Every finding on record at Ralls Nursing Home

Based on interviews and record review, the facility failed to maintain sufficient nursing staff with appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 4 (LVN A) nursing staff reviewed in that: The facility failed to ensure LVN A maintained an active nursing license while working as a nurse on [DATE]. This failure could place residents at risk of receiving care from an unlicensed professional. The findings included: Record review of the facility employee records on [DATE] at 3:20 PM, LVN A was noted to have an LVN/LPN license with an expiration date of [DATE]. Record review of the facility's punch-detail report from [DATE] to [DATE] revealed the following:LVN A worked: [DATE] - 11.83 hours During an interview on [DATE] at 3:21 PM, the BOM stated she just realized LVN A's license was expired. The BOM stated she called LVN A today ([DATE]) and told her she was suspended until her license was approved and active. The BOM stated she was trained to review staff files yearly upon their hire date anniversary. The BOM stated LVN A told her she thought her license did not expire until next year. The BOM stated staff were trained that they were responsible for renewing their license on time, not letting their license expire, and maintaining their education courses. The BOM stated she was responsible for checking employee files annually. The BOM stated a potential negative outcome was that residents would not continue to get the care they had been getting and the care they deserved. During an interview on [DATE] at 4:16 PM, the ADM stated the BOM was responsible for checking licenses and certificates for the nursing staff but ultimately it was his responsibility to ensure licenses were not expired. The ADM stated he preferred the BOM to audit employee files monthly to check their licenses. The ADM stated he was not sure if the BOM was trained to complete monthly audits of employee files. The ADM stated he was not aware LVN A worked with an expired/delinquent license, but LVN A renewed it today after LVN A was informed of the issue. The ADM stated LVN A was suspended today ([DATE]) and would not work again until her license was approved and active. The ADM stated there was no training provided for nursing staff on maintaining their licenses, but it was the nurse's responsibility to ensure their licenses did not expire. The ADM stated he expected all licensed individuals to renew licenses in a timely manner and he also expected the BOM to check employee files monthly. The ADM stated a potential negative outcome to the residents was that they would be receiving nursing services from someone who did not have a license. Record review of the facility's policy titled, Licensure, Certification, and Registration of Personnel, with a revised date of 04/07 reflected the following in part: Policy Statement: Employees who require a license, certification, or registration to perform their duties must present such verification with their application for employment. Policy Interpretation and ImplementationPersonnel who require a license, certification, or registration to perform their duties must present verification of such license/certification/registration to the human resources director/designee prior to or upon employment. 2. A copy of the current license, certification, or registration number must be filed in the employee's personnel record. 3. A copy of recertifications (e.g. annual, bi-annual, etc., as applicable) must be presented to the human resources director/designee upon receipt of such recertifications and prior to the expiration of current licensure, certification, and/or registration. A copy of the recertification must be filed in the employee's personnel record.

Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to the abuse coordinator, the facility Administrator for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to follow their policy for reporting abuse and neglect when LVN A, CNA B and CNA C did not report an incident with Resident #1 for 2 days. LVN A, CNA B and CNA C continued to work with Resident #1 because they failed to report the abuse to the ADM. The noncompliance was identified as PNC. The IJ began on 12/19/25 and ended on 01/07/2026. The facility had corrected the noncompliance before the survey began on 01/12/2026.These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm.Findings include:Record review of Resident #1's face sheet, dated 1/13/26 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Alzheimer's disease (memory loss), paranoid schizophrenia (delusions), muscle weakness, difficulty in walking, generalized anxiety (worrying), conversion disorder with seizures and convulsions (jerking, limb shaking), insomnia (sleep disorder), schizoaffective disorder, bipolar type (hallucinations with mood swings), intermittent explosive disorder (sudden aggressive outburst).Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE] revealed: Section C BIMS summary score revealed a score of 6 which indicated severe cognitive impairment. Section E Behavior indicated Resident #1 had potential behavior of psychosis that included hallucinations and delusions. Resident #1 rejected care and this type of behavior occurred daily. Section GG Mobility devices indicated Resident #1 used a wheelchair.Record review of Resident #1's care plan dated 12/14/25 revealed:Focus: I (Resident #1) made an allegation that I was abused verbally and physically by staff on 12/19/25.Interventions: Monitor me for signs of fear, crying, increased agitation and notify MD if indicated. Date initiated 12/22/25.Focus: Resident #1 had potential for physical/verbal aggressive secondary to Alzheimer's disease and schizoaffective disorder.Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated 05/02/22Focus: I have potential for delirium and am at risk for an acute confusional episode r/t inattention and disorganized thinking.Interventions: Communication: Use my preferred name. Identify yourself at each interaction.Face me when speaking and make eye contact. Reduce any distractions- turn off TV,radio, close door etc. I understand consistent, simple, directive sentences. Provide me with necessary cues- stop and return if agitated. Date initiated 05/02/22Focus - I have a mood problem r/t depression/anxiety AEB pacing, sitting in floor, aggressive behaviors. I take medication to help me feel less anxious and happier. Interventions - Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing toeat or drink, refusing med or therapies, sense of hopelessness or helplessness,impaired judgment or safety awareness. Date initiated 05/02/22Record review of progress notes for Resident #1 revealed on 12/22/25 at 9:46 AM, the ADON documented Resident #1 voiced that she had been dragged down the hall on a blanket when she refused to go to bed a t an early time. She wanted to watch TV in the dining room and the night shift would not her they turned it off and forced her. Stated that they dumped her out of her wheelchair and then dragged her down the hall on a blanket. Issue reported to ADM, Medical Director, and family.Record review of skin assessment for Resident #1 dated 12/22/25, completed by ADON revealed: Bruising to lower forearm.Record review of Resident #1's physician orders dated 1/13/26 Resident #1 was not prescribed blood thinners at the time of the incident.During an interview on 1/12/26 at 11:30 AM, the DON stated LVN A, and CNA B, and CNA C continued to work after this incident, because no one reported the incident. On 12/21/25 Resident #1 mentioned the incident to the ADON, and the ADON asked the BOM to review the camera's video. The BOM informed the ADON of the findings that included an incident confirming Resident #1 had been dragged to her room. On 12/21/25 the ADON and the ADM returned to the facility and LVN A, CNA B, and CNA C were terminated immediately. The DON said this incident occurred at 7:00 PM on Friday 12/19/25 and LVN A and CNA B, and CNA C continued to work the night shift until 6:00 AM on 12/20/25, and Resident #1 had no other incidents during this shift. The DON said the next day on 12/20/25 LVN A, and CNA B, and CNA C returned to work and worked the night shift from 6 PM until 6 AM on 12/21/25 and continued to care for Resident #1. On Sunday 12/21/25 LVN A, and CNA B, and CNA C returned to work; they started their shift at 6:00 PM shortly after that time they were terminated. LVN A, CNA B, and CNA C were the only staff on shift and none of them reported the incident because they didn't think they had done anything wrong since Resident #1 had not been taking her medication.During an interview on 1/12/26 at 2:00 PM, the ADM stated he reviewed the video that included the incident with Resident #1 and and it was bad. He stated LVN A, CNA B, and CNA C abused Resident #1 and it was on video. The bad thing was all 3 staff were implicated and didn't report it. Resident #1 reported it to the ADON two days later on Sunday, 12/21/25. It happened on a Friday 12/19/25; however, Resident #1 report to the ADON they dragged me down the hall last night. The ADON was at work when Resident #1 told her and the ADON told the BOM and asked her to review the camera footage. Once it was found on the video footage the ADM, the ADON and the BOM went to the facility and immediately fired LVN A, CNA B, and CNA C, who were at the facility to start their shift at 6 PM on 12/21/25.During an interview on 1/12/26 at 2:46 PM, the BOM stated that the ADON called her on that Sunday when she left work around 6PM. She stated the ADON told her that Resident #1 reported an allegation of abuse at the end of her shift. The ADON asked her to please review the video. She stated the ADON did not know if the allegation happened and if it did happen what staff were involved. She reviewed the footage and found the incident and notified the ADM, ADON and corporate nurse. She stated at that time the ADM, ADON and her returned to the facility since the staff involved LVNa, CNA b and CNA C were working. Staff were terminated immediately. She stated, during an interview with CNA C it was explained to her that when she put her hand on that sheet and pulled Resident #1, she was involved, and she didn't call and report the incident.During an interview on 01/12/26 at 3:59 PM, Medication Aide (MA) said she did not witness the incident involving Resident #1 being dragged to her room. MA said before and after Resident #1 was dragged to her room, she had received training to prevent abuse and neglect, reporting abuse, that included taking a test and was in-serviced on resident rights.Review of the facility's Inservice Training Report dated 01/07/26 for Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident. Indicated MA signed these in-services on 01/07/2026.During an interview on 01/12/26 at 4:38 PM CNA, G said before and after Resident #1 was dragged to her room, she had received training to prevent abuse and neglect, reporting abuse which included taking a test and was in-serviced on resident rights. CNA G, said a resident should not be forced to go to bed and to go to sleep, should not be forcefully pushed in their wheelchair from one area to another, when they are refusing to leave the area, and should not be dragged on the floor to their room.Review of the facility's Inservice Training Report dated 12/21/25 for Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident. Indicated CNA G signed these in-services on 12/21/25.During an interview on 1/12/26 at 4:43 PM, LVN A stated she worked at the facility a little over a year. She stated it had never been policy to not do that and whatever is safest for her staff and resident she will do. The administrative staff doesn't understand this goes on all the time. Resident #1 hits hard and gets agitated and she had been up all night and all day and since she had gone a month and a half without her meds. That she did what she thought was the safest thing for all involved that night. That in no way did anyone abuse Resident #1 that night. That her pride was really hurt because there was no way she would hurt anyone. She would never cause harm and the safest way was to use a sheet or blanket because you can't always use a mechanical lift to move them to get a blanket and carry a resident was safer that using the mechanical lift. That resident's had the right to stay up all night but Resident #1 did not have the right to go into other resident's rooms. She knew she was upset that night and she thought about calling the police that night because it was out of hand. She stated the facility has trained her on ANE and put papers out. She stated she was trained over resident rights. There was so many different behaviors that she did not know how to explain it but it was very, very hard. She stated she was the night nurse, and she knew it was up to her to take care of the residents. She stated she felt that night she made the best decision for everyone so no one got hurt. She stated she did not remember everything that happened. That they have the right to sit up all night if they want that is their home. She stated she did not know if dragging her on the bed sheet was abuse because she was heavy and there was no way she could have been hurt on the sheet because each staff had each end of the sheet, she would not get hurt.During an interview on 01/12/26 at 5:00 PM, CNA E said before and after Resident #1 was dragged to her room, she had received training to prevent abuse and neglect, reporting abuse which included taking a test and was in-serviced on resident rights. CNA E, said a resident should not be forced to go to bed and to go to sleep, should not be forcefully pushed in their wheelchair from one area to another, when they are refusing to leave the area, and should not be dragged on the floor to their room.Review of the facility's Inservice Training Report dated 12/21/25 for Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident. Indicated CNA E signed these in-services