposes concerning the staff. The test consisted of 20 questions covering the different types of abuse and reporting of allegations. There was a situation question at the end of the test. Record review of an In-Service Form indicated an in-service for the Administrator and the DON was held on 02/23/24. The in-service was presented by the Regional Clinical Consultant. The topic was the Grievance - Voicing and Resolution facility policy. The policy included how to file a grievance and promptly attempting to resolve grievances. Record review of an In-Service Form indicated an in-service for the Administrator and the DON was held on 02/23/24. The in-service was presented by the Regional Clinical Consultant The topic was Abuse/Neglect and reportable events. The In-service included definitions of abuse, screening of personnel, training of personnel, prevention of abuse, identification of abuse, reporting, and protection of the residents. Record review of an In-Service Form indicated an in-service for all staff was held on 02/23/24. The in-service was presented by the DON. The topic was the Grievance - Voicing and Resolution facility policy. The policy included how to file a grievance and promptly attempting to resolve grievances. Record review of an In-Service Form indicated an in-service for all staff was held on 02/23/24. The in-service was presented by the DON. The topic was Abuse/Neglect and reportable events. The In-service included definitions of abuse, screening of personnel, training of personnel, prevention of abuse, identification of abuse, reporting, and protection of the residents. Record review of Employee Disciplinary Reports for CNA E, CNA F, LVN G, and CNA J dated 02/24/24 indicated they received verbal counseling for failing to report an allegation of abuse/neglect to the Abuse Coordinator. The report indicated the employees were re-educated on the abuse/reportable events policy/procedure. Each employee had signed their report. During interviews and observations conducted on 2/24/24 beginning at 1:30 p.m. through 2:00 p.m., 12 of 51 residents were observed and they showed no signs of untimely care and there were no signs of abuse. Out of the 12 residents observed, 7 were interviewable. Each said they had been educated in the last 24 hours concerning abuse and who to report any abuse to. Each of the 7 residents denied abuse of any kind. The also said they had been assessed by a nurse. (Residents interviewed and observed were Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #14) (Non-interviewable observed were Resident #15, Resident #16, Resident #17, Resident #18, and Resident #19). Record review of the observed residents indicated each had been assessed by a nurse. There were skin assessments dated 2/23/24 for each of the 12 residents. Each of the 12 residents' care plan had been revised to include being at risk for mental/emotional distress on 2/23/2024. During interviews conducted on 02/24/24 beginning at 2:00 p.m. through 3:38 p.m., 19 of 33 of all staff in-serviced (including staff across all shifts that were the Administrator, the DON, the Treatment Nurse, CNAs, LVNs, RNs, Dietary Manager, Medical Records/Housekeeping Supervisor, and Activity Director) were interviewed. All staff said they received education on signs and symptoms of abuse, who and when to report abuse, types of abuse, reporting requirements, how to file a grievance, timely resolution, and resident being able to voice grievances without fear of reprisal or discrimination. The Treatment nurse said she had assisted in completing the head-to-toe assessments and skin assessments of each resident on 02/23/24. CNA E, CNA F, LVN G and CNA J said they had received verbal counseling on reporting abuse to the abuse coordinator immediately if they became

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property and establish policies and procedures to report and investigate such allegations, for 6 of 7 residents (Resident #3, Resident #5, Resident #7, Resident #2, Resident #6, Anonymous Resident) reviewed for abuse/neglect. The facility failed to follow the facility's policy to ensure CNA B did not verbally and mentally abuse Resident #7, Resident #5, Resident #3, and Anonymous Resident. The facility failed to follow the facility's policy to ensure CNA B did not cause Resident #7 and Anonymous Resident pain when providing ADL care. The facility failed to follow the facility's policy to ensure Resident #2 did not experience verbally aggressive behaviors from CNA B. The facility failed to follow the facility's policy to ensure Resident #6 did not experience emotional distress when CNA B would refuse to change her or speak to her in an unprofessional manner. The facility failed to ensure when Resident #3 filed a complaint/grievance on 02/09/24 indicating CNA B treated him like trash, it was investigated by the facility's ADM/ Abuse Preventionist within 24 hours of the complaint/grievance per the facility's policy. The facility ADM/ Abuse Preventionist had not completed the investigation process until surveyor entrance on 02/14/24. The facility failed to ensure when Resident #3 filed a complaint/grievance on 02/09/24 indicating CNA B treated him like trash, it was reported to HHSC within 2 hours of allegation by the facility's ADM/ Abuse Preventionist per the facility's policy. The facility ADM/ Abuse Preventionist had not reported alleged allegations of abuse until surveyor entrance on 02/14/24. The facility failed to ensure the ADM/Abuse Preventionist, followed the facility's policy to identify, correct, and intervene in situations for possible abuse or mistreatment by CNA B when Resident #4 filed a complaint/grievance on 02/09/24 indicating CNA B was mean and he had overhead a CNA being ugly to another resident. The facility failed to ensure the ADM/Abuse Preventionist, CNA E, CNA J, CNA F, LVN G and AE #1, followed the facility's policy to implement measures to protect residents from harm during and following alleged allegations of abuse by CNA B. The facility failed to ensure CNA E, CNA J, CNA F, LVN G and AE #1 immediately verbally reported allegations of abuse and mistreatment to the ADM/Abuse Preventionist per the facility's policy. The facility failed to ensure AR was not afraid of retaliation for reporting abuse by CNA B. An Immediate Jeopardy (IJ) situation was identified on 02/23/24 at 3:10 p.m. while the IJ was removed on 02/24/24 at 3:45 p.m., the facility remained out of compliance at a potential for actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, neglect, and decreased quality of life. Findings included: Record review of a facility's Abuse/Reportable Events policy dated 01/17 indicated .all residents have the right to be free from abuse, neglect .residents should not be subjected to abuse by anyone .it is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect .and situations that may constitute abuse or neglect to any resident in the facility .abuse: the willful infliction of injury .intimidation .pain or mental anguish .it included verbal abuse, sexual abuse, physical abuse, and mental abuse .mental abuse .includes, but not limited to humiliation, harassment, threats of punishment or deprivation .verbal abuse .any use of oral written or gestured language that willfully disparaging and derogatory terms to resident .mistreatment: means inappropriate treatment or exploitation of a resident .all reports or suspicion of abuse/neglect .will investigated as facility protocol .investigations will be reviewed by the facility administrator and/or Abuse Preventionist within 24 hours of complaint .appropriate notification to state and home office will be the responsibility of the administrator .the facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect .facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents .to the facility administrator .the facility administrator or designee will report the allegation to HHSC .if allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation .comprehensive investigations will be the responsibility of the administrator and/or Abuse Preventionist .the facility will take necessary measure to protect residents and employees from harm during and following an abuse, neglect, exploitation, mistreatment of resident . Record review of the facility's Grievance/Complaint log dated 02/24 indicated .02/09/24 .Resident: Resident#3 .Person filing report: Resident #3, Date of Incident: 2/9/24 .Person Investigating: ADM .Date Resident/Family Informed of Findings: 2/9/24 .Disposition of Complaint: CNA treat him like trash . Record review of Resident #3 's Grievance/Complaint Investigation Report dated 02/09/24 indicated .Describe the incident as provided by the resident/individual: Res [Resident #3] states that CNA B treat him like trash .Recommendations/corrective action taken .CNA B have been counseled regarding their care administration and how they address Resident #3 . There was no documented date of when the recommendations/corrective action taken was done. There was no documentation noted for, Describe your findings of the incident, Was grievance/complaint resolved to the satisfaction of all concerned, Date resident/individual received report of findings, or .I, blank, certify that I have received a copy of the documents surrounding the grievance/complaint filed on . Record review of the facility's Grievance/Complaint log dated 02/24 indicated .02/09/24 Resident: Resident #4 .Person filing report: Resident #4 .Date of Incident: 2/9/24 . Person Investigating: ADM .Date Resident/Family Informed of Findings: 2/9/24 .Disposition of Complaint: CNA 's mean . Record review of Resident #4's Grievance/Complaint Investigation Report dated 02/09/24 indicated .Describe the incident as provided by the resident/individual: Res [Resident #4] state CNA's .CNA B .are mean .Res [Resident #4] has overheard CNA being ugly to other Res . There was no documentation noted for, Describe your findings of the incident, Recommendation/corrective action taken, Was grievance/complaint resolved to the satisfaction of all concerned, Date resident/individual received report of findings, or .I, 'blank', certify that I have received a copy of the documents surrounding the grievance/complaint filed on . 