Based on observation, interview, and record review, the facility failed to prevent any future potential abuse, neglect, exploitation, or mistreatment while an investigation of misappropriation was in progress, when the facility allowed one staff member (RN A) to return to the facility to work as the only nurse on duty causing one resident (Resident #1) to be fearful of retaliation and taking steps to leave the facility due to the fear. The facility census was 44. The Administrator was notified on 09/08/25, at 2:18 P.M., of an Immediate Jeopardy (IJ) which began on 09/08/25. The IJ was removed on 09/08/25 as confirmed by surveyor on-site verification. …
Based on interview and record review, the facility failed to ensure staff followed their Abuse, Neglect and Exploitation, Freedom From policy by failing to immediately notify the Administrator/Designee or Director of Nurses (DON)/Designee and promptly begin an investigation regarding one resident's allegation on 10/24/23 around 4:30 P.M. to 5:00 P.M., of being slapped or hit in the face/mouth by Certified Nursing Assistant (CNA) A. In addition, the facility failed to ensure CNA A was immediately suspended from work pending the results of an investigation. CNA A continued to work on 10/24/23 until 10:38 P.M., returned to the facility on [DATE], and worked from 6:34 A.M. until 3:27 P.M., before being suspended from work. …
D · No harm, potential for more than minimal, isolatedAugust 31, 2026
Based on record review and interview the facility failed to investigate an injury of unknown source as per their policy Abuse Investigation and Reporting when Resident #1 was found to have a fractured knee cap with no known fall, or injury to the area. The facility census was 62.Review of the facility provided policy Abuse Investigation and Reporting dated July 2017 showed:-All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source shall be promptly reported to the Administrator, local , state and federal agencies, and thoroughly investigated;-If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation… …
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