on 12/21/25.During an interview on 1/12/26 at 5:40 PM, ADON stated she worked on Sunday, and when she left for the day staff told her Resident #1 reported an allegation of abuse, that staff were mean to her. She stated she did not know if the allegation happened and if it did what staff were involved. She called the BOM and asked her to look at the videos. She stated once the video footage was reviewed, they discovered LVN A, CNA B and CNA C were the staff involved. Stated she reported back to the facility Sunday evening, when she got there, she met BOM, ADM and Law Enforcement Officer outside. They interviewed LVN A in the office and she told them yes we did that we dragged her down the hall what else am I supposed to do with her y'all know she has been off her meds for a long time. That's on me because I told them to do it, we are getting beat up slapped and kicked and y'all don't do anything about it. We told her that it was resident abuse and staff cannot do that. Resident #1 had the right to refuse medications, the right to sit up and watch tv when she wanted. She could read her Bible do puzzle books because this was her home. They could not make her go to bed. That was abuse to do those things to her. She stated that after the incident with Resident #1 she printed out anything she could on ANE and then spoke with the Corporate Nurse Regional Nurse and went over with staff that you cannot drag a resident down the hall, you do not turn the lights off, that they have rights and can watch tv, stay up. Stated when staff turned the lights off on Resident #1 that was violation of her rights. When staff dragged her down the hall on a bed sheet it was abuse. ADON stated she received training and in-service on abuse and neglect reporting abuse and protecting the residents. Review of the facility's Inservice Training Report dated 12/21/25 for Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse, protecting resident's, with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident. Indicated ADON signed these in-services on 12/21/25 and 01/07/26. During an interview on 01/12/26 at 6:01 PM, CNA I said before and after Resident #1 was dragged to her room, she had received training to prevent abuse and neglect, reporting abuse that included taking a test and was in-service on resident rights. CNA I said a resident should not be forced to go to bed and to go to sleep, should not be forcefully pushed in their wheelchair from one area to another, when they are refusing to leave the area, and should not be dragged on the floor to their room.Review of the facility's Inservice Training Report dated 12/21/25 for Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident. Indicated CNA I signed these in-services on 12/21/25.During an interview on 01/12/26 at 6:17 PM, CNA J said before and after Resident #1 was dragged to her room, she had received training to prevent abuse and neglect, reporting abuse and take a test and was in-service on resident rights. CNA J said a resident should not be forced to go to bed and go to sleep, should not be forcefully pushed in their wheelchair from one area to another, when they are refusing to leave the area, and should not be dragged on the floor to their room.Review of the facility's Inservice Training Report dated 12/21/25 for Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident. Indicated CNA J signed these in-services on 12/21/25.During an interview on 01/12/26 at 6:33 PM, LVN K indicated Resident #1 does not sleep during the night and spends most of the night watching the tv in the dining area. LVN K said most of the residents go to bed around 8:00 pm to 8:30 pm, and it is unusual for Resident #1 to be the only resident awake during the nights. LVN K said before and after Resident #1 was dragged to her room, she had received training to prevent abuse and neglect, reporting abuse which included taking a test and was in-service on resident rights. LVN K said a resident should not be forced to go to bed and to go to sleep, should not be forcefully pushed in their wheelchair from one area to another, when they are refusing to leave the area, and should not be dragged on the floor to their room.Review of the facility's Inservice Training Report dated 12/21/25 for Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident. Indicated LVN K signed these in-services on 12/21/25.On 01/13/26 at 10:18 AM, Resident #1 said she was watching tv show in the dining area, when the lady turned off the tv and told her she had to go to bed. The lady put a blanket over her head, and the ladies grabbed her feet and dragged her to her room. When she tried to leave her room that night, the lady (CNA) would tell her to go back to her room, and she would say no, you are not my boss. Resident #1 said she stayed in her room all night and did not come out. On Saturday 12/20/25, she did not report to anyone she had been abused, instead she stayed in her room, and the ladies did not hit her because she told them to leave her alone. Resident #1 said on Sunday she reported the abuse to CNAs E and G, and the ladies who dragged her to her room are not here anymore because they took them to jail.During an interview on 1/13/26 at 11:30 AM, the ADM stated once the video footage was observed that it was clear the staff (LVN A, CNA B and CNA C) that worked on Friday violated Resident #1's residents rights, and it was verbal and physical abuse.During an interview on 1/13/26 at 12:20 PM, DON stated that what those staff did to Resident #1 was horrible. What they said to her was verbal abuse and physical abuse when they dragged her down the hall and grabbed her arm. That resident rights were violated when they told her she had to go to bed and when staff turned off the lights to leave her in the dark.During an interview on 1/13/26 at 3:34 PM, attempted to call CNA B , no answer left a voice message with call back information. Followed up with a text message. CNA B did not respond to the call or text.During an interview on 1/13/26 at 3:36 PM, Attempted call to previous staff CNA C no answer mailbox is full unable to leave a voice message. Followed up with a text message. CNA C did not respond to the call or text.During an interview on 1/14/26 10:22 AM, the ADON stated she did not understand why staff did that to Resident #1. She stated staff violated her rights when they turned the lights off in the dining room. This was her home, and they shouldn't have done that.Staff could have caused injury to her when they dumped her out of the wheelchair. They put her in harm's way when we are supposed to be protecting her. They put her at risk in so many ways when all they had to do was leave her alone. She has rights everyone in here to do what they want in their own home (within reason). Just because you (staff) want to have a nice and easy night and do what you want, doesn't give you the right to turn off the lights and make them go to bed. Its abuse mental, emotionally and physical. We are dealing with people that already had trauma and all they did was make it worse. She stated based on policy she expects staff to report any abuse immediately. She stated staff did not follow the policy when they did not report the abuse the night it happened. She stated they did not follow the ANE policy of free from abuse.During an interview on 1/14/26 at 10:26 AM, the AD stated she learned of the incident with Resident #1 after it happened. She stated that at her resident council meeting last month she went over forms of abuse and reporting abuse to try and help the residents to under to report it. She stated she felt like they were hearing her and understood. Stated no one had made any complaints of abuse to her prior. Stated she was in-serviced on resident rights, types of abuse to report immediately resident property, misappropriation of property.Review of the facility's Inservice Training Report dated 12/21/25 for Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident. Indicated AD signed these in-services on 12/21/25.During an interview on 1/14/26 at 11:58 AM, Local Law Enforcement stated an officer did report to the facility over an incident with Resident #1 and staff. He stated after the local law enforcement office reviewed the details it was believed it would be more of a violation of policy that staff broke. That they would not be filing charges against the staff involved.Record review of the facility's in-service dated 12-21-25, Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident.Abuse and neglect in-service test dated 12/22/25 were completed and signed by staff.Behavioral Management test dated 12/22/25 - 1/7/26 were completed and signed by staff, staff.Abuse and neglect questionnaires for staff dated 12/22/25- 1/7/26 were completed and signed by staff.Record Review of Resident Safety Survey dated 12/21/25, 01/06/26 and 01/12/26 indicated the facility's residents were asked the following.1. Do you feel safe here?2. Do you have any concerns you would like to report?3. Are you afraid or fearful of any staff members here? If yes, who?There were no negative findings on these reports, including Resident #1.Record review statement LVN A provided to the ADM, ADON and BOM, typed by ADON revealed the following: on 12/21/2025 at 8:30 PM LVN A was asked about pulling Resident #1 down the hall on a blanket. LVN A replied, yes we did it, that's on me. Are we supposed to just get hit and kicked all the time? Y'all know she's not been taking her meds for a long time now and no one has done anything about it. Typed statement signed by ADON and ADM as staff did not provide a written statement to the facility.Record review statement by CNA B provided to the ADM and BOM typed by the ADM revealed the following: on 12/21/2025 at or around 8:30 PM CNA B stated she did not do anything wrong because of all the behaviors they have in the building, and the resident was attacking them. CNA B was informed she was terminated, and she violated the resident's rights by physical and verbal abuse according to the video evidence. Typed and signed by ADM as staff did not provide a written statement to the facility.Record review statement by CNA C provided to the ADM and BOM typed by the ADM revealed the following: on 12/21/2025 at or around 8:30 PM CNA C stated she did not do anything wrong because she did what she was told, and she didn't think it was a big deal. CNA C was informed that she did something wrong by failure to report the incident and she grabbed the sheet to drag the resident down the hall with the others. Staff terminated staff failed to report a violation of resident rights and abuse of a resident.Record review of LVN A 's employee file revealed hire date 07/18/2024 and termination date 12/21/2025. LVN A was trained on abuse, awareness and prevention on 10/03/2024. Record review of CNA B's employee file revealed hire date 04/19/2023 and termination date 12/21/2025. CNA B was trained on abuse, awareness and prevention 07/22/2024.Record review of CNA C's employee files revealed hire date of 12/04/2023 and termination date of 12/21/2025. CNA C was trained on abuse, awareness and prevention 07/26/2024.Record review of punch time detail for LVN A revealed she worked 12/19/25 from 5:52 PM until 6:37 AM; on 12/20/2025 from 5:47 PM until 6:33 AM and 12/21/25 from 5:30 PM until 9:06 PM.Record review of punch time detail for CNA B revealed she worked 12/19/25 from 5:56 PM until 6:12 AM; on 12/20/2025 from 6:03 PM until 6:05 AM and 12/21/25 from 5:30 PM until 9:0 6PM.Record review of punch time detail for CNA C revealed she worked 12/19/25 from 5:52 PM until 6:14 AM; on 12/20/2025 from 5:46 PM until 6:04 AM and 12/21/25 from 5:57 PM until 7:45 PM.Record review of corrected action plan by ADM dated 12/21/2025 revealed safe surveys were to be done weekly for three months to make sure this did not happen again. In-service abuse and neglect, resident rights, and misappropriation. Reviewed in QAPI for three months and discussed with staff. Monitored camera footage from different shifts to monitor staff.Record review of facility policy revised April 2021: Abuse, Neglect, Exploitation and Misappropriation Prevention Program undated revealed the following:Policy Statement: The resident has 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, verbal, mental, sexual or physical abuse, and physical abuse or chemical restraint not required to treat the resident's symptoms. and any physical or chemical restraint not required to treat the residents' medical symptoms.Policy Interpretation and ImplementationThe resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:Facility staff5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.6. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.9. Investigate and report any allegations within timeframes as required by federal requirements.10. Protect resident from any further harm during investigations.Record review of facility policy: Freedom From Abuse, Neglect and Exploitation undated revealed the following:Purpose: Ensure each resident's right to be free from abuse, neglect, and corporal punishment of any type by anyone.Procedure:1. The resident has 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.2. This facility does not tolerate abuse, neglect, or exploitation of any kind. Any staff member that has reason to suspect such activity is going on or has witnessed such activity, must immediately report same to the Administrator or his/her designee when Administrator is absent.Definitions:Abuse Is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. (S'183.5)Covered Individual is anyone who Is an owner, operator, employee, manager, agent or contractor of the facility.Willful as used in the definition of abuse, means the individual must have acted deliberately, not that the Individual must have intended to inflict injury or harm. (S483,5)The noncompliance was identified as PNC. The IJ began on 12/19/25 and ended on 01/07/26. The facility had corrected the noncompliance before the survey began on 01/12/26.