1. Record review of Resident #3's face sheet printed 02/15/24 indicated Resident #3 was a [AGE] year-old male and admitted on [DATE] with diagnoses including schizoaffective disorder (is a mental health condition), generalized anxiety disorder (is a condition of excessive worry about everyday issues and situations), cognitive communication (problems with communication that have an underlying cause in a cognitive deficit), and muscle wasting and atrophy (shortening). Record review of Resident #3's quarterly MDS assessment dated [DATE] indicated Resident #3 was understood and had the ability to understand others. The MDS indicated Resident #3 had unclear speech, adequate hearing, and adequate vision. The MDS indicated Resident #3 had a BIMS score of 13 which indicated intact cognition. The MDS indicated Resident #3 did not have psychosis, behavioral symptoms, or rejection of care. The MDS indicated Resident #3 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, shower/bathe self, lower body dressing, personal hygiene, and partial/moderate assistance (helper does less than half the effort) for oral hygiene, upper body dressing and toilet transfer. The MDS indicated Resident #3 was occasionally incontinent for urine and frequently incontinent for bowel. Record review of Resident #3's care plan dated 06/12/22, edited on 01/11/24 indicated Resident #3 had potential for injury related to falls due to history of previous fall. Intervention included remind/encourage resident to use call light to gain assistance. During an interview on 02/15/24 at 12:04 p.m., Resident #3 said CNA B acted like she was better than him. He said CNA B said mean stuff to him all the time. He said CNA B did cuss at him and recently cussed him out after she helped him in the shower. He said CNA B made him feel like an outcast. 2. Record review of Resident #5's face sheet printed 02/15/24 indicated Resident #5 was a [AGE] year-old male and admitted on [DATE] with diagnoses including hemiplegia (is paralysis that affects only one side of your body) and hemiparesis (is weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction affecting non dominant side, cerebral infarction (stroke), acquired absence of right leg below knee, and end stage renal disease (is a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). Record review of Resident #5's quarterly MDS assessment dated [DATE] indicated Resident #5 was understood and had the ability to understand others. The MDS indicated Resident #5 had adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #5 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #5 had functional limitation range of motion to lower extremities to one side. The MDS indicated Resident #5 required partial/moderate assistance (helper does less than half the effort) for oral and toileting hygiene, shower/bathe self, dressing, and personal hygiene, and substantial/maximal assistance for sit to stand, chair/bed-to-chair, toilet, and tub/shower transfer. The MDS indicated Resident #5 had frequent incontinence for urine and bowel. Record review of Resident #5's care plan dated 01/20/24 indicated Resident #5 had an ADL self-care performance deficit and limited physical mobility. Intervention included the resident required extensive assistance for bed mobility, toilet use and transfer. During an interview on 02/15/24 at 12:00 p.m., Resident #5 said CNA B was not easy to work with. He said the facility wanted CNA B to use the mechanical lift to transfer him, but she did not which made her pick him up from the wheelchair and push him on the bed. He said she sometimes acted like she was afraid to transfer him because she thought he would put poop on her. He said sometimes she put his coat in his wheelchair to sit on so he could poop on it instead of the facility's linen. He said CNA B did not want him eating his snacks because it made him have loose bowels. He said CNA B talked rough to him and kind of turned and cleaned him rough. He said he was not afraid of her. He said sometimes she tells him, Don't talk to me! He said CNA B did not know how to talk to people. He said CNA B put him in hospital gowns instead of shirts, which he would ask for, but was always told gowns were easier. He said CNA B was not very nice to Resident #3, his roommate. He said she throws his clothes in the trash and talked rough to him. 3. Record review of Resident #7's face sheet printed on 02/15/24 indicated Resident #7 was a [AGE] year-old female and admitted on [DATE] and latest return on 02/15/24 with diagnoses including nontraumatic intracranial hemorrhage (brain bleed), flaccid hemiplegia affecting left side non dominant (the affected extremity exhibits decreased muscle tone and cannot be actively moved by the patient), legal blindness, muscle weakness, muscle wasting and atrophy (shortening), body mass index 50.0-59.9 (morbidly obese), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of Resident #7's quarterly MDS assessment dated [DATE] indicated Resident #7 was understood and had the ability to understand others. The MDS indicated Resident #7 had adequate hearing, clear speech, and severely impaired vision. The MDS indicated Resident #7 had a BIMS score of 14 which indicated intact cognition. The MDS indicated Resident #7 had functional limitation in range of motion to her upper and lower extremities on one side. The MDS indicated Resident #7 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, shower/bathe self, dressing, personal hygiene, roll left and right and dependent for chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. The MDS indicated Resident #7 was always incontinent for urine and bowel. Record review of Resident #7's care plan dated 06/10/22, edited 02/14/24 indicated Resident #7 had an ADL self-care performance deficit and limited physical mobility. Intervention included bed mobility, bathing and toilet use required extensive assistance and total assistance required for transfers. Record review of Resident #7's care plan dated 08/02/22, edited 02/14/24 indicated Resident #7 had demonstrated demanding behaviors towards others, yelling out for assistance when request for assistance is not answered immediately, desiring one on one constant help/assist from staff. Intervention included offer an outlet for resident to express feelings, wishes and frustrations. During an interview on 02/14/24 at 10:35 a.m., Resident #7 said she did not get along CNA B. She said CNA B jerked her arm and caused her pain when she got her up and called her fat. She said CNA B said things like I'm [CNA B] a buck 75 and you're [Resident #7] 300 pounds, so you need to help me or You [Resident #7] don't even try to help me [CNA B]. She said her left arm was bad so she could not help from that side. She said her family member filed a grievance about CNA B treatment of her. She said the ADM and DON were aware of CNA B's being mean and saying hurtful things to her. She said when CNA B said mean things to her, it made her sad. She said the DON and CNA B were friends, and nothing seemed to happen when you complained about CNA B. During an interview on 02/14/24 at 11:00 a.m., Resident #7's family member #1 said she complained to the DON and ADM about CNA B being mean to Resident #7, but nothing happened. She said the first time she reported CNA B was probably in November 2023. She said the DON told her CNA B would not be Resident #7's CNA. She said as time went on CNA B still was Resident #7's aide. She said the family kind of dealt with CNA B still being Resident #7's aide because the facility was short staffed. She said around December 2023, AE #1 called her at home and told her she needed to check on Resident #7 because CNA B was mistreating her. She said AE #1 told her she reported CNA B's mistreatment to the DON. She said when she filed the complaint on 12/26/23, she told the DON that CNA B said rude and hurtful things to her family member. She said she told the DON, CNA B always commented on Resident #7's weight. She said CNA B also told Resident #7, nobody care is she told her family about things because if her family really cared about Resident #7, they would not have put her in nursing home. She said CNA B also said things like I don't have time to be doing this or I'm busy, so I ain't doing that. She said the family had been pretty much just accepting any care that was given from CNA B, because nothing was being done. She said CNA N and the DON were pretty cool with each other so maybe that was why nothing happened. During an interview on 02/15/24 at 10:20 a.m., Resident #7's family member #2 said Resident #7 told her CNA B was rough, mean, and talked to her in a demeaning way. She said CNA B behavior upset Resident #7 and when CNA B was not working, Resident #7 was happy and relieved. During an interview on 02/15/24 at 11:00 a.m., Resident #7's family member #3 said Resident #7 complained CNA B was rude to her and does not treat her right. He said Resident #7 complained CNA B commented on her weight and told him I can't stand her! 4. Record review of Resident #2's face sheet printed 02/15/24, indicated Resident #2 was an [AGE] year-old, female and admitted on [DATE] and 04/22/22 with diagnoses including unilateral primary osteoarthritis (is a chronic condition affecting the joints), depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest), and generalized anxiety disorder (is a condition of excessive worry about everyday issues and situations). Record review of Resident #2's annual MDS assessment dated [DATE], indicated Resident #2 was understood and had the ability to understand others. The MDS indicated Resident #2 had adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #2 had a BIMS score of 14 which indicated intact cognition. The MDS indicated Resident #2 required set-up or clean-up assistance for oral and toilet hygiene, shower/bathe self, and upper body dressing and supervision or touching assistance for lower body dressing, putting on/taking off footwear, transfers, and personal hygiene. The MDS indicated Resident #2 was occasionally incontinent of urine and bowel. Record review of Resident #2's care plan dated 03/01/22, edited on 01/30/24, indicated Resident #2 had potential for injury related to falls due to unsteady gait, attempted to stand unassisted, and lost balance easily. Intervention included resident educated on importance of using call light to gain assistance. During an interview on 02/14/24 at 12:45 p.m., Resident #2 said CNA B was verbally aggressive to her and other residents. She said the few times CNA B was verbally aggressive to her, it made her mad. She said she had not reported CNA B to the ADM because when she was admitted 2 years ago, other residents told her not to talk to the state or corporate people because the staff would retaliate. She said, so I've kept my mouth shut. 5. Record review of Resident #6's face sheet printed 02/15/24 indicated Resident #6 was an [AGE] year-old, female and admitted on [DATE] with diagnoses including age related cognitive decline (overall slowness in thinking and difficulties sustaining attention, multitasking, holding information in mind and word-finding), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), and chronic kidney disease, stage 3 (is a type of kidney disease in which a gradual loss of kidney function occurs over a period of months to years). Record review of Resident #6's quarterly MDS assessment dated [DATE] indicated Resident #6 was understood and had the ability to understand others. The MDS indicated Resident #6 had adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #6 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #6 required partial/moderate assistance for oral hygiene, upper body dressing, and personal hygiene and substantial/maximal assistance for toilet hygiene, shower/bathe self, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident #6 was always incontinent of urine and bowel. During an interview on 02/15/24 at 10:03 a.m., Resident #6 said CNA B spoke to you a nasty way. She said when you asked CNA B for something, she would say, What you want? or Well, I [CNA B} ain't got no time for that! She said CNA B did not say those things in a joking manner. She said CNA B had smarted off at her and a bunch of folks. She said CNA B refused to change her and would get someone else to do it. She said CNA B's actions hurt her feelings and made her feel like she did something wrong. 6. Record review of Resident #4's face sheet printed 02/15/24 indicated Resident #4 was a [AGE] year-old, male and admitted on [DATE] and 03/28/23 with diagnoses including multiple sclerosis (is a potentially disabling disease of the brain and spinal cord (central nervous system)), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and muscle wasting and atrophy (shortening). Record review of Resident #4's quarterly MDS assessment dated [DATE] indicated Resident #4 was understood and had the ability to understand others. The MDS indicated Resident #4 had adequate hearing, clear speech, and adequate vision. The MDS indicated Resident #4 had a BIMS score of 14 which indicated intact cognition. The MDS indicated Resident #4 required partial/moderate assistance for toileting hygiene, shower/bath self, and dressing. The MDS indicated Resident #4 was occasional incontinent of urine and frequently incontinent of bowel. Record review of Resident #4's care plan dated 12/26/23, edited on 01/09/24 indicated Resident #4 had potential for injury related to fall due to history of previous falls. Intervention included encourage resident to participate in activities program that encourages exercise and physical activity for strengthening and improved mobility. During an interview on 02/14/24 at 1:15 p.m., Resident # 4 said CNA B intimated the poor, old ladies on her hall. He said CNA B was so mean to AR sometimes, AR would start shaking. He said about 1-2 weeks ago, he heard CNA B tell Resident #3, Now, take your a** back to your room after she helped him take a shower. He said LVN G was standing by the shower door, so he did not know how LVN G did not hear CNA B cussing at Resident #3. He said he had filed a grievance at the beginning of the month about CNA behavior. He said it did not really do any good to report stuff because nothing happened. 7. During an interview and observation on 02/14/24 at 1:30 p.m., AR said he/she had been putting up with CNA B's behaviors for a while. AR said CNA B got a better attitude for a while then she went back to being bad. AR said she never hit her/him or anything, but CNA tells you to hurry up! AR said CNA B was always in a hurry and rough with cares. AR said she/he had pain in her/his arms and CNA B, who knew she/he had pain in the arms, would pull the arm up and yank her/his clothes off or pull on the hurt arm. AR said CNA B pushes you or throws you in the bed when she's transferring you. AR said she/he was afraid of CNA B. AR body was shaking in the chair and increased as she/he talked. During an interview on 02/14/24 at 11:22 a.m., AE #1 said CNA B was mean and aggressive with cares. AE #1 said CNA B picked on Resident #7 all the time. AE #1 said CNA B made Resident #7 cry sometimes because of how bad she [CNA B] talked about her. AE #1 said Resident #7 had behaviors of throwing herself out of the bed or wheelchair, but it was because she [Resident #7] was so mad and frustrated with CNA B picking on her all day long. AE #1 said she/he heard CNA B say things like, wipe your own a**! AE #1 said CNA B took Resident # 5's food away from him after he got back from dialysis, because sometimes he would be hungry and eat a lot of food since he did not eat at dialysis. AE #1 said she [CNA B] complained in front of Resident #5 if he ate too much, he was going to sh** everywhere. AE #1 said another resident [AR] complained CNA B was rude and rough with her/him, but the resident was too scared to report it because of retaliation. AE #1 said the resident [AR #5] was so scared about reporting CNA B, the resident [AR] was literally shaking from the fear of CNA B. AE #1 said she/he reported the resident [AR] complaint about CNA B's treatment to a nurse and the nurse said CNA B was being investigated. AE #1 said she/he did not want to disclose the nurse's name. During an interview on 02/14/24 at 4:07 p.m., LVN G said she had worked at the facility for 22 years. She said she had not heard or seen any abuse at the facility. She said she had never been told by a resident or staff CNA B was rough or rude to residents. She said she did not hear CNA B say cuss words to Resident #3. She said she knew to report abuse and neglect to DON or ADM immediately. During an interview on 02/14/24 at 4:14 p.m., CNA E said she had worked at the facility for 5 years on the 2pm-10pm shift. She said she had heard residents being yelled at or refusing staff the resident care which she considered verbal abuse. She said it took the choices away from the resident making them feel helpless. She said she never saw who was verbally abusing the resident, just heard it. She said it happened on the 6am-2pm and 2pm-10pm shift. She said she knew she was supposed to report abuse allegation but felt it was pointless because nothing happened to the person. She said not reporting abuse risked the abuse to keep happening. She said the verbal abuse made the residents defensive and not ask for help from staff. During an interview on 02/14/24 at 4:15 p.m., CNA B said she had been employed at the facility for a year. She said she normally worked the 2pm-10pm shift. She said she had recently received abuse training. She said she did not abuse any residents or was rough with cares. She said she did not have any issues with any of the residents. She said she did not have any issues with Resident #3, but she did try to take another person with her when she dealt with him. During an interview on 02/15/24 at 10:30 a.m., CNA J said she had been working for the facility since June 2022 but had previously worked at the facility for 4 years. She said she worked all shifts at the facility. She said she worked the middle hall (Rooms 201-216) and sometimes the B long hall (room [ROOM NUMBER]-228). She said several residents had complained about CNA B to her. She said Resident #3, Resident #5, Resident #7, and AR had complained about how CNA B talked to and treated them. She said she had reported the complaints, in the last 1-2 months, to the DON. She said CNA B's treatment of the residents made them feel like she did not like them. She said another resident told her CNA B cussed out Resident #3 and LVN G was there. She said when CNA B treats Resident #3 bad, he always said, I'm not putting with this sh**! During an interview on 02/15/24 at 11:22 a.m., CNA