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure a safe environment free from physical and verbal abuse for Resident #1 when LVN A, CNA B and CNA C forced Resident #1 to leave the dining room and go to bed when they dragged Resident #1 with a blanket to her room.LVN A, CNA B and CNA C made verbal comments about Resident #1 on front of and to Resident #1 mind your own business, calling to find another place for her to live, why haven't they made her move yet.The noncompliance was identified as PNC. The IJ began on 12/19/25 and ended on 01/07/2026. The facility had corrected the noncompliance before the survey began on 01/12/2026.These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm.Findings include:Record review of Resident #1's face sheet, dated 1/13/26 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Alzheimer's disease (memory loss), paranoid schizophrenia (delusions), muscle weakness, difficulty in walking, generalized anxiety (worrying), conversion disorder with seizures and convulsions (jerking, limb shaking), insomnia (sleep disorder), schizoaffective disorder, bipolar type (hallucinations with mood swings), intermittent explosive disorder (sudden aggressive outburst).Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE] revealed: Section C BIMS summary score revealed a score of 6 which indicated severe cognitive impairment. Section E Behavior indicated Resident #1 had had potential behavior of psychosis that included hallucinations and delusions. Resident #1 rejected care and this type of behavior occurred daily. Section GG Mobility devices indicated Resident #1 used a wheelchair.Record review of Resident #1's care plan dated 12/14/25 revealed:Focus: I made an allegation that I was abused verbally and physically by staff on 12/19/25.Interventions: Monitor me for signs of fear, crying, increased agitation and notify MD if indicated. Date initiated 12/22/25Focus: Resident #1 had potential for physical/verbal aggressive secondary to Alzheimer's disease and schizoaffective disorder.Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated 05/02/22Focus: I have potential for delirium and am at risk for an acute confusional episode r/t inattention and disorganized thinking.Interventions: Communication: Use my preferred name. Identify yourself at each interaction.Face me when speaking and make eye contact. Reduce any distractions- turn off TV,radio, close door etc. I understand consistent, simple, directive sentences. Provide me with necessary cues- stop and return if agitated. Date initiated 05/02/22Focus - I have a mood problem r/t depression/anxiety AEB pacing, sitting in floor, aggressive behaviors. I take medication to help me feel less anxious and happier. Intrventions - Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing toeat or drink, refusing med or therapies, sense of hopelessness or helplessness,impaired judgment or safety awareness. Date initiated 05/02/22Record review of progress notes for Resident #1 revealed on 12/22/25 at 9:46 AM, the ADON documented Resident #1 voiced that she had been dragged down the hall on a blanket when she refused to go to bed at an early time. She wanted to watch TV in the dining room and the night shift would not let her they turned it off and forced her. Stated that they dumped her out of her wheelchair and then dragged her down the hall on a blanket. Issue reported to ADM, Medical Director, and family.Record review of skin assessment for Resident #1 dated 12/22/25, completed by ADON revealed: Bruising to lower forearm.Record review of Resident #1's physician orders dated 1/13/26 indicated Resident #1 was not prescribed blood thinners at the time of the incident.Record review on 1/12/26 at 3:23 PM, of the facility's video recording dated 12/19/23 revealed Resident #1 was observed sitting in her wheelchair in the dining room with a book in her hand. She was the only resident in the dining room. There was a conversation with staff LVN A and CNA B, and Resident #1 told staff to stop talking about someone. Staff told Resident #1 to mind her business. The conversation goes back and forth with Resident #1 repeating what staff said to her. LVN A observed as she walked past Resident #1 and stated, I am fixing to wheel her to her room CNA B was overheard but not seen and said, it's not your business. Resident #1 stated oh shut up. LVN A was heard but not seen and she stated, why haven't they made her move yet. LVN A observed walking past Resident #1 and stated, I am going to find her a new place to live, she can't stay here. CNA B stated, I wish. LVN A walked towards Resident #1 and stated, I think we should call around and see who would take her. Resident #1 stated something back to staff, but it is inaudible. LVN A continued to tell Resident #1 mind your business Resident #1 stated oh be quiet, mind your business, stop talking about me. LVN A walked over to Resident #1 and stated, you are in our business. Resident #1 stated you are talking about me, LVN A stated, your husband said for you to and makes with her mouth (Brrrtrt sound sticking her tongue out and blowing air) and a hand gesture moving her hand across her neck. Resident #1 stated for you too. CNA B is heard but not see and stated, for you to go to bed. Resident #1 stated you need to shut up, mind your own business. CNA B stated, you need to go to bed. Resident #1 stated you don't need to tell me what to do. CNA B repeated to Resident #1 you need to go to bed. Resident #1 stated you are not my mother to tell me what to do. CNA B stated to Resident #1 I don't want to be your momma. There was something said by staff and Resident #1 but it was inaudible. CNA B was seen walking over to Resident #1 and asked her you don't want to go to bed, why don't you want to go to bed. Resident #1 stated oh don't tell me what to do. CNA B looked up at the two ceiling fans, moved a chair over, stood in the chair and turned both lights off on Resident #1. CNA B stated, but why don't you want to go to bed. Resident #1 stated I don't want you here. CNA B stated, its nighttime, come on Resident #1 come to bed. Resident #1 stated something to staff, but it was inaudible. Resident #1 moved to the TV room and continued reading her book. CNA B walked to the TV room and stated, Resident #1 you need to go lay down already, there is nobody here you need to go lay down. Resident #1 stated you do not pay for it as CNA B turned the light off in the TV room. CNA B stated, it's bedtime. Resident #1 stated It's not bedtime. Resident #1 observed going towards the light switch and stated, you need to turn the light on. CNA B stated, it's bedtime Resident #1. Resident #1 stated move CNA B stated, you want to tell me why you don't want to go to bed. Resident #1 stated you got bedtime. CNAB stated can you tell me why you don't want to go to bed. Resident #1 stated something, but it was inaudible. CNA B stated, can you tell me why you don't want to go to bed you used to always go to bed. Resident #1 stated no I don't have to go to bed. CNA B was observed pushing the wheelchair with Resident #1 sitting in the wheelchair and Resident #1 was pushing her feet towards the ground and stated, stop it. LVN A was heard but not seen say it's her fault. Resident #1 was observed reaching her right hand for an overbed table as CNA B pushed her down the hall and Resident #1 was observed going forward out of the wheelchair. Staff pushed the wheelchair seat over Resident #1's legs and the seat against her left side. LVN A stated, ok leave her there. Resident #1 stated stop it. LVN stated leave her there. Resident #1 stated stop it, CNA B stated, hitting and swinging. Resident #1 stated you stop it don't tell me what to do. CNA B stated, get up LVN A stated, Resident #1 stop, stop. Resident #1 stated no you stop. LVN A stated, you can just stay right there. Resident #1 stated mind your own business, you're not my mother. CNA C was observed walking towards and Resident #1 took her right hand and moved it towards her left arm and stated to CNA C you stay away from me. LVN A stated stop CNA C stated, nobody's doing nothing to you Resident #1. Resident #1 stated yes you are. CNA C stated, what are we doing LVN A stated, stop punching them Resident #1 stated you to stop punching. LVN A and CNA B and Resident #1 all spoke at the same time, and it was inaudible. CNA C stated, hey everybody just separate. LVN A stated y'all just walk away. Observation made of Resident #1 sitting on the floor and CNA B was standing to her left side with the wheelchair, and CNA B was standing to her right. CNA B pushed the wheelchair to go in front of Resident #1, and the front right wheel was pushed up against Resident #1's left foot. Resident #1 stated go,go,go,go and Resident #1 was turned by that motion more towards the right facing towards the hall. LVN A walked around Resident #1 on Resident #1's right side, Resident #1 stated stop and Resident #1 used her right hand to hit LVN A on her right leg. LVN A stated, stop it Resident #1 stated stop it you stop it. LVN A walked down the hall towards the nurse's station. CNA B was observed standing in front of Resident #1 and leaned down towards Resident #1 and stated, stop hitting her. CNA C reached out her right hand towards the wheelchair to move it. Resident #1 attempted to speak, and CNA B stated no, you stop hitting. Resident #1 stated you stop and CNA B stated stop hitting. Resident #1 observed leaning to her left side then on her back. LVN A stated walk away from her. Resident #1 observed hitting LVN A on the back of her left leg. LVN A pointed her index finger at Resident #1 and stated, Resident #1 stop, stop Resident #1 stated you stop, LVN A pointed her index finger at Resident #1 and stated, that's enough, Resident #1 stated you stop. CNA B stated, should we get a blanket and take her to her room and LVN A stated probably. CNA C stated something in Spanish and LVN A laughed. Resident #1 observed laying on the floor on her back with her legs bent at the knees. LVN A observed walking behind the nurse's station and CNA C turned and walked down the hall. LVN A stated, god dang she can hit girl. CNA B was observed walking down the hall towards Resident #1 with a blanket. LVN A walked out from behind the nurse's station and stated, this is crazy Resident #1 stated something inaudible. LVN A stated, they need to send her out, CNA B stated, they do need to send her out. Resident #1 attempted to grab the blanket as CNA B and LVN A attempted to cover Resident #1. Resident #1 attempted to kick CNA B and LVN A stated, don't let her kick you girl, CNAB stated she's not hurting me. CNA B placed the blanket over Resident #1 and Resident #1 attempted to hit CNA B and CNA B reached for Resident #1's right arm and grabbed her forearm and stared to drag Resident #1 down the hall holding on to the blanket and Resident #1's arm. LVN A walked down the hall at Resident #1's feet and CNA C grabbed the blanket at Resident #1's feet and assisted with CNA B drag Resident #1 down the hall. CNA B was heard not seen and stated y'all watch out she's heavy as explicit. Observation made of CNA B walking backwards dragging Resident #1 and LVN A on the right side of Resident #1 at with CNA C on the left side of Resident #1, then staff turned and dragged Resident #1 into her room.During an interview on 1/12/26 at 11:30 AM, the DON stated Resident #1 was sitting in the dining room reading her Bible and watching tv. LVN A and CNA B, decided she needed to go to bed at 7:00 PM. CNA B turned the lights out on her and turned the tv off. Stated, then Resident #1 tried to turn the lights back on and CNA B and LVN A started cussing and yelling at her. Resident #1 started off calm but began to get upset the more CNA B, and LVN A did to her. CNA B physically stood in front of the light switch so Resident #1 could not turn the lights back on. CNA B stood on a chair and turned the lights off on the ceiling fans. Resident #1 was yelling and telling staff she was not ready to go to bed then staff started pushing her in her wheelchair out of the dining room and Resident #1 ended up on the floor. Either she put herself on the floor or they dumped her on the floor. CNA B got a blanket and LVN A, CNA B, CNA C got her on the blanket and they dragged her with the blanket on the floor all the way down the hall to her room which is at the end of the hall. She stated she was told that staff said y'all know she has not been taking her meds. She stated that has nothing to do with it, if someone is sitting in the dining room reading their Bible, she is fine. Stated then LVN A was observed on the camera footage making threats to Resident #1 to get her kicked out of the facility. Stated, to her knowledge there were no injuries to Resident #1. Stated that after the incident all 3 staff continued to work because no one reported the incident. Resident #1 mentioned the incident to the ADON and the ADON asked the BOM to review the camera and she reported to the ADON the findings and the ADON and ADM returned to the facility and staff were terminated immediately. Stated the time of the incident was 7:00 PM on Friday 12/19/25 and staff worked until 6:00 AM with Resident #1 no other incidents that shift. She stated then the next day 12/20/25 they worked their shift with Resident #1, On Sunday 12/21/25 they started their shift and then it was discovered and they were terminated. LVN A, CNA B, and CNA C were the only staff on shift and none of them reported the incident because they didn't think they had done anything wrong because Resident #1 was not taking her medication. She stated staff should have left her alone, she was not doing anything wrong.During an interview on 1/12/26 at 12:30 PM, the NP stated she came to the facility for her regular visits on Monday and staff notified her of the incident with Resident #1 and staff. That Resident #1 was fine a little down but no bad thoughts and was still eating and sleeping and didn't recall what really happened but did tell her something about watching tv. Stated Resident #1 did not require any changes to her medication or any additional treatment over the incident. Stated Resident #1 is very resilient and at times will put herself on the floor and say she is going to die and will slide out of the wheelchair However, it was inappropriate for staff to have dragged her on the floor.During an interview on 1/12/26 at 2:00 PM, the ADM stated that the incident with Resident #1 that he had video of all of that and it was bad. He stated LVN A, CNA B and CNA C verbally abused Resident #1 and it was on video. They forced her down the hall in her wheelchair and they pushed the wheelchair so hard they dumped her on the floor. They wrapped her in a sheet and forced her to her room and to bed. The bad thing is all 3 staff were implicated and didn't report it. Resident #1 reported it to ADON two days later on Sunday. It happened on a Friday. Stated that Resident #1 told ADON they dragged me down the hall last night. The ADON was at work when Resident #1 told her and the ADON told the BOM and asked her to review the camera footage. Once it was found on the video footage the BOM reported to him what happened and him, the ADON, and BOM came to the facility. They fired the staff, and they worked the floor for about two hours, and called in additional staff to work. He stated he watched the video, and staff went in the dining room and Resident #1 was in the dining room reading her Bible not bothering