F said she had worked at the facility for 10 years on the 6am-2pm shift. She said she normally worked B long hall which were rooms 216-228. She said verbal and mental abuse was happening at the facility by CNA B. She said Resident #5 told her CNA B was too rough during cares and he was afraid of her. She said Resident #5 always asked the 6a-2pm shift to put him back to bed before they left because he did not want CNA B doing it. She said another resident reported to her CNA B was rough, talked harsh, and made them go to bed when she wanted them to. She said Resident #3 told her CNA B cussed at him and was ugly to him. She said she had reported the resident's complaint to LVN G, and she said CNA B treatment to resident had been reported. She said the residents being abused probably felt sad, disgusted, or isolated themselves. She said she had abuse training and knew the ADM was the abuse coordinator. During an interview on 02/15/24 at 1:20 p.m., the DON said she had known CNA B for a while and sometimes her tone was taken the wrong way. She said sometimes CNA B's tone and demeanor was aggressive. She said CNA B's aggressive tone or demeanor was not directed at the residents. She said it was just how CNA B was. She said staff had not recently told her of any residents complaining about CNA B's care or demeanor. She said recently Resident #3 told her CNA B and him had verbally got into, but he had called her a bit**. She said no formal disciplinary actions or report had been done on CNA B. She said she did not know if a safe survey had been done recently because the SW did those. She said staff should first report abuse allegations to the ADM and then her (DON). She said staff should report abuse allegation to the ADM or DON, immediately. During an interview on 02/15/24 at 2:09 p.m., the ADM said he was the abuse coordinator. He said CNA B had employee disciplinary reports on file. He said CNA B had been monitored due to the previous abuse allegations by doing rounds. He said he expected staff to immediately notify him of any allegation of abuse. He said staff were told in orientation and in-serviced on the abuse policy. He said residents were educated on reporting abuse allegations in resident council meetings and he had an open-door policy. He said he had communicated with staff and resident that retaliation would not occur if they reported allegations of abuse. CNA B's employee disciplinary reports were requested during the interview and not received before exit. CNA B's employee disciplinary reports were received 6 days after exit. During an interview on 02/15/24 at 2:26 p.m. the SW said she was responsible for documenting resident's grievances on the grievance/complaint log and report. She said the grievance then went to department heads the complaint was related to. She said she did not remember receiving a complaint/grievance about abuse from a resident. She said she had received a complaint from Resident #4, but it was a CNA but not CNA B. During an interview on 02/15/24 at 2:30 p.m., the ADM said CNA B had been mentioned in February 2024 grievances by Resident #4. He said he had not given February's grievance report when requested at entrance because he was still investigating the allegations. During an interview on 02/23/24 at 3:26 p.m., the ADM said typically Social Services wrote up any grievance or complaints and brought them to him to be resolved. He said he then went to the appropriate department heads for resolution. He said he was working through the grievances and there were 3 - 4 that had not been resolved at the time of the initial complaint investigation. He said it had only been 2 - 3 days since he had received the grievances when the initially investigation started on 02/14/24. Record review of CNA B's proficiency dated 04/11/23 indicated .knowledge of abuse/neglect protocol .satisfactory .communication skills (respect/dignity) .satisfactory . Record review of CNA B's employee disciplinary report dated 02/02/04, indicated .CNA B .verbal counseling .Resident #3 complained that CNA B talked to him disrespectfully while attempting to provide care .reminded CNA B that this was the 2nd complaint regarding her tone with Resident #3 .another complaint would result in her suspension and/or termination .CNA B reported that she was only trying to get Resident #3 to get up and take a shower .Resident #3 needed to be cleaned up and was refusing .signature of supervisor presenting EDR:ADM .employee refused to sign .ADM (supervisor initial) .to be retained in employee's personnel file . The employee disciplinary report did not reveal CNA B's signature or date received and a witness initials of CNA B's refusal to sign. Record review of the facility's 12/23 staff sign in sheet indicated CNA B worked 24 days, 2pm-10pm shift on the hall where Resident #3, Resident #5, and Resident #7 resided. Record review of a facility's Be mindful of your tone and how you say things to and around the residents[TRUNCATED]

Based on interview and record review, the facility failed to ensure all alleged violations involving mistreatment, neglect, abuse, or misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation is made, if the event that cause the allegation involved abuse to the administrator of the facility and to other officials (including to the State Agency) for 2 of 7 residents (Resident #3 and Resident #4) and 6 of 9 staff members (ADM, CNA E, CNA J, CNA F, LVN G, and AE #1) reviewed for reporting of abuse, neglect and mistreatment. The facility failed to ensure when Resident #3 filed a complaint/grievance on 02/09/24 indicating CNA B treated him like trash, it was reported to HHSC within 2 hours of allegation by the facility's ADM/ Abuse Preventionist. The facility ADM/ Abuse Preventionist had not reported alleged allegations of abuse by CNA B . The facility failed to ensure when Resident #4 filed a complaint/grievance on 02/09/24 indicating CNA B was mean and he had overhead a CNA being ugly to another resident it was reported to HHSC within 2 hours of allegation by the facility's ADM/ Abuse Preventionist. The facility ADM/ Abuse Preventionist had not reported alleged allegations of abuse by CNA B . The facility failed to ensure CNA E reported to the ADM when she heard staff verbally abusing residents. CNA E did not report verbal abuse because it was pointless because nothing would happen. The facility failed to ensure CNA J reported to the ADM when she received multiple complaints of abuse and mistreatment from CNA B. The facility failed to ensure CNA F reported to the ADM when she received multiple complaints of abuse from CNA B. CNA F only informed LVN G of the allegations of abuse and mistreatment from CNA B. LVN G informed CNA F, CNA B's mistreatment to the residents had been reported. The facility failed to ensure LVN G reported to the ADM when CNA F reported allegations of abuse and mistreatment from CNA B. The facility failed to ensure AE #1 reported to the ADM when she received complaints of abuse and witnessed verbal/mental abuse from CNA B. An Immediate Jeopardy (IJ) situation was identified on 02/23/24 at 3:10 p.m. while the IJ was removed on 02/24/24 at 3:45 p.m., the facility remained out of compliance at a potential for actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for continued alleged violations, diminished quality of life and harm. Findings included: Record review of the facility's Grievance/Complaint log dated 02/24 indicated .02/09/24 .Resident: Resident #3 .Person filing report: Resident #3, Date of Incident: 2/9/24 .Person Investigating: ADM .Date Resident/Family Informed of Findings: 2/9/24 .Disposition of Complaint: CNA treat him like trash . Record review of the facility's Grievance/Complaint log dated 02/24 indicated .02/09/24 Resident: Resident#4 .Person filing report: Resident #4 .Date of Incident: 2/9/24 . Person Investigating: ADM .Date Resident/Family Informed of Findings: 2/9/24 .Disposition of Complaint: CNA 's mean . During an interview on 02/14/24 at 11:22 a.m., AE #1 said CNA B was mean and aggressive with cares. AE #1 said she/he reported the resident [AR] complaint about CNA B's treatment to a nurse, not the ADM, and the nurse said CNA B was being investigated. AE #1 said she/he did not want to disclose the nurse's name. AE #1 said she/he did not report the incident to the ADM because she/he was told it was being investigated. During an interview on 02/14/24 at 4:07 p.m., LVN G said she had never been told by a resident or staff CNA B was rough or rude to residents. She said she did not hear CNA B say cuss words to Resident #3. She said she knew to report abuse and neglect to DON or ADM immediately. During an interview on 02/14/24 at 4:14 p.m., CNA E said she had heard residents being yelled at or staff refusing the resident care which she considered verbal abuse. She said she knew she was supposed to report abuse allegations but felt it was pointless because nothing happened to the person. She said not reporting abuse risked the abuse to keep happening. During an interview on 02/15/24 at 10:30 a.m., CNA J said several residents had complained about CNA B to her. She said she had reported the complaints, in the last 1-2 months, to the DON, not the ADM. During an interview on 02/15/24 at 11:22 a.m., CNA F said verbal and mental abuse was happening at the facility by CNA B. She said another resident reported to her CNA B was rough, talked harsh, and made them go to bed when she wanted them to. She said she had reported the resident's complaint to LVN G but not the DON or ADM, and she said CNA B's treatment to residents had been reported. She said which was why she did not