anyone. Staff told Resident #1 it was bedtime, and she said something back to them. Then staff turned the lights out on Resident #1 in the dining room and said something else to her. Then staff proceeded to force her to go down the hall in the wheelchair. He fired LVN A and CNA B first then fired CNA C and explained to her she hadn't done anything wrong until she grabbed the sheet and helped them pull Resident #1 down the hall then didn't report the incident. He stated 1 staff member was pushing the wheelchair and Resident #1 was fighting it and then the CNA B was pushing the wheelchair so hard Resident #1 comes out of the chair and she goes down on one side. She didn't get hurt thank god. Resident #1 got upset and at that point it was fight or flight and so Resident #1 was hitting staff telling them to leave her alone and to quit. CNA B got the sheet with CNA B and then CNA B tells the CNA C to help and that is when they dragged her down the hall using the sheet to her room and forced her to bed. They dragged her from the nurse's station down the hall to her room [ROOM NUMBER] feet. He stated Resident #1 was telling them to stop and the staff didn't. Staff forced her to her room and put her to bed. He stated that staff worked the rest of their shift, since no one reported it. Staff worked 6PM-6 AM. He stated staff worked Saturday 6PM-6AM with Resident #1 and it still was not reported. They were the only staff in the building, and they were all guilty. Then Sunday came around and ADON was working and Resident #1 reports they dragged me down the hall but didn't say who dragged her. ADON told Resident #1 she would investigate and that was when she asked BOM to review the cameras. He stated ADON left the facility and roughly 2 hours later BOM found the camera footage and that is when she reported it to him and ADON and that is when they went to the facility contacted the police and terminated the staff. Then he made rounds and passed medication, and it was about 2 hours before he was able to report it to HHSC. He stated it was a lot, and he could not believe it happened. He stated he spoke to each staff individually with the police and staff tried to justify their actions. He stated we expect our residents to be free from abuse or neglect and any excuses they gave him were not good ones and he fired them. He stated he fired them for abuse and for failure to report. He stated LVN A, the nurse tried to make excuses for her actions, CNA B the same thing and CNA C said she didn't do anything, and he played the video back and showed her right here where you grab the sheet and help drag her down the hall is abuse and you didn't report the incident. Then CNA C said the nurse told her to grab the sheet, and she did what she was told but didn't report it.The staff involved stated the night before Resident #1 stayed up all night and they were tired of these residents staying up all night. Resident #1 had stayed up all night the night before and slept all day and so they forced her to bed because they were tired of residents staying up all night.He stated there were no injuries to Resident #1. He stated the ADON assessed her.He stated he did talk to Resident #1 and she said, they did drag her down the hall. He stated he called and notified the family, and they were not too happy; he told them it would never happen again because he fired them.He stated they have in-serviced staff on ANE reporting ANE, reminded them there are cameras and they will review camera footage from each shift, they discussed QAPI and will discuss over three months then they had the NP for psych services to see her and make sure she was ok. He stated they in-serviced staff on resident rights and let staff know that residents can stay up all night if they want. He stated they completed safe surveys, and they will continue to do safe surveys weekly and as needed for three months.He stated he contacted the Medical Director and he had them assess the resident report to the family and make sure she is ok.He stated he spoke with Corporate Nurse, and she stated to fire them all that were involved.During an interview on 1/12/26 at 2:46 PM, the BOM stated that the ADON called her on that Sunday when she left work around 6PM. She stated the ADON told her that Resident #1 said the girls were mean to her, and they dragged her with a sheet. The ADON asked her to please review the video. She was looking and started with Sunday and then went back to Saturday and then Friday and found it. Resident #1 was in the dining room and Resident #1 thought staff were talking about staff and they told her to mind her own business. Then Resident #1 says something again and LVN A went over to Resident #1 and tells her to mind her own business and then tell CNA B that Resident #1 needs to get out of this facility. Then time passed and Resident #1 was doing a crossword puzzle or reading her Bible and CNA B went in and stood on the chair and turned the lights off. She stated we never turn off the lights in the dining room or tv area. The CNA B stood on a chair and turned off the lights while Resident #1 was reading or doing her puzzle. Then CNA B moved the chair over and turned off other lights. Then Resident #1 moves herself with her wheelchair and went over by the tv and turned the lights on. Then CNA B realized the lights are on and told Resident #1 you need to go to sleep. Resident #1 said I don't want to go to sleep. Resident #1 told CNA B you don't pay the bills. LVN A told Resident #1 you better stop, or I am going to call the cops. Staff upset her when they turned the lights off. Then staff pushed her in the wheelchair and Resident #1 fell out of the chair. LVN A stated, just leave her there and CNA B said she would get a sheet. Staff had the sheet and Resident #1 was fighting them and they get the sheet over her and pulled her down the hall. CNA C helped pull the sheet but didn't report the incident. Stated she found the video footage around 7:33 PM and she sent it to the group ADM text and Corporate Nurse told her to fire them and she would not tolerate that. At that point they all went to the facility ADM, ADON and herself and they took over care and had two CNA's go in and help. CNA L and CNA J came in and helped from about and the ADON stayed and worked as a nurse.She stated the ADM, and she arrived back at the facility within 10-15 minutes and notified the local police department and they came to the facility. Local Law Enforcement took their ID's, DOB and opened a case with the videos and would see if they could press charges. She stated they interviewed staff involved and due to the incident with Resident #1 they no longer needed them as employees. That what happened was verbal abuse and the way they pulled her with the sheets would not be tolerated. Stated CNA B said well y'all are not here 12 hours like we are and that had to put up with all these behaviors. She stated she let staff know this was facility with behaviors and not every day will be a good day for a resident, but they were there to take care of them. That CNA B said well y'all are just in our offices. LVN A said well y'all already saw it and I am not telling y'all anything. She told the Local Law Enforcement they already saw it and I am not saying anything.CNA C said she didn't do anything, but it was explained to her that yes she did when she put her hand on that sheet and pulled Resident #1, she was involved, and she didn't call and report the incident. Staff said that Resident #1 had stayed up all night and had not slept, and they wanted her to go to bed. She stated but Resident #1 was not bothering anybody. Resident #1 does stay up all night, but she does put herself to bed when she wanted. She stated Resident #1 had the right to stay up all night this was her home.During an interview on 1/12/26 at 3:58 PM, the ADM stated that after the incident with the three staff and Resident #1 they changed the codes to all the access gates/doors.During an interview on 01/12/26 at 3:59 PM, Medication Aide (MA) said she did not witness the incident involving Resident #1 being dragged to her room. MA said before and after Resident #1 was dragged to her room, she had received training to prevent abuse and neglect, reporting abuse that included taking a test and was in-serviced on resident rights.Review of the facility's Inservice Training Report dated 01/07/26 for Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident. Indicated MA signed these in-services on 01/07/2026.During an interview on 01/12/26 at 4:38 PM, CNA G said before and after Resident #1 was dragged to her room, she had received training to prevent abuse and neglect, reporting abuse which included taking a test and was in-serviced on resident rights. CNA G, said a resident should not be forced to go to bed and to go to sleep, should not be forcefully pushed in their wheelchair from one area to another, when they are refusing to leave the area, and should not be dragged on the floor to their room.Review of the facility's Inservice Training Report dated 12/21/25 for Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident. Indicated CNA G signed these in-services on 12/21/25.During an interview on 1/12/26 at 4:43 PM, LVN A stated she worked at the facility a little over a year. She stated there were several things with Resident #1. It was every night thing with Resident #1 because she went over a month refusing her meds and her behaviors increased. She stated she did not remember if the lights were turned off. She stated she was at the nurse's station talking to one of the CNAs about another resident and Resident #1 kept interrupting. She would move and try again, and Resident #1 continued to talk so she told staff they would talk about it later. That Resident #1 said y'all don't need to be talking about that resident. She stated Resident #1 followed them around and told them not to talk about the other resident. Resident #1 stayed up every night going into rooms and her behavior was way off because she refused her medication. Resident #1 escalated the situation. She stated Resident #1 had pulled CNA B hair pulled from behind, she didn't see that happen, but she heard Resident #1 and CNA and told staff let's just get her to her room. That this escalated to the point where she told staff let's just stop all this. Resident #1 was combative, and she told CNA B to get a blanket She stated it had never been policy to not do that and whatever is safest for her staff and resident she will do. They rolled her on the blanket and carried her to her room and placed her in bed. That Resident #1 punched her in the stomach and kicked her behind her knee. The administrative staff doesn't understand this goes on all the time. Resident #1 hits hard and gets agitated and she had been up all night and all day and since she had gone a month and a half without her meds. That she did what she thought was the safest thing for all involved that night. That in no way did anyone abuse Resident #1 that night. That her pride was really hurt because there was no way she would hurt anyone. She would never cause harm and the safest way was to use a sheet or blanket because you can't always use a mechanical lift to move them to get a blanket and carry a resident was safer that using the mechanical lift. That resident's had the right to stay up all night but Resident #1 did not have the right to go into other resident's rooms. Stated they rolled her, put the sheet under her and rolled her back and then the two CNAs had the ends of the sheet, then they lifted her up and carried her in the sheet to her room. Stated she could not remember if it was a blanket or a sheet. She stated the CNAs took her to her room she didn't go to her room she walked halfway down the hall. Resident #1 didn't get back up that night. She needed her in her room and in bed so she could take care of other residents. That Resident #1 was fighting staff while they were trying to push her in the wheelchair and then Resident #1 slid herself in the floor like she always does. She did not recall saying she would call the police on Resident #1 that night or saying she will find someplace else for her to live. She said she might have said they would find someplace else for her to live. She knew she was upset that night and she thought about calling the police that night because it was out of hand. She stated the facility has trained her on ANE and put papers out. She stated she was trained over resident rights. There was so many different behaviors that she did not know how to explain it but it was very, very hard. She stated she was the night nurse, and she knew it was up to her to take care of the residents. She stated she felt that night she made the best decision for everyone so no one got hurt. She stated she did not remember everything that happened. She stated if staff did turn off the lights, then it would be a violation against resident rights. That they have the right to sit up all night if they want that is their home. She stated she did not know if dragging her on the bed sheet was abuse because she was heavy and there was no way she could have been hurt on the sheet because each staff had each end of the sheet, she would not get hurt. She stated that it was normal for Resident #1 to put herself on the floor that she did that for attention.During an interview on 01/12/26 at 5:00 PM, CNA E said before and after Resident #1 was dragged to her room, she had received training to prevent abuse and neglect, reporting abuse which included taking a test and was in-serviced on resident rights. CNA E, said a resident should not be forced to go to bed and to go to sleep, should not be forcefully pushed in their wheelchair from one area to another, when they are refusing to leave the area, and should not be dragged on the floor to their room.Review of the facility's Inservice Training Report dated 12/21/25 for Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident. Indicated CNA E signed these in-services on 12/21/25.During an interview on 1/12/26 at 5:40 PM, ADON stated she worked on Sunday, and when she left for the day staff told her Resident #1 reported that they dragged her down the hall on a blanket. She called BOM and asked her to look at the videos. Stated she didn't know when it happened that Resident #1 didn't say when it happened just that she was down the hall. She got home showered and then got information on her phone about the videos and text with BOM Corporate Nurse and ADM, Corporate Nurse told them to get to the facility and get the staff out she wanted them gone. Stated when she got there she met BOM, ADM and Law Enforcement Officer outside. They interviewed LVN A in the office and