report the complaints to the DON and ADM. She said she had abuse training and knew the ADM was the abuse coordinator. Unable to interview AE #1 due to AE #1 calling from an undisclosed phone number. During an interview on 02/15/24 at 1:20 p.m., the DON said staff had not recently told her of any residents complaining about CNA B's care or demeanor. She said staff should first report abuse allegations to the ADM and then her (DON). She said staff should report abuse allegations to the ADM or DON, immediately. During an interview on 02/15/24 at 2:09 p.m., the ADM said he was the abuse coordinator. He said he expected staff to immediately notify him of any allegation of abuse. He said abuse allegation had been reported to him a couple months ago in November or December 2023. He said he did not recall the resident and staff involved in the allegation, but he had made a self-report. He said CNA B had been verbally counseled a few times regarding how she spoke to residents. He said CNA B had been accused of abuse during full book survey in June 2023. He said he did not know the results of investigation but if CNA B was guilty, she would not still be working at the facility. He said CNA B had employee disciplinary reports on file. He said CNA B had been monitored due to the previous abuse allegations by doing rounds. He said staff were told in orientation and in-serviced on the abuse policy. During an interview on 02/23/24 at 2:50 p.m., LVN G said the abuse coordinator was the ADM. She said any abuse of any kind should be reported to him immediately. She said any staff could get in trouble for not reporting abuse to the Abuse Coordinator. She said not reporting abuse could hurt a resident. During an interview on 02/23/24 at 2:57 p.m., CNA F said the DON was the Abuse Coordinator. She said if she saw anything wrong, she would tell the whole thing. She said, We are there to take care of them. She said she would report any abuse immediately. During an interview on 02/23/24 at 3:17 p.m., CNA E said the ADM was the Abuse Coordinator. She said she would report any kind of abuse to him. This included verbal abuse, financial abuse, physical abuse, and sexual abuse. She said any abuse should be reported immediately. She said not reporting abuse could cause residents to have mood changes and/or depression. During an interview on 02/23/24 at 3:26 p.m., the ADM said typically Social Services wrote up any grievance or complaints and brought them to him to be resolved. He said he then went to the appropriate department heads for resolution. He said he was working through the grievances and there were 3 - 4 that had not been resolved at the time of the initial complaint investigation. He said it had only been 2 - 3 days since he had received them. During an interview on 02/23/24 at 3:40 p.m., CNA J said the ADM and DON were the Abuse Coordinators. She said she would report any form of abuse. She said abuse could be physical, financial, sexual, or verbal. She said she would report anything concerning that was going on with the resident. She said not reporting abuse puts the residents in danger and would make her as bad at the one giving the abuse. Record review of a facility's Abuse, Neglect, and reportable events in-service dated 01/30/24 indicated .it is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect . LVN G, CNA E, and CNA F's signatures were noted on the attendance roster. CNA J's signature was not noted on the attendance roster. Record review of a facility's Abuse/Reportable Events policy dated 01/17 indicated .all resident have the right to be free from abuse, neglect . it is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect . facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents .to the facility administrator .the facility administrator or designee will report the allegation to HHSC .if allegations involve abuse or result in serious bodily injury, the report is the be made within 2 hours of the allegation . This was determined to be an Immediate Jeopardy (IJ) on 02/23/24 at 3:10 p.m. The facility Administrator, and DON were notified. The Administrator was provided with the IJ template on 02/23/24 at 3:10 p.m. 2/24/2024 Plan of Removal - F 609 Immediate Action Taken Resident Specific Allegations of verbal abuse brought to the Administrator on 2/15/2024 at 3:30pm. Allegations of verbal abuse reported to HHSC by the Administrator on 2/15/2024 at 4:00pm. CNA B was suspending pending investigation on 2/15/2024 at 3:30pm. CNA B was terminated on 2/21/2024 at 2:21pm. CNA B did not work in the facility after allegations of verbal abuse were brought to the Administrator, by the HHSC surveyor on 2/15/2024. Residents #3, #5, and #7 were interviewed by the Administrator on 2/15/2024. Residents #3, #5, and #7's Responsible Parties notified of the verbal abuse allegation on 2/15/2024. Residents #3, #5, and #7 had head to toe assessments performed by the Treatment Nurse on 2/15/2024. MD notified of the IJ on 2/23/2024 at 4:48pm by Administrator, no new orders received. CNA E, CNA J, CNA F, and LVN G were given 1:1 in-service regarding abuse reporting - who to report to and when to report, on 2/24/2024 by Director of Nursing. CNA E, CNA J, CNA F, and LVN G were given documented verbal disciplinary action for failing to follow the facility's abuse policy, on 2/24/2024 by Administrator. System Changes All interviewable residents were interviewed by Administrator regarding abuse, safety, who to report concerns to, and complaint resolution on 2/23/2024. All non-interviewable residents received a head-to-toe skin assessment, to assess for any injuries or evidence of abuse, by Charge Nurses, Director of Nursing and Treatment Nurse on 2/23/2024. All residents in the facility received head to toe skin assessments, to assess for any injuries or evidence of abuse, by Charge Nurses, Director of Nursing and Treatment Nurse on 2/23/2024. All resident care plans revised to include being at risk for mental/emotional distress on 2/23/2024 by Regional Reimbursement Consultant. Abuse/Reportable Event policy reviewed on 2/23/2024 at 5:15pm by Administrator, Regional Nurse, and Director of Nursing. No changes made to policy at this time. Education Director of Nursing provided education to all staff regarding signs and symptoms of abuse, and who/when to report it on 2/23/2024, at 6pm. Staff not present for the education will receive the education prior to their next shift. Director of Nursing provided education to all staff regarding the Abuse/Reportable Event Policy, including types of abuse, definition of verbal and mental abuse, reporting requirements. All staff present in the facility were educated on2/23/2024, at 6pm. Staff not present for the education will receive the education prior to their next shift. Director of Nursing provided education to all staff regarding the Grievance Policy, including how to file a grievance, timely resolution, and that residents are able to voice grievances without fear of reprisal or discrimination. All staff present in the facility were educated on2/23/2024, at 6pm. Staff not present for the education will receive the education prior to their next shift. Director of Nursing provided education to all staff regarding Examples of Mental/Verbal Abuse, how to report those allegations, and that retaliation should never occur. All staff present in the facility were educated on 2/24/2024, at 11:30am. Staff not present for the education will receive the education prior to their next shift. Regional Clinical Consultant provided education to Administrator and Director of Nursing regarding the Abuse/Reportable Event Policy including types of abuse, definition of verbal and mental abuse, and reporting requirements to HHSC, on 2/23/2024 at 5:45pm. Regional Clinical Consultant provided education to Administrator and Director of Nursing regarding the Grievance Policy including how to file a grievance, their responsibility to investigate, assess and resolve, timely resolution of the grievance, and that residents are able to voice grievances without fear of reprisal or discrimination on 2/23/2024 at 5:45pm. On 02/24/24 a surveyor confirmed the facility implemented there plan of removal sufficiently to remove the IJ by: Record review of CNA B's termination letter. CNA B was suspended immediately and was officially terminated by telephone on 02/21/24. Record review of an Abuse Pre/Post test. The administrator said this was the test used for educational purposes concerning the staff. The test consisted of 20 questions covering the different types of abuse and reporting of allegations. There was a situation question at the end of the test. Record review of an In-Service Form indicated an in-service for the Administrator and the DON was held on 02/23/24. The in-service was presented by the Regional Clinical Consultant. The topic was the Grievance - Voicing and Resolution facility policy. The policy included how to file a grievance and promptly attempting to resolve grievances. Record review of an In-Service Form indicated an in-service for the Administrator and the DON was held on 02/23/24. The in-service was presented by the Regional Clinical Consultant The topic was Abuse/Neglect and reportable events. The In-service included definitions of abuse, screening of personnel, training of personnel, prevention of abuse, identification of abuse, reporting, and protection of the residents. Record review of an In-Service Form indicated an in-service for all staff was held on 02/23/24. The in-service was presented by the DON. The topic was the Grievance - Voicing and Resolution facility policy. The policy included how to file a grievance and promptly attempting to resolve grievances. Record review of an In-Service Form indicated an in-service for all staff was held on 02/23/24. The in-service was presented by the DON. The topic was Abuse/Neglect and reportable events. The In-service included definitions of abuse, screening of personnel, training of personnel, prevention of abuse, identification of abuse, reporting, and protection of the residents. Record review of Employee Disciplinary Reports for CNA E, CNA F, LVN G, and CNA J dated 02/24/24 indicated they received verbal counseling for failing to report an allegation of abuse/neglect to the Abuse Coordinator. The report indicated the employees were re-educated on the abuse/reportable events policy/procedure. Each employee had signed their report. During interviews and observations conducted on 2/24/24 beginning at 1:30 p.m. through 2:00 p.m., 12 of 51 residents were observed and they showed no signs of untimely care and there were no signs of abuse. Out of the 12 residents observed, 7 were interviewable. Each said they had been educated in the last 24 hours concerning abuse and who to report any abuse to. Each of the 7 residents denied abuse of any kind. The also said they had been assessed by a nurse. (Residents interviewed and observed were Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #14) (Non-interviewable observed were Resident #15, Resident #16, Resident #17, Resident #18, and Resident #19). Record review of the observed residents indicated each had been assessed by a nurse. There were skin assessments dated 2/23/24 for each of the 12 residents. Each of the 12 residents' care plan had been revised to include being at risk for mental/emotional distress on 2/23/2024. During interviews conducted on 02/24/24 beginning at 2:00 p.m. through 3:38 p.m., 19 of 33 of all staff in-serviced (including staff across all shifts that were the Administrator, the DON, the Treatment Nurse, CNAs, LVNs, RNs, Dietary Manager, Medical Records/Housekeeping Supervisor, and Activity Director) were interviewed. All staff said they received education on signs and symptoms of abuse, who and when to report abuse, types of abuse, reporting requirements, how to file a grievance, timely resolution, and resident being able to voice grievances without fear of reprisal or discrimination. The Treatment nurse said she had assisted in completing the head-to-toe assessments and skin assessments of each resident on 02/23/24. CNA E, CNA F, LVN G and CNA J said they had received verbal counseling on reporting abuse to the abuse coordinator immediately if they became aware of any abuse. During an interview on 2/24/24 at 3:27 p.m., the DON said she conducted the initial in-service on 02/23/24 and another on the morning of 02/24/24. She said she planned to in-service every shift as they come on duty, until ever staff member was in-serviced. She said she had in-serviced not just nursing staff but all staff in the facility. She said in-services were about the grievance policy, the abuse and neglect policy, reporting of abuse, and signs and symptoms of abuse. The DON said she was by the Regional Nurse Consultant. She said she was in-serviced on the different types of abuse and reporting abuse. She said the Administrator was the Abuse Coordinator. The DON said she was in-serviced on grievance and following up on them. She said grievances should be followed up on immediately and at least within 24 hours. She said all abuse should be report immediately. During an interview on 2/24/24 at 3:34 p.m., Regional Clinical Consultant said she in-serviced the Administrator and DON on the evening of 2/23/24. She said she in-serviced them on abuse and the reporting abuse. She said she in-serviced them on reporting abuse immediately. She said she in-serviced them on grievances being taken very seriously and following up on them immediately. She said they focused on verbal abuse and mental abuse but did discuss all types of abuse including physical, financial, and sexual abuse. They also discussed neglect. During an interview on 2/24/24 at 3:38 p.m., the Administrator said he was in-serviced the evening of 2/23/24 by Regional Nurse Consultant. He was in-serviced on abuse policy, grievance policy and reporting abuse. He said they went through the whole thing the different types of abuse, reporting of abuse, and following up timely on grievances. The Administrator was informed the Immediate jeopardy was removed on 02/24/24 at 3:45 p.m. the facility remained out of compliance at a severity level of potential harm with a scope of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one of five residents (Resident #38) reviewed for accidents and hazards in that: 1. The facility failed to ensure Resident #38 did not elope after he was identified to be of high risk for elopement. Resident #38 eloped on 06/09/23 through his window. 2. The facility failed to put alarms on all unit windows after the elopement as indicated in the PIR. 3 windows were missing alarms. 2 of 3 windows had screws to keep them permanently closed. 3. The facility failed to establish a system to monitor alarms. 4. The facility failed to have sufficient staff to safely monitor residents on the secured unit. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 07/10/23 at 03:59 PM. While the IJ was removed on 07/11/23 at 2:59 PM, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place the residents at risk for harm, serious injury, or death. Findings included: Record review of Resident #38's undated face sheet indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. He had diagnoses that included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #38's admission MDS, dated [DATE], indicated he had a BIMS score of 05, which indicated severe cognitive impairment. Resident #38 was independent in bed mobility and transfers. He required supervision assistance for walking and locomotion on unit, dressing, toileting, eating, and personal hygiene. He received antipsychotics, antidepressants, and anticoagulants 7 of 7 days of the assessment window. Record review of Resident #38's physician's orders, dated 07/11/23, indicated he had this order: *Admit to secured unit related to wandering / elopement risk. The start date was 05/15/23. Record review of Resident #38's care plan, with a review date of 06/09/23, indicated a focus of elopement risk as evidenced by elopement on 06/09/23. The interventions included staff will monitor resident's location frequently and to monitor and record behavior when it occurs. Record review of Resident #38's progress notes, dated 06/09/23 through 06/30/23, indicated Resident #38 eloped on 06/09/23, and was later found 25-30 minutes later down the street. The progress notes further indicated that on 06/17/23 the alarm in Resident #38's room had been removed from the window and was reapplied by facility staff. Record review of Resident #38's elopement/wandering observation, dated 05/16/23, indicated he was a high risk for wandering. The assessment further indicated that Resident #38 had a history of elopement, exhibited wandering behavior, has shown exit seeking behavior, is likely to follow someone through a facility exit, and resident was physically able to exit on foot or by wheelchair. Record review of Resident #38's elopement/wandering observation, dated 06/09/23, indicated he was a high risk for wandering. The assessment further indicated that Resident #38 had a history of elopement, exhibited wandering behavior, had shown exit seeking behavior, is likely to follow someone through a facility exit, had verbalized the need and/or desire to go home or to another location and had the ability to act on that verbalization, and resident was physically able to exit on foot or by wheelchair. Record review of Resident #38's elopement incident report, dated 06/09/23, indicated he was found at 10:05 AM on 06/09/23. Record review of the Provider Investigation Report, dated 06/15/23, indicated Resident #38 was noted missing from the facility on 06/09/23 at approximately 9:30 AM. Facility staff searched the facility and were unable to locate him internally. The facility expanded their search outside and Resident #38 was found at an EZ Mart gas station down the street. The report indicated that the facility staff estimated Resident #38 was out of the facility for an estimated 20-25 minutes. The PIR indicated the facility had taken action by placing alarms on all occupied resident room windows. Record review of Resident #38's vital signs after his elopement indicated his vital signs were taken on 06/09/23 at 10:24AM and his blood pressure was 125/81 and his pulse was 99 beats per minute. No temperature reading was found. No respiration reading was found. During an observation and interview on 07/10/23 at 10:57 AM, Resident #38 was observed walking out of his room [ROOM NUMBER] in the secured unit. He was independently able to open and close his bedroom door and ambulate throughout the unit. He said he remembered leaving the unit and said he was trying to go visit his mom and dad. During an observation on 07/10/23 at 10:59 AM, room [ROOM NUMBER], at the end of the unit, was observed with the door open. Residents wandering in the unit had open access to this room. The window alarm for the window in this room was not attached to the window and was laying in the windowsill. This surveyor was able to open the window fully and the alarm did not make any noise. During an observation and interview on 07/10/23 at 11:06 AM, CNA E said she was not working the day Resident #38 eloped. She said she was familiar with him and she monitors him if he started fidgeting or exit seeking. She