Based on observation, interview and record review the facility failed to implement written policies and procedures that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of known source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Administrator for 1 of 8 residents (Resident #1) reviewed for abuse. The facility failed to follow their policy for abuse and neglect when LVN A, CNA B and CNA C failed to report an incident with Resident #1 for 2 days and the ADON and BOM failed to immediately report Resident #1's allegation of abuse to the ADM prior to investigation. The noncompliance was identified as PNC. The IJ began on 12/19/25 and ended on 01/07/2026. The facility had corrected the noncompliance before the survey began on 01/12/2026.These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm.Findings included:Record review of Resident #1's face sheet, dated 1/13/26 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Alzheimer's disease (memory loss), paranoid schizophrenia (delusions), muscle weakness, difficulty in walking, generalized anxiety (worrying), conversion disorder with seizures and convulsions (jerking, limb shaking), insomnia (sleep disorder), schizoaffective disorder, bipolar type (hallucinations with mood swings), intermittent explosive disorder (sudden aggressive outburst).Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE] revealed: Section C BIMS summary score revealed a score of 6 which indicated sever impairment. Section E Behavior indicated Resident #1 had potential behavior of psychosis that included hallucinations and delusions. Resident #1 rejected care and this type of behavior occurred daily. Section GG Mobility devices indicated Resident #1 used a wheelchair.Record review of Resident #1's care plan dated 12/14/25 revealed:Focus: I made an allegation that I was abused verbally and physically by staff on 12/19/25.Interventions: Monitor me for signs of fear, crying, increased agitation and notify MD if indicated. Date initiated 12/22/25.Focus: Resident #1 had potential for physical/verbal aggressive secondary to Alzheimer's disease and schizoaffective disorder.Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated 05/02/22.Focus: I have potential for delirium and am at risk for an acute confusional episode r/t inattention and disorganized thinking.Interventions: Communication: Use my preferred name. Identify yourself at each interaction.Face me when speaking and make eye contact. Reduce any distractions- turn off TV,radio, close door etc. I understand consistent, simple, directive sentences. Provide me with necessary cues- stop and return if agitated. Date initiated 05/02/22.Focus - I have a mood problem r/t depression/anxiety AEB pacing, sitting in floor, aggressive behaviors. I take medication to help me feel less anxious and happier. Interventions - Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing toeat or drink, refusing med or therapies, sense of hopelessness or helplessness,impaired judgment or safety awareness. Date initiated 05/02/22.Record review of progress notes for Resident #1 revealed on 12/22/25 at 9:46 AM, the ADON documented Resident #1 voiced that she had been dragged down the hall on a blanket when she refused to go to bed a t an early time. She wanted to watch TV in the dining room and the night shift would not let her they turned it off and forced her. Stated that they dumped her out of her wheelchair and then dragged her down the hall on a blanket. Issue reported to ADM, Medical Director, and family.Record review of skin assessment for Resident #1 dated 12/22/25, completed by the ADON revealed: Bruising to lower forearm.Record review of Resident #1's physician orders dated 1/13/26 Resident #1 was not prescribed blood thinners at the time of the incident.During an interview on 1/12/26 at 11:30 AM, the DON stated after the incident with Resident #1 on 12/19/25, LVN A, CNA B and CNA C continued to work because they were the only staff that worked at the time of the incident and none of them reported the incident to any administrative staff. She stated the incident happened around 7:00 PM on Friday 12/19/25 and it was not reported until 12/21/25. On Sunday 12/21/25 LVN A, CNA B, and CNA C started their shift 6:00 PM - 6:00 AM and the incident was discovered on facility video footage shortly after that time. LVN A, CNA B, and CNA C were the only staff on shift on 12/19/25, and none of them reported the incident because they didn't think they had done anything wrong because Resident #1 was not taking her medication.During an interview on 1/12/26 at 12:30 PM, the NP stated she came to the facility for her regular visit on Monday 12/22/25 and staff notified her of the incident with Resident #1 and LVN A, CNA B and CNA C. She stated she did not recall getting notified over the weekend and her phone number was posted at the nurse's station, and she has received calls from the facility.During an interview on 1/12/26 at 2:00 PM, the ADM stated that the incident with Resident #1 that he had video of all of that and it was bad. He stated LVN A, CNA B and CNA C abused Resident #1, and it was on video. He stated the bad thing is all 3 staff LVN A, CNA B, and CNA C were implicated and didn't report it. Resident #1 reported it to ADON two days later on Sunday 12/21/25. He stated he fired them for abuse and for failure to report.During an interview on 1/12/26 at 2:46 PM, the BOM stated that the ADON called her on that Sunday when she left work around 6PM. She stated the ADON told her that Resident #1 reported an allegation of abuse at the end of her shift. The ADON asked her to please review the video. She stated the ADON did not know if the allegation happened and if it did happen what staff were involved. She reviewed the footage and found the incident and notified the ADM, ADON and corporate nurse. She stated at that time the ADM, ADON and her returned to the facility since the staff involved LVNa, CNA b and CNA C were working. Staff were terminated immediately. She stated, during an interview with CNA C it was explained to her that when she put her hand on that sheet and pulled Resident #1, she was involved, and she didn't call and report the incident.During an interview on 01/12/26 at 3:59 PM,MA M said she did not witness the incident involving Resident #1 being dragged to her room. MA M said before and after Resident #1 was dragged to her room, she had received training to prevent abuse and neglect, reporting abuse, that included taking a test and was in-serviced on resident rights.Review of the facility's Inservice Training Report dated 01/07/26 for Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident. Indicated MA signed these in-services on 01/07/2026.During an interview on 01/12/26 at 4:38 PM, CNA G said before and after Resident #1 was dragged to her room, she had received training to prevent abuse and neglect, reporting abuse which included taking a test and was in-serviced on resident rights. CNA G, said a resident should not be forced to go to bed and to go to sleep, should not be forcefully pushed in their wheelchair from one area to another, when they are refusing to leave the area, and should not be dragged on the floor to their room.Review of the facility's Inservice Training Report dated 12/21/25 for Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident. Indicated CNA G signed these in-services on 12/21/25.During an interview on 1/12/26 at 4:43 PM, LVN A stated she worked at the facility a little over a year. She stated it had never been policy to not do that and whatever is safest for her staff and resident she will do. The administrative staff doesn't understand this goes on all the time. Resident #1 hits hard and gets agitated and she had been up all night and all day and since she had gone a month and a half without her meds. That she did what she thought was the safest thing for all involved that night. That in no way did anyone abuse Resident #1 that night. That her pride was really hurt because there was no way she would hurt anyone. She would never cause harm and the safest way was to use a sheet or blanket because you can't always use a mechanical lift to move them to get a blanket and carry a resident was safer that using the mechanical lift. That resident's had the right to stay up all night but Resident #1 did not have the right to go into other resident's rooms. She knew she was upset that night and she thought about calling the police that night because it was out of hand. She stated the facility has trained her on ANE and put papers out. She stated she was trained over resident rights. There was so many different behaviors that she did not know how to explain it but it was very, very hard. She stated she was the night nurse, and she knew it was up to her to take care of the residents. She stated she felt that night she made the best decision for everyone so no one got hurt. She stated she did not remember everything that happened. That they have the right to sit up all night if they want that is their home. She stated she did not know if dragging her on the bed sheet was abuse because she was heavy and there was no way she could have been hurt on the sheet because each staff had each end of the sheet, she would not get hurt. During an interview on 01/12/26 at 5:00 PM, CNA E said before and after Resident #1 was dragged to her room, she had received training to prevent abuse and neglect, reporting abuse which included taking a test and was in-serviced on resident rights. CNA E, said a resident should not be forced to go to bed and to go to sleep, should not be forcefully pushed in their wheelchair from one area to another, when they are refusing to leave the area, and should not be dragged on the floor to their room.Review of the facility's Inservice Training Report dated 12/21/25 for Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident. Indicated CNA E signed these in-services on 12/21/25.During an interview on 1/12/26 at 5:40 PM, ADON stated she worked on Sunday, and when she left for the day staff told her Resident #1 reported an allegation of abuse, that staff were mean to her. She stated she did not know if the allegation happened and if it did what staff were involved. She called the BOM and asked her to look at the videos. She stated once the video footage was reviewed, they discovered LVN A, CNA B and CNA C were the staff involved. Stated she reported back to the facility Sunday evening, when she got there, she met BOM, ADM and Law Enforcement Officer outside. They interviewed LVN A in the office and she told them yes we did that we dragged her down the hall what else am I supposed to do with her y'all know she has been off her meds for a long time. That's on me because I told them to do it, we are getting beat up slapped and kicked and y'all don't do anything about it. We told her that it was resident abuse and staff cannot do that. Resident #1 had the right to refuse medications, the right to sit up and watch tv when she wanted. She could read her Bible do puzzle books because this was her home. They could not make her go to bed. That was abuse to do those things to her. She stated that after the incident with Resident #1 she printed out anything she could on ANE and then spoke with the Corporate Nurse Regional Nurse and went over with staff that you cannot drag a resident down the hall, you do not turn the lights off, that they have rights and can watch tv, stay up. Stated when staff turned the lights off on Resident #1 that was violation of her rights. When staff dragged her down the hall on a bed sheet it was abuse. ADON stated she received training and in-service on abuse and neglect reporting abuse and protecting the residents. Review of the facility's Inservice Training Report dated 12/21/25 and /01/07/26 for Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse, protecting residents with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident. Indicated ADON signed these in-services on 12/21/25. and 01/07/26. During an interview on 01/12/26 at 6:01 PM, CNA I said before and after Resident #1 was dragged to her room, she had received training to prevent abuse and neglect, reporting abuse that included, taking a test and was in-service on resident rights. CNA I, said a resident should not be forced to go to bed and to go to sleep, should not be forcefully pushed in their wheelchair from one area to another, when they are refusing to leave the area, and should not be dragged on the floor to their room.Review of the facility's Inservice Training Report dated 12/21/25 for Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident. Indicated CNA I signed these in-services on 12/21/25.During an interview on 01/12/26 at 6:17 PM, CNA J said before and after Resident #1 was dragged to her room, she had received training to prevent abuse and neglect, reporting abuse and take a test and was in-service on resident rights. CNA J said a resident should not be forced to go to bed and go to sleep, should not be forcefully pushed in their wheelchair from one area to another, when they are refusing to leave the area, and should not be dragged on the floor to their room.Review of the facility's Inservice Training Report dated 12/21/25 for Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident. Indicated CNA J signed these in-services on 12/21/25.During an interview on 01/12/26 at 6:33 PM, LVN K indicated Resident #1 does not sleep during the night and spends most of the night watching the tv in the dining area. LVN K said most of the residents go to bed around 8:00 pm to 8:30 pm, and it is unusual for Resident #1 to be the only resident awake during the nights. LVN K said before and after Resident #1 was dragged to her room, she had received training to prevent abuse and neglect, reporting abuse which included taking a test and was in-service on resident rights. LVN K said a resident should not be forced to go to bed and to go to sleep, should not be forcefully pushed in their wheelchair from one area to another, when they are refusing to leave the area, and should not be dragged on the floor to their room.Review of the facility's Inservice Training Report dated 12/21/25 for Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident. Indicated LVN K signed these in-services on 12/21/25.On 01/13/26 at 10:18 AM, Resident #1 said she was watching tv show in the dining area, when the lady turned off the tv and told her she had to go to bed. The lady put a blanket over her head, and the ladies grabbed her feet and dragged her to her room. When she tried to leave her room that night, the lady (CNA) would tell her to go back to her room, and she would say no, you are not my boss. Resident #1 said she stayed in her room all night and did not come out. On Saturday 12/20/25, she did not report to anyone she had been abused, instead she stayed in her room, and the ladies did not hit her because she told them to leave her alone. Resident #1 said on Sunday she reported the abuse to CNAs E and G, and the ladies who dragged her to her room are not here anymore because they took them to jail.During an interview on 1/13/26 at 3:34 PM, attempted to call CNA B, no answer left a voice message with call back information. Followed up with a text message. CNA B did not respond to the call or text.During an interview on 1/13/26 at 3:36 PM, Attempted call to previous staff CNA C no answer mailbox is full unable to leave a voice message. Followed up with a text message. CNA C did not respond to the call or text.During an interview on 1/14/26 10:22 AM, ADON stated She stated based on policy she expects staff to report any abuse immediately. She stated staff did not follow the policy when they did not report the abuse the night it happened. She stated they did not follow the ANE policy of free from abuse.During an interview on 1/14/26 at 10:26 AM, the AD, stated she learned of the incident with Resident #1 after it happened. She stated that at her resident council meeting last month she went over forms of abuse and reporting abuse to try and help the residents to under to report it. She stated she felt like they were hearing her and understood. Stated no one had made any complaints of abuse to her prior. Stated she was in-serviced on resident rights, types of abuse to report immediately resident property, misappropriation of property.Review of the facility's Inservice Training Report dated 12/21/25 for Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident. Indicated AD signed these in-services on 12/21/25.During an interview on 1/14/26 at 11:58 AM, Local Law Enforcement stated an officer did report to the facility over an incident with Resident #1 and staff. He stated after the local law enforcement office reviewed the details it was believed it would be more of a violation of policy that staff broke. That they would not be filing charges against the staff involved.Record review of the facility's in-service dated 12-21-25, Abuse & Neglect revealed the facility in-serviced staff on abuse and neglect, reporting abuse with an emphasize on dragging a resident down the hall on a blanket is in fact abuse. Turning off the lights when staff want them to go to bed, which is also considered abuse. The residents have the rights in their home to sit up and watch TV all night if they want to. Residents have the right to read a book all night long if they want to. Staff are not allowed to force a resident to go to bed, turn off the lights or any other form that would cause injury or distress to a resident.Abuse and neglect in-service test dated 12/22/25 were completed and signed by staff.Behavioral Management test dated 12/22/25 - 1/7/26 were completed and signed by staff, staff. Abuse and neglect questionnaires for staff dated 12/22/25- 1/7/26 were completed and signed by staff.Record Review of Resident Safety Survey dated 12/21/25, 01/06/26 and 01/12/26 indicated the facility's residents were asked the following.1. Do you feel safe here?2. Do you have any concerns you would like to report?3. Are you afraid or fearful of any staff member here? If yes, who?There were no negative findings on these reports, including Resident #1.Record review statement LVN A provided to the ADM, ADON and BOM, typed by ADON revealed the following: on 12/21/2025 at 8:30 PM LVN A was asked about pulling Resident #1 down the hall on a blanket. LVN A replied, yes, we did it, that's on me. Are we supposed to just get hit and kicked all the time? Y'all know she's not been taking her meds for a long time now and no one has done anything about it. Typed statement signed by ADON and ADM as staff did not provide a written statement to the facility.Record review statement by CNA B provided to the ADM and BOM typed by the ADM revealed the following: on 12/21/2025 at or around 8:30 PM CNA B stated she did not do anything wrong because of all the behaviors they have in the building, and the resident was attacking them. CNA B was informed she was terminated, and she violated the resident's rights by physical and verbal abuse according to the video evidence. Typed and signed by ADM as staff did not provide a written statement to the facility.Record review statement by CNA C provided to the ADM and BOM typed by the ADM revealed the following: on 12/21/2025 at or around 8:30 PM CNA C stated she did not do anything wrong because she did what she was told, and she didn't think it was a big deal. CNA C was informed that she did something wrong by failure to report the incident and she grabbed the sheet to drag the resident down the hall with the others. Staff terminated staff failed to report a violation of resident rights and abuse of a resident.Record review of LVN A 's employee file revealed hire date 07/18/2024 and termination date 12/21/2025. LVN A was trained on abuse, awareness and prevention on 10/03/2024. Record review of CNA B's employee file revealed hire date 04/19/2023 and termination date 12/21/2025. CNA B was trained on abuse, awareness and prevention 07/22/2024.Record review of CNA C's employee files revealed hire date of 12/04/2023 and termination date of 12/21/2025. CNA C was trained on abuse, awareness and prevention 07/26/2024.Record review of punch time detail for LVN A revealed she worked 12/19/25 from 5:52 PM until 6:37 AM; on 12/20/2025 from 5:47 PM until 6:33 AM and 12/21/25 from 5:30 PM until 9:06 PM.Record review of punch time detail for CNA B revealed she worked 12/19/25 from 5:56 PM until 6:12 AM; on 12/20/2025 from 6:03 PM until 6:05 AM and 12/21/25 from 5:30 PM until 9:0 6PM.Record review of punch time detail for CNA C revealed she worked 12/19/25 from 5:52 PM until 6:14 AM; on 12/20/2025 from 5:46 PM until 6:04 AM and 12/21/25 from 5:57 PM until 7:45 PM.Record review of corrected action plan by ADM dated 12/21/2025 revealed safe surveys were to be done weekly for three months to make sure this did not happen again. In-service abuse and neglect, resident rights, and misappropriation. Reviewed in QAPI for three months and discussed with staff. Monitored camera footage from different shifts to monitor staff.Record review of policy and procedure for Abuse, Neglect, Exploitation, Misappropriation Prevention Program dated 2001 and revised April 2021 indicated: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, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.Policy Interpretation and Implementation:The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to:a. facility staffe. staff from other agenciesj. any other individual2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment3. Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and turnover rates.5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.6. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.7. Implement measures to address factors that may lead to abusive situations, for example: a. adequately prepare staff for caregiving responsibilities b. provided staff with opportunities to express challenges related to their job and work environment without reprimand or retaliation.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.9. Investigate and report any allegations within timeframes required by federal requirements.10. Protect residents from any further harm during investigations.The noncompliance was identified as PNC. The IJ began on 12/19/25 and ended on 01/07/26. The facility had corrected the noncompliance before the survey began on 01/12/26.

Based on observation, interview, and record review the facility failed to ensure of 5 of 8 residents (Residents #2, #3, #4, #5, and #6) were free from misappropriation of personal property.The facility did not prevent RN D from taking residents #2, #3, #4, #5 and #6's personal property. This failure could place residents at risk for decreased quality of life and distrust for the staff.Findings include:Record review of Resident #2's face sheet, dated 01/14/2026, revealed a [AGE] year-old female who was admitted to facility on 01/13/25 with diagnosis that included bilateral hearing loss (reduction of hearing ability to both ears), paraplegia (paralysis affecting the lower half of the body), major depressive disorder (persistent sadness, loss of interest in daily activities), anxiety disorder (mental health condition characterized by persistent, excessive fear and worry), age-related cataract of the left eye (clouding of the eye's natural lens), and bilateral optic atrophy (damage to the visual pathway).Record review of Resident #2's Annual Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 13, which indicated resident's cognition was intact. MDS Section GG-Functional Abilities revealed Resident #2 required setup or clean-up assistance with eating and oral hygiene, and was dependent on staff for toileting, shower/bathe self, upper and lower body dressing, putting on/ taking off footwear, and personal hygiene.During an interview 01/12/26 at 3:00 PM, Resident #2 said somebody had taken her wine bottle with flowers and faux water, signs with saying, a container with dry colorful flowers, container with markers, and her unopened container of Revitalift by Loreal face cream. Resident #2 said she liked these items and wanted them returned to her.Record review of Resident #3's face sheet, dated 01/14/2026, revealed a [AGE] year-old male who was admitted to facility on 07/20/23 with diagnosis that included age-related cataract of the left eye (clouding of the eye's natural lens), optic atrophy (damage to the visual pathway), mood disorder (emotional state like deep sadness (depression) or intense highs (manic/hypomania), depressive episodes (sadness, loss of interest in daily activities), and anxiety disorder (mental health condition characterized by persistent excessive fear and worry).Record review of Resident #3's Quarterly MDS, dated [DATE], revealed Resident #3 had a BIMS of 14, which indicated resident's cognition was intact. MDS's Section GG-Functional Abilities revealed Resident #3 required setup or clean-up assistance with eating, and was dependent on staff for oral hygiene, toileting, shower/bathe self, upper and lower body dressing, putting on/takin off footwear, and personal hygiene.During an interview 01/13/26 at 3:25 PM, Resident #3 said as far as he knew, he did not have any personal items missing from his room.Record review of Resident #4's face sheet, dated 01/14/2026, revealed a [AGE] year-old male who was admitted to facility on 10/08/25 with diagnosis that included squamous blepharitis of the right and left eye (seasonal allergies), bilateral age-related cataract of the left eye (clouding of the eye's natural lens), depression (sadness, loss of interest in daily activities), and delusional disorders (fixed false beliefs that aren't rooted in reality). Record review of Resident #4's MDS, dated [DATE], revealed Resident #4 had a BIMS of 11, which indicated resident's cognition was moderately impaired. Resident #4's Care Plan review date 10/16/25 revealed his Activities of Daily Living required setup or clean-up assistance with eating, and was dependent on staff for oral hygiene, toileting, shower/bathe self, upper and lower body dressing, putting on/off footwear, and personal hygiene.Resident #4 was not interviewed because he had been discharged from the facility on 12/12/25.During an interview on 01/13/26 at 12:20 pm the Family Member (DON) was interviewed and verified her dad Resident #4 did not know any of his items were missing and she only became aware of these missing items when they were given to her to return to Resident #4.Record review of Resident #5's face sheet, dated 01/16/2025, revealed a [AGE] year-old male who was admitted to facility on 09/26/25 with diagnosis that included Alzheimer's Disease (progressive brain disorder that slowly destroys memory and thinking skills), Schizoaffective Disorder (brain disorder affecting though, emotion, and behavior, causing hallucinations, delusions, disorganized speech and impaired functioning), bilateral age-related nuclear cataract (clouding of the eye's natural lens), and depression (sadness, loss of interest in daily activities). Record review of Resident #5's Quarterly MDS, dated [DATE], revealed Resident #5 had a BIMS of 4, which indicated resident's cognition was severely impaired. MDS's Section GG-Functional Abilities revealed Resident #5 was independent with eating, required substantial/maximal assistance with oral hygiene, and was dependent on staff for toileting, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, and personal hygiene.During an interview on 01/13/26 at 3:22 PM, Resident #5 moved his head sideways to indicate no, when he was asked if anybody had taken his personal items.Record review of Resident #6's face sheet, dated 01/14/2025, revealed a [AGE] year-old male who was admitted to facility on 03/02/45 with diagnosis that included Alzheimer's Disease (progressive brain disorder that slowly destroys memory and thinking skills), Impulse Disorder (persistent inability to resist strong urges or impulses, leading to repetitive behaviors that often harm oneself or others), retinal hemorrhage of left eye (bleeding in the retina), and depressed episodes (persistent feelings of sadness, emptiness, or loss of interest in nearly all activities). Record review of Resident #6's Quarterly MDS, dated [DATE], revealed Resident #6 had a BIMS of 1, which indicated resident's cognition was severely impaired. Resident #6's Care Plan dated 11/06/25 revealed he was independent with eating and oral hygiene; however, he was dependent on staff for personal hygiene, toileting, shower/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene.During an interview on 01/13/26 at 3:40 PM, Resident #6 said as far as he was aware, nobody had taken his personal items.Record review on 01/12/26 at 3:23 PM of the facility's video footage revealed RN D used a code to unlock and enter the gate on the side of the facility and place a bag in a wheelchair. Then he walked around to the other side of the building with a bag in his hand and exited through the gate. RN D re-entered through the gate carrying bags in his hand and walked to the side of the building. RN D was observed stepping out of a car at the front gate of the facility where he hung something on this front gate, then drove off.During an interview on 01/12/26 at 12:03 PM, the Director of Nurses (DON) stated Registered Nurse (RN D) stole several things from the residents and the facility, then over a few days, he returned these items to the facility by leaving trash bags of stuff outside of the facility near the gates. A search of these bags revealed there was clothing and various items that belonged to residents. The DON said the facility did not know these items were missing until RN D returned them to the facility. Residents did not report this information as they did not know their items were missing and did not report them missing. The only resident that reported anything missing was, Resident #2, who said her wallet and ID were missing. The facility did attempt to locate the wallet and ID and assisted Resident #2 with getting a new ID and bank card and verified there was not any money missing from Resident #2's bank account. They did not know the wallet was stolen until RN D returned it. The facility did contact the police and made a self-report once the items were returned and that was when they realized all the items were stolen. There is an intake number for this and a complainant made a report after the facility contacted her to let her know items were stolen and returned.During an interview on 01/12/26 at 2:00 PM, the ADM indicated RN D worked the night shift (6 PM to 6 AM) and that was how he was able to take items out of the building one backpack at a time he always brought his backpack to work. The ADM said RN D worked at the facility for about 2 months. Then the AD reported seeing large bags outside of the her office. The ADM asked why these large bags were outside, and the AD said RN D had dropped them off. He stated well we need to go through them and see what's in the bags. The ADM stated that RN D had apparently dropped off bags at the facility that morning and then was pulled over for speeding by DPS. RN D eventually informed DPS that he borrowed items from the residents but had returned them. Afterwards, the ADM stated his staff searched the bags and found jewelry, cell phones, laptops, clothes, CD's, random items, money, and a wallet with an ID that belonged to Resident #2. The interviews with staff said they did not know the items were missing and residents had not reported them missing. ADM stated that he texted RN D to let him know that due to the residents' missing items being in his possession, he was terminating his employment with the facility. ADM