said she tries to keep him occupied. She took this surveyor into Resident #38's room ( room [ROOM NUMBER]) and the window had a screw in the frame so it could not be opened. It did not have an alarm attached. During an interview on 07/10/23 at 11:14 AM, RN F said she was taking care of Resident #38 that day. She said she was not working the day he eloped. She said when he starts exit seeking, she attempts to distract him by talking to him or having him call his daughter. During an interview on 07/10/23 at 11:18 AM, the Social Worker said she was in her office on the day Resident #38 eloped when she noticed staff were looking for him so she went outside to help. She said she was unable to find him in the facility so she jumped into her car to assist looking for him. She had looked around the neighborhood and they had already found him when she came back to the facility. She said the staff gave him water and assessed him. She said it was warm outside, and he had a sweater on. She said he looked tired and hot. She said she did not talk to him directly. She said the Marketing, business office, and medical records staff found Resident #38 and brought him back. During an interview on 07/10/23 at 11:30AM, CNA G said she was the CNA that noticed Resident #38 was not in his room. She said she was not assigned to the unit that day. She said she was weighing residents around the facility that day. She said she was trying to go get Resident #38 to weigh him and was unable to locate him in his room. She said she told the nurse Resident #38 was not in his room or in the unit. She said she then left the unit to weigh another resident. After this she came back to the unit to assist the nurse in finding Resident #38. She said her and the nurse looked around the unit and then notified the DON. Then the facility staff searched the facility for Resident #38 and were unable to locate him. She said they eventually found him near a busy roadway at a gas station about 0.8 miles away from the facility. She said he was gone from the facility about an hour. She said when he returned he was wearing a sweater and he was hot and sweaty. She said he eloped from the unit through the window in his room. She said this was the first time that she recalls Resident #38 eloping from the facility. She said there was only typically one staff member assigned to the unit. She said there was only a nurse assigned to the unit on the day Resident #38 eloped. She said the Marketing Director brought Resident #38 back to the facility. She said the facility put window alarms in place to keep the unit residents from eloping and Resident #38 likes to take the alarms off the windows. During an observation on 07/10/23 at 11:47AM, the Super Bingo and the EZ Mart were both located off of N [NAME] Road, approximately 0.6 to 0.8 miles from the facility. The speed limit was 35 miles per hour. It was a busy 4 lane street. The EZ mart was on the opposite side of the street and Resident #38 would have crossed the street to reach the EZ mart. During an interview on 07/10/23 at 12:05PM, LVN D said she was assigned to the unit the day Resident #38 eloped. She said she was in the middle of medication pass. She said she was giving the resident next door to Resident #38 and noticed Resident #38 had walked down the hallway and entered his room. She said a CNA came to get Resident #38's weight and said he was not in his room. She said she immediately stopped medication pass and searched for Resident #38. She said she could not find him in the dining area and the MDS coordinator came to help. She said had not heard any alarms. She said her and the MDS coordinator searched all over the unit. She said she noticed the screen in Resident #38's room window appeared to be bent. She said she was unable to open the window. She then notified the DON and they searched all over the facility. She said eventually other facility staff found Resident #38 offsite. She assessed him and he was hot and sweaty. She said he was found first at the EZ Mart and then they finally picked him up at the Super Bingo hall. She said she obtained his vitals and he had a sweat shirt on and long pants. She said they got him some ice water because he was tired and sweaty. She said it was hot outside. She said Resident #38 had no bruises or injuries. She said Resident #38 told the staff he wanted to go walking. She said He has not eloped at this facility but he has eloped before at another facility before he came to this one. She said they put alarms on the windows to ensure the residents do not escape through the windows. She said she checks the windows at least once a shift, but she was not told by administration how often she should check them. She said she works back in the unit by herself most of the time. She said she has only had another staff member assigned with her about 5-6 times since she started working there in February of 2023. She said she does her nursing duties as well as the CNA duties when she was the only staff assigned to the unit. She said she performed incontinent care when she was back there alone. She said she tries to do as many baths as possible and will notify the next shift when she was not able to complete all the baths. She said there were typically around 9 residents back in the unit. She said she saw Resident #38 about 10 mins before anyone noticed he was missing. During an interview on 07/10/23 at 12:21PM, the Marketing Director said she went out front to help the Social Worker look for Resident #38. After they searched the facility she and the Business Office Manager jumped into her car to look for Resident #38. She said they found him at a bingo hall near a busy roadway. She said Resident #38 was leaning against the telephone pole. He was hot and sweaty and was wearing a sweater. They got him into the car and brought him back to the building and got him some water. They handed him back to the nurse assigned to the unit that day. During an interview on 07/10/23 at 12:25PM, the Business Office Manager said the DON asked her if she saw Resident #38. She said the staff looked all over the facility for the resident. She said she and the Marketing Director went out the side door to make sure he was not out in the patio. She said they hopped in the Marketing Director's vehicle to look for Resident #38. She said they travelled down a busy roadway and found him near the bingo hall. She said she got out of the vehicle and talked to Resident #38 and he said he was walking. They got him back in the vehicle to take him back to the facility. She said he was wearing a sweater, hat and long pants. She said he was hot and sweaty. They got him back to the facility and used cool rags to cool him off. She said she notified Resident #38's daughter. She said she left him with the nursing staff. She said it was warm outside that day. During an interview on 07/10/23 at 12:30PM, the Maintenance Supervisor said after Resident #38 eloped they put a screw in Resident #38's room window and the window next door to his room to make the window stay closed. He said he put alarms on all windows in the unit and made sure the alarms on the unit doors were functioning properly. He said he tries to check the window alarms in the unit at least 3 times a week. He said he will also go check on them if he was notified by the CNAs in the unit. He said he did not keep any log or documentation of him checking the alarms. During an interview on 07/10/23 at 12:36PM, CNA E said she checks the alarms as often as possible. She said she was not told by administration how often to check the alarms. She said she did not keep a log of when she has checked the alarms. During an interview on 07/10/23 at 12:37PM, RN F said she does not routinely check the alarms. She said she did not keep a log of when they were checked. She said she thought the maintenance director was responsible for checking the alarms routinely. During an observation on 07/10/23 at 2:15PM, the middle window in the secured unit dining room had no alarm attached to the window. There were residents in the room and they had free access to it. There was a screw in the frame of the window that was supposed to keep it from opening. During an observation on 07/10/23 at 2:20PM, Resident #38's room [ROOM NUMBER] had no alarm attached to the window. The screw was still in place on the window frame. During an observation on 07/10/23 at 2:30PM, room [ROOM NUMBER] alarm was still in the windowsill, not attached to the window. This surveyor was able to lift the window open and then close it back. During an interview on 07/11/23 at 9:45AM, the DON said the facility does not have a policy that addresses supervision of residents. She said they do not have a policy that addresses alarms or monitoring of alarms. During an interview on 07/11/23 at 02:50PM, Resident #38's Responsible Party said she was not surprised when the facility notified her that Resident #38 had eloped. She said he had eloped before he came to this facility. During an interview on 07/12/23 at 1:12PM, the ADON said she did not work in this facility when Resident #38 eloped. She said she started working in this facility on 06/20/23. The incident occurred on 06/09/23. She said she was not aware of anyone being assigned to check the alarms routinely before surveyor intervention this week. She said before surveyor intervention this week, they tried to have two staff members assigned to the unit during the day, and only one staff nurse assigned from 10pm-6am. She said she does not think one staff member assigned in the unit was enough staff to properly monitor all the unit residents and keep them from eloping. She said the one staff member would not be able to get their work done, or even leave the unit to go to the bathroom. During an interview on 07/12/23 at 02:01PM, the DON said after Resident #38 eloped they installed window alarms on occupied rooms and the room next to him. She said they did not put a procedure in place to monitor the alarms. She said the staff would report the alarms missing whenever they saw it. She said they did in-services about the alarms. there were 1 -2 staff members assigned to the unit at times, there was not a specific set schedule of how many people should have been back there at a time. She said she did not have enough staff to assign more staff to the unit. She said there was an average of eight residents back in the unit at a time. She said they did not increase staff immediately after the elopement. She said on 07/05/23 they increased staffing to 2 staff assigned to the unit all the time except for 10PM to 6AM. she said they finally had enough staff then to be able to permanently assign more staff back in the unit. She said she did not feel like one nurse would be able to adequately monitor the residents in the unit while passing medications. She said the nurse that was assigned to the unit was primarily responsible for ensuring the residents did not elope. She said it was ultimately all staff's responsibility to prevent residents from eloping. She said there was risk to all residents if they eloped for serious injury, serious harm, or death. During an interview on 07/12/23 at 2:20PM, the ADON said if a resident eloped like Resident #38 did there was a potential for serious injury, serious harm, or death. During an observation on 07/12/23 at 2:44PM, the Administrator said after Resident #38 eloped, they put window alarms on all occupied rooms in the unit. He said they increased rounding and supervision of Resident #38. He said they reported the elopement to the state, notified his family and the doctor. He said the MD director was notified. He said the nurse took an assessment of Resident #38 and they gave him water and made sure he did not suffer heat exhaustion. He said the Administrator, Maintenance and all other staff were responsible for ensuring that the alarms were in place. He said that the Administrator and the other management were constantly replacing window alarms in the unit. He said they did not document that they were checking alarms. He said he was in the unit daily along with maintenance and other staff assigned to the unit, and they were checking the alarms. He said there was no documentation that logged the staff checking the alarms. He did not know without checking the schedule if there was only one staff assigned to the unit at a time before 07/05/23. He said on 7/05/23 they changed the staffing to ensure that 2 staff members were assigned to the unit all the time except for 10pm to 6am. He said after surveyor intervention on 07/10/23 the staffing was changed to ensure 2 staff were assigned to the unit at all times. He said he expected one nurse to be able to take care of 8 residents in the unit while passing meds. He said he expected the nurse to be able to keep the 8 residents from eloping. He said that all staff were responsible for ensuring that the residents do not elope, but the nurse was assigned to take care of the residents in the unit that day. He said a resident that eloped like Resident #38 was at risk for heat stroke, heat exhaustion, a possible vehicle accident, fall, serious harm, serious injury, or death. The Administrator was notified of an IJ on 07/10/23 at 3:59PM and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 07/11/23 at 9:45AM and included the following: 7/11/2023 Plan of Removal - F 689 Immediate Action Taken Resident Specific * Resident #38 was located by Business Office Manager and Marketer on 6/9/2023 at 10:02am and returned to the facility. * Resident #38 assessed by licensed nurse on 6/9/2023 at 10:15am. Findings documented in Matrix. No injuries or adverse effect noted. * Elopement Risk Assessment for Resident #38 completed on 6/9/2023 at 11:13am by RN. * Elopement Risk Careplan for Resident #38 updated on 6/9/2023 at 11:30am by RN. * NP notified of elopement on 6/9/2023 at 10:15am by LVN. No new orders received. * Responsible party notified of elopement on 6/9/2023 at 10:15am by LVN. No concerns voiced. * MD notified of the IJ on 7/10/2023 at 4:45pm by Director of Nursing, no new orders received. * Resident #38 remains in the Secured Unit and has had no further elopement attempts. System Changes * Elopement Risk Assessments completed for all residents in the facility on 6/9/2023 at 1:40pm by DON and RN. * Window alarms placed on windows of all occupied rooms on 6/9/2023 at 12:30pm. * Window alarms placed on all secured unit windows on 7/10/23 at 4:45pm. * Staff increased in Secured Unit to 1 Licensed Nurse and 1 Nurse Aide, from 6am to 10pm on 7/5/23. * Staff increased in Secured Unit to 1 Licensed Nurse and 1 Nurse Aide, 24 hours a day on 7/10/2023. * Secured Unit rounds established on 7/10/2023 at 6:00pm. This is to monitor that all windows have alarms, alarms are functioning properly, and all residents are in place. * All windows in the Secured Unit secured and raise a minimum of 4 inches, as of 7/11/23 at 6:30am. * Elopement policy reviewed on 6/9/23 at 11:30am by Administrator, Regional Nurse, and Director of Nursing. No changes made to policy at this time. Education * Director of Nursing provided education to all staff regarding the Elopement Policy. All staff present in the facility were educated on 7/10/2023, at 5pm. Staff not present for the education will receive the education prior to their next shift. * Director of Nursing provided education to nursing staff regarding the Secured Unit Rounds to ensure residents are in place, alarms are on windows, and alarms are functioning properly. All nursing staff present in the facility were educated on 7/10/2023, at 5pm. Staff not present for the education will receive the education prior to their next shift. * Director of Nursing provided education to nursing staff regarding the Secured Unit staffing pattern - 2 staff members on all shifts. All nursing staff present in the facility were educated on 7/11/2023, at 8:30am. Staff not present for the education will receive the education prior to their next shift. Monitoring * Administrator/designee to review Secured Unit rounds 5x/week to ensure compliance. The surveyor verification of the Plan of Removal from 07/11/23 was as follows: During an observation on 07/11/23 at 7:56AM room [ROOM NUMBER] has an alarm on the window and the screw was removed. Resident #38's room [ROOM NUMBER] had an alarm on the window and the screw was removed. During an observation on 07/11/23 at 7:59AM, all three unit dining room windows had alarms and the screw in the middle window was removed. During an observation on 07/11/23 at 08:05AM, two staff members were assigned and working in the unit. During an observation on 07/11/23 at 10:54AM, it was observed that all windows in the unit had alarms installed and they were turned on. During interviews conducted from 07/11/23 11:52AM through 3:20PM, 21 of 38 staff (15 from day shift, and 6 from night shift and including CNAs, LVNs, and RNs) were interviewed. All staff said they received education on elopement, rounding on the unit and checking alarms every two hours, and that there will be two staff assigned to the unit at all times. Record review of in-service training, dated 06/09/23, after the elopement, indicated training related to window alarms in the secured unit was provided to facility staff. The training stated: .Residents on the unit will have window alarms on their windows, please ensure the alarm is on and functioning, if you find one that does not work, please contact Admin/DON/maintenance director. If you hear any alarms going off, you are to respond immediately. The Weather Underground website, accessed on 07/13/23 at 10:59AM, indicated that the temperature in the city of Texarkana was 82 degrees Fahrenheit on 06/09/23 at 9:53AM. The wind speed was 5 miles per hour with 0 miles per hour wind gusts. There was 0.0 inches of precipitation and the condition was fair. The humidity was 67%. Record review of facility's policy titled Elopement, effective December 2017, stated: It is the policy of this home to provide a systematic approach to searching for a resident who may have left the home and/or home grounds. Procedure The following steps are to be followed when a resident is noted absent and is not found on initial search of the home. This also includes when a resident leaves the home grounds without staff notification. Home staff will: *Search the home and grounds *Send staff member(s) out to locate the resident *Notify Administrator or on-call person immediately *If resident is not located within 30 minutes, call the local police Charge Nurse will: *Notify responsible party (this may be done when the search is initiated) *Notify the resident's physician *Assess the resident on return to the home *Document the time resident absence is noted, time of return, assessment of resident, and notification of physician and responsible party *Complete and incident report in the clinical software *Follow-up charting for 24 hours if no injuries . .Administrative / supervisory staff will: *Determine if elopement is reportable to state regulatory agency *Interview staff and obtain written statements . *Establish a monitoring system for resident until flight risk is resolved *Determine what measures can be taken to prevent it from happening again On 07/11/23 at 02:59PM, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.