stated his staff were able to return the items promptly to the residents, and then anything that was left over and not identified as belonging to the residents was turned over to the police for evidence. The ADM said the facility is pressing charges against RN D and to his knowledge all missing items were replaced. ADM said he was informed Resident #2 had a cell phone missing; however, it was returned to her. He stated he is unaware as to why RN D took these items, because he was trained over ANE that includes misappropriation. ADM said RN D should not have taken items belonging to the residents, because it could mess with their psyche diagnosis, and because they are limited to personal items. The ADM said his expectations of staff was to prevent them from exploiting residents by taking and borrowing their personal items. The ADM stated the facility had counselors come to the facility and evaluate them for their psyche issues. Since this incident, the ADM had his staff trained over ANE to prevent this from happening again, and staff will not be allowed to bring big bags to work.During an interview on 01/12/26 at 2:46 PM, the Business Office Manager (BOM) stated the incident involving RN D was recorded on the facility's cameras 12/16/25. The BOM said she reviewed the camera footage on 12/19/25 revealing RN D carried trash bags to the facility and placed these bags on wheelchairs that were outside of the facility. Then RN D moved around to the other side of the facility, returned and put items into the bags. The BOM said on 12/15/25 the AD informed her that she heard someone outside of her office, and it was RN D leaving bags near her office. The BOM said the facility received a call from DPS, who wanted to know if RN D had worked at the facility and they reported yes, but he was currently not working because he was off duty. DPS reported that RN D had a lot of property in his car. Afterwards, the Maintenance Supervisor (MS) did a walkthrough of the facility's exterior area and found bags placed around the facility. The bags included food, clothes, perfume, cologne, amazon items, Hey [NAME] shoes, phones, iPad, rings, jewelry, cash app card, and a Social Security card and debit card that belonged to Resident #2. This card was reviewed and it had the correct balance, indicating RN D had not taken take any money. BOM said Resident #2 had reported that her wallet was missing, but the facility's staff were unable to find it. Resident #2's wallet was found but, but it didn't include her DL or SS card. The BOM said Resident #2 had reported the wallet missing but no one else had reported items missing. BOM stated RN D called and spoke with her, and she asked him why he took the residents' property and he stated, he loves those residents and would never do anything to then. Afterwards, BOM said RN D asked her if he could apply for the DON position, and she replied no.During an interview on 01/12/26 at 3:59 PM, Medication Aide (MA) on 12/16/25 indicated Resident #2 reported to her that her purse and wallet were missing. MA said she assisted with searching for these items, when the Maintenance Supervisor (MS) asked MA if she knew anything about the envelope with Resident #2's drivers' license. MA directed MS to report finding Resident #2's purse on 12/16/25 in the trash bag. MA said this bag had items labeled with names of people that had not lived at this facility. MA said she had never witnessed RN D taking items that belonged to a resident, if she had she would have reported this to the ADM. During an interview on 01/12/26 at 5:00 PM, CNA E said during Resident #2's shower on unknow date, Resident #2 asked CNA E to help search for her personal items, wallet, perfume, and credit card that were missing. CNA E searched for Resident 2's missing items; however, she did not find these items in her room. CNA E said she reported Resident #2's missing items to the DON and ADON, who said they would talk to Resident #1.Record review of the facility's inventory list indicated the following items were discovered in the trash bags left at the facility on 12/16/25 by the RN D as follows: Resident #2'sElizabeth [NAME] Red Door Perfume,Neutrogena Retinol,[NAME] reversal day cream,[NAME] Hills MD sculpting cream,Neutrogena retinol moisturizer night cream,Youth Dew Parfum spray,White Diamonds spray,Cash App Card,ID card,SS card,iPad,Phone,Wallet-brown.Resident #3'sBlack Texas Tech cup.Resident #4'sBlack Hey Dudes-size 11,2-green short sleeve (shirt)Plaid long sleeve blue shirt.Resident #5's1 small plaid red/white short sleeve (shirt),1 pair of brown [NAME] shoes,1 large Texas flag button shirt,1 SS button blue shirt1 van (shoes)1 ls gray button shirt.Resident #6'sPhillips Norelco Razor with guards and bag.The following items were sent to the police department:Gold chain,Wedding ring band, diamond,Diamond wedding ban,Gold band,Silver band,Men's silver band,Inseego power bank,2-Unifi cameras,3-aluminum flashlights,Duracell pack AAA batteries,Thermometer,1 left brace.During an interview on 01/14/25 at 11:58 PM with Officer from the sheriff's department, stated he responded to the incident involving possession of stolen property by RN D. The officer said RN D was in possession of stolen property and in possession of ID of an elderly. He stated RN D will be charged with 5 counts of theft and a felony for having the identification of an elderly.Record review of RN D's personnel file revealed he had received training for Resident's Rights on 10/27/2025, and he signed on that date. And he received training on Abuse Prohibition Policy and Procedures and signed on 10/27/2025. The employee file revealed the facility completed a background check on RN D and RN D was eligible for employment. The employee file revealed he was terminated on 12/16/25.Record review of the facility's Freedom from Abuse, Neglect, Exploitation that was undated, included Purpose: Ensure each resident's right to be free from abuse, neglect, and corporal punishment of any type by anyone. This policy defined Misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Examples of misappropriation of resident property included, but are not limited to:Identity theft,Theft of money from bank accounts,Unauthorized or coerced purchases on a resident's credit card,Unauthorized or coerced purchases from residents' funds, etc.Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021, included Resident have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to facility staff, etc.During an interview on 01/12/26 at 3:59 pm, Medication Aide (MA) said she had received training on resident rights: Ma Said a resident is not supposed to be forced to do anything against their will, and staff should not borrow, use, or take resident's personal items. During an interview on 01/12/26 at 4:38 PM CNA G said she had received training on resident rights. CNA G said a resident is not supposed to be forced to do anything against their will, and staff should not borrow, use, or take residents' personal items.During an interview on 01/12/26 at 5 PM CNA E said she had received training on resident rights. CNA E said a resident is not supposed to be forced to do anything against their will, and staff should not borrow, use, or take residents' personal items.During an interview on 01/12/26 at 6:01 PM, CNA I said he had received training on resident rights. CNA I said a resident is not supposed to be forced to do anything against their will, and staff should not borrow, use, or take residents' personal items.During an interview on 01/12/26 at 6:17 PM, CNA J said she had received training on resident rights. CNA J said a resident is not supposed to be forced to do anything against their will, and staff should not borrow, use, or take residents' personal items.During an interview on 01/12/26 at 6:33 PM, LVN K said she had received training on resident rights. LVN K said a resident is not supposed to be forced to do anything against their will, and staff should not borrow, use, or take residents' personal items.During an interview on 01/13/26 at 10:45 AM, AD said she had received training on resident rights. AD said a resident is not supposed to be forced to do anything against their will, and staff should not borrow, use, or take residents' personal items.Record Review of the facility's Safe Surveys for residents were completed 12/16/25, 12/21/25, 01/06/26 and 1/12/26. The Safe Survey indicated the residents were asked the following questions:1. Do you feel safe?2.Do you have any concerns that you would like to report?3. Are you afraid or fearful of any staff member: If yes, who?There were no negative findings reported by the facility's residents on these reports.Record review of the facility's in-service dated 12/16/25 staff were in-serviced on Abuse and Neglect, which included Exploitation and Misappropriation.

Based on Observations, interviews and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 1 resident (Resident #1), reviewed for pharmacy services. The facility failed to ensure Resident #1 was free of significant medication errors when MA B administered Tegretol 200mg (prescribed for seizures, bipolar disorder, and nerve pain), Lipitor 40mg (prescribed to lower cholesterol), Baclofen10mg (muscle relaxer), Metoprolol 25mg (prescribed to lower blood pressure), Neurontin 300mg (prescribed for seizures and nerve pain), Quetiapine Fumarate 200mg (medication prescribed for bipolar disorder and schizophrenia) to Resident #1 on 10/13/25, when these medications were prescribed to another resident. This failure could place residents at risk of adverse reaction related to taking medications not ordered by the physician.Findings Included: Record review of Resident #1's undated face sheet revealed a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: Alzheimer's disease with early onset (loss of cognitive functioning), essential hypertension (high blood pressure), cognitive communication deficit (inability to communicate clearly), Intermittent Explosive Disorder (mental health condition characterized by sudden, intense episodes of anger or aggression), psychotic disorder with hallucinations due to known physiological condition (mental health disorder), dry eye syndrome of bilateral lacrimal glands (dry eyes), acute atopic conjunctivitis, right eye (infection in the eye), and muscle weakness . Record review of Resident #1's annual MDS, dated [DATE] revealed a BIMS score of 99, which indicated the resident's cognitive status could not be determined using the BIMS assessment. Record review of Resident #1's physician orders dated 10/16/25, did not reveal orders for Tegretol 200mg, Lipitor 40mg, Baclofen10mg, Metoprolol 25mg, Neurontin 300mg, Quetiapine Fumarate 200mg. Record review of physician orders did not reveal any new orders regarding the medication error. Record review of Resident #1's Medication Administration Record, dated 10/01/25-10/31/25, did not reveal physician ordered medications for Tegretol 200mg, Lipitor 40mg, Baclofen10mg, Metoprolol 25mg, Neurontin 300mg, Quetiapine Fumarate 200mg. Record review of Resident #1's Medication Error Report, dated 10/13/25, revealed Resident #1 was given the wrong medication on 10/13/25 at 15:20 (3:30 PM). Record review of Progress notes dated 10/13/25, revealed in part, on 10/13/25 the ADON noted she was advised by MA B that he had given Resident #1 the wrong medications at 15:20 (3:30PM). Record review of Progress notes dated 10/13/25, revealed in part, on 10/13/25 the LVN A noted she was instructed to contact emergency medical services to have Resident #1 transferred to the local hospital at 21:45 (9:45PM). Record review of hospital records, dated 10/14/25, revealed Resident #1 was admitted into the hospital for close monitoring. During an interview on 10/16/25 at 09:30 AM, the ADM said MA B gave Resident #1 the wrong medications. The ADM said the MD was notified and instructed staff to monitor the resident but later instructed staff to send Resident #1 to the hospital. The ADM said Resident #1's vitals were stable when EMS arrived, however Resident #1 was transferred to the hospital as per physician orders. The ADM said Resident #1 returned to the facility on [DATE] with no additional orders. During an observation and interview on 10/16/25 at 11:40 AM, Resident #1 was observed rolling up and down the facility hallways holding a shirt. She said she was doing good. She said she needed a shirt for work and then she rolled away. Resident #1 was active and alert. During an observation and interview on 10/16/25 at 2:48 PM, Resident #1 was observed at the nurse station talking with staff. During an interview on 10/16/25 at 3:45 PM, MA B said Resident #1 was having behaviors and hollering in the dining room when he was passing out medications. He said he was parked with the medication cart in front in the nurses station when the ADON brought Resident #1 by the nurse station. MA B said he became irritated as he had verbalized before that he did not like when they set the residents around him when he prepared medications because it caused him to become distracted. He said he mistakenly gave Resident #1 the wrong medications. He immediately realized the mistake and reported it to the ADON and the DON. During an interview on 10/16/25 at 4:26 PM, the ADON said she was in the medication room when she heard Resident #1 hollering. She said Resident #1 indicated she wanted to be moved to the area by where the medication cart was by pointing her finger in that direction when she parked her there, then she went back to the office to continue working. She said MA B was at the medication cart passing out medications. She said MA B told her he gave Resident #1 the wrong medication. She said the MD instructed staff to monitor Resident #1. She said she had received training on and in-services on medications pass. She said staff were provided in-services and completed competency checklists after the incident. The ADON said she did not know what system was implemented to prevent medications errors from happening. She said the MA and nurses were responsible to ensure the medications were given to residents. She said she expected staff do what they knew they were supposed to do, check blood pressures if required, and notify the nurse of any issues. She said MAs went to school and should know how to pass out medications correctly. She said a potential negative outcome of taking the wrong medication was that a resident could end up in the hospital or could experience anaphylaxis- a severe, immediate, potential fatal systemic allergic reaction. During an interview on 10/16/25 at 5:06 PM, the MD said he was notified of the medication error and instructed staff to observe the resident, check vitals, and to send her to the hospital if she was lethargic. He said her vitals were stable and they were monitoring for changes but he then sent her to the hospital for closer observation. He said staff followed the facility protocol. He said an error was an error and the significance of an error did not matter and that he expected staff to follow the medication error protocol. He said errors happened all the time. He said an adverse outcome of an error of one dose was lower. He said a potential negative outcome was the resident could get sleepy, they could have an allergic reaction, or they could die. He said the important thing was to determine how it happened, check the patient, and to do what you could to tend to the patient. During an observation and interview on 10/16/25 at 5:22 PM, Resident #1 was observed rolling down the hallways. She said she was sick in the hospital. She said she was better. During an observation and interview on 10/17/25 at 10:05 AM, Resident #1 was observed in her bedroom dressed as she went through clothes in her dresser. She said she was at the hospital but could not verbalize the reason. During an interview on 10/17/25 at 10:50 AM, the DON said the policy for medication errors was to suspend staff, complete an investigation, complete the medication error form, monitor the resident, and to ensure all medications were given correctly to other residents. She said she became aware of the medication error after the incident occurred via text message from staff. She said the resident's allergies were verified. She said the MD ordered continued monitoring but later ordered staff to contact EMS to transport Resident #1 to the hospital. She said the system in place to prevent medication errors was to re-educate staff and provide them with in-services on medication pass. She said the nurse on duty was responsible to ensure medications were given to residents correctly. She said she expected staff to follow the six rights of residents which were to ensure the dose, person, route, medication, time and documentation were all correct and to make sure they were passing medications correctly. She said she could not speculate what could happen if a person received the wrong medication, they must call the doctor, inform him, take vital signs, follow his orders, and provide close supervision to the resident. During an interview on 10/17/25 at 11:27 AM, the ADM said the policy for when a medication error occurred was to complete notifications and all were done. He said staff completed competencies and were in-serviced on medication pass afterwards. He said he was notified of the medication error immediately after it occurred and the MD ordered staff to monitor the resident. He said staff continued to monitor Resident #1 until the MD ordered the resident to be transferred to the hospital for monitoring. He said the resident was admitted to the hospital for observations and monitoring for 48 hours. He said there had been no issues since she returned to the facility and she was discharged with no new orders. He said the system the facility had in place to prevent medication errors was to provide in-services to staff, educate them, and review competencies. The ADM said the previous DON and ADM provided staff with in-services on medication pass in August 2025. He said the DON and nurse on shift were responsible to ensure medications were passed out correctly, and ultimately he was responsible as well. He said he expected staff to follow the six medication rights when passing out medications, which were the to ensure the dose, person, route, medication, time, and documentation were all correct. He said he could not speculate potential negative outcomes to residents when taking the wrong medications as it was determined on a case-by-case basis, and the outcome could be serious or not be serious. Record review of facility policy titled, Administering Medications, revised in April 2019, revealed in part: Policy StatementMedications shall be administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation3. Medications must be administered in accordance with the orders, including any required time frame.6. The individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include:a. Checking identification band;b. Checking photograph attached to medical record; andc. If necessary, verifying resident identification with other facility personnel.7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Record review of facility policy titled, Medication Errors and Drug Reactions, undated, revealed in part: Purpose: Establish uniform guidelines for reporting and recording of medications errors and drug reactions. Definitions:Medication Error means the observed or identified preparation or administration of medications or biologicals which is not In accordance with:1. The prescriber's order;2. Manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological or3. Accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the various practice regulations in each State, and current commonly accepted health standards established by national organizations, boards, and councils. Significant medication error means one which causes the resident discomfort or jeopardizes his or her health and safety. Criteria for judging significant medication errors as well as examples are provided below. Significance may be subjective or relative depending on the individual situation and duration, e.g., constipation that Is unrelieved because an ordered laxative is omitted for one day, resulting in a medication error, may cause a resident slight discomfort or perhaps no discomfort at all. However, If this omission leads to constipation that persists for greater than three days, the medication error may be deemed significant since constipation that causes an obstruction or fecal impaction can directly jeopardize the resident's health and safety.

Based on observation, interview, and record review, the facility failed to provide a private meeting space for residents' monthly council meetings for 14 of 35 confidential residents who were reviewed for resident council.The facility failed to provide a private space for resident council meetings.Based on observation, interview, and record review, the facility failed to provide a private meeting space for residents' monthly council meetings for 14 of 35 confidential residents who were reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents at risk of not being able to voice concerns due to a lack of privacy. Findings include: Observation of the dining room on 9/15/25 revealed multiple staff and residents coming in and out of the dining room while the Resident Council meeting was in session. In a confidential group interview on 9/15/25 14 alert and orientated residents, who attended resident council, stated resident council was always held in the dining room. They stated staff came in and out with no privacy, and they filtered what they said due to staff presence. Residents stated there was no sign posted asking for privacy during Resident Council. They also stated they are not comfortable with the Resident Council being held in the dining room as it was right outside the ADM's office. They stated they would prefer the Resident Council be held in a more private setting. Interview on 9/16/25 at 2:40PM, the Activities Director stated Resident Council was held in the dining room for the entirety of her employment with the facility, 10 years. The AD stated it was not a private space; she stated there was no sign posted during resident council to request privacy. The AD stated there was a partition that could be pulled on the East side of the dining room to hold Resident Council in a more private area. The AD stated she did not hold Resident Council with the partition being used because she is not used to utilizing the partition. There were no doors to close to the dining room. She stated there were no barriers to utilizing the partition in the future for Resident Council meetings. The AD stated the potential negative outcome for not providing privacy during the Resident Council meeting was Residents may not speak freely due to staff overhearing their conversations. Interview on 9/16/25 at 3:00PM the Administrator stated she did not feel the dining room was a private setting for hosting Resident Council. She stated she thought the AD would host Resident council behind the partition on the East side of the Dining Room. The ADM stated the AD did not host Resident Council behind the partition due to lack of training. The ADM stated she oversaw training the AD to hold Resident Council in a private setting. She stated the potential negative outcome of not having a private setting for Resident Council was the Residents may not feel comfortable sharing their needs, thoughts, feelings, and complaints. Record review of Resident Council Minutes for June 2025 revealed Resident Council was held in the dining room with 8 residents present. Record review of Resident Council Minutes for July 2025 revealed Resident Council was held in the dining room with 10 residents present. Record review of Resident Council Minutes for August 2025 revealed Resident Council was held in the dining room with 12 residents present. Record Review of the facility's Resident Council Policy Revised April 2017, revealed the following: Policy StatementThe facility supports residents' rights to organize and participate in the Resident Council.Policy Interpretation and Implementation1. The purpose of the Resident Council is to provide a forum for:a. Residents, families, and resident representatives to have input in the operation of the facility.b. Discussion of concerns and suggestions for improvement.c. Consensus building and communication between residents and facility staff; andd. Disseminating information and gathering feedback from interested residents.

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 14 of 35 confidential residents reviewed for resident rights. The facility failed to ensure 14 confidential residents were provided, the Grievance Procedure, information in regard to who the facilities' grievance officer was, their contact information, and how to file an anonymous grievance. Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 14 of 35 confidential residents reviewed for resident rights. The facility failed to ensure 14 confidential residents were provided, the Grievance Procedure, information in regard to who the facilities' grievance officer was, their contact information, and how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings included: Interviews and Record Review during Resident Council on 09/15/2025 revealed 14 confidential residents stated they did not have access to a Grievance form, they did not know they could file a Grievance anonymously, and they had not observed a posting of the Grievance procedure on the Resident bulletin board. Observation of the facility on 9/15/2025 at 3:45pm revealed the following: Facility postings did not include instructions regarding the Grievance procedure with any of the prominent postings. Grievance forms were not available to Residents in the facility.There was no access to submit a Grievance anonymously. Interview with the ADM on 9/16/2025 at 3:15pm, the ADM stated she was the Grievance Officer for the facility. The ADM stated she was responsible for the review of Grievances and to assign them to department heads. The ADM stated the Grievance forms are available, upon request, at the nurses' station. The ADM stated the staff complete a Grievance form if a resident has a complaint. The ADM stated there was no procedure for Residents to submit Grievances anonymously. The ADM stated the facility had a responsibility to resolve Grievances immediately with a final resolution being completed within 5 days. The ADM stated she assigned the Grievance to the appropriate department, that department addressed the grievance with the complainant, resolved the grievance, and explained the resolution to the complainant. The resolution was documented on the Grievance form and the completed form was submitted to the ADM for review. The ADM stated completed Grievance forms were kept in a notebook. The ADM stated she monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance, the ADM stated she would also meet with the complainant to ensure they were satisfied with the resolution. The ADM stated the CNA supervisor, laundry supervisor, and the DON were responsible for ensuring staff were trained on the Grievance process. Record Review of the Grievance Policy updated April 2017 reflected the following: Policy Statement:Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or their representative. The Resident and/or the representative has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have. Policy Interpretation and Implementation: Any resident, family member, or representative may file a grievance or complaint.Upon admission, residents are provided with written information on how to file a grievance. A copy of the Grievance/Complaint Procedure should be posted on the resident bulletin board.Grievances may be submitted orally or in writing and may be filed anonymously.The contact information for the individual with whom a grievance may be filed is provided to the residents or representative upon admission.If the grievance is filed anonymously the grievance officer will inform the resident that a grievance has been anonymously filed on his or her behalf and the steps that will be taken to investigate the grievance and report the findings. This policy will be provided to the residents or the resident's representative upon request.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed to ensure frozen pork was not stored above ready-to-eat foods in the freezer. The facility failed to ensure the window seal directly above the kitchen sink was free of dirt build-up and grime.The facility failed to ensure a container of ice used to prepare drinks for lunch, did not have a scoop stored inside of it.The facility failed to ensure all condiments had expiration or use-by dates. The facility failed to ensure a cleaning schedule was followed and monitored. These failures could place residents who received meals and/or snacks from the kitchen at risk of food contamination and food borne illness.Findings included: During the initial tour and observation of the kitchen on 09/14/25 at 11:20 AM the following were revealed: *Two packages of uncooked pork loin stored in a kitchen freezer above ready-to-eat and prepared food items such as a chocolate pie and sweet potato casserole. *A window seal above the kitchen sink had a thick yellow and brown build-up of dirt and grime. *The wall above the kitchen stove contained a yellow layer of grease, dirt, and grim. *The cart used for storing silverware and meal trays contained a build-up of food and grease. *The floor and wall beside the refrigerator in the kitchen were soiled with dirt, grease, and grime. *Plastic containers of individual condiments such as mayonnaise, mustard, picante sauce, tabasco sauce, tartar sauce, ranch dressing, and ketchup did not contain expiration or used by dates on the individual packets or on the storage containers. *A plastic scoop was observed to be stored in a bucket of ice used to prepare resident's drinks for lunch. During an observation of the kitchen on 09/15/2025 at 10:30 AM revealed the following:*Two packages of pork loin were stored above ready-to-eat and prepared food items in the kitchen freezer. *A window seal above the kitchen sink had a thick yellow and brown build-up of dirt and grime. *The wall above the kitchen stove contained a yellow layer of grease, dirt, and grim. *The cart used for storing silverware and meal trays contained a build-up of food and grease. *The floor and wall beside the refrigerator in the kitchen were soiled with dirt, grease, and grime. *Plastic containers of individual condiments such as mayonnaise, mustard, picante sauce, tabasco sauce, tartar sauce, ranch dressing, and ketchup did not contain expiration or used by dates on the individual packets or on the storage containers. During an interview on 09/16/2025 at 2:30 PM the DM stated she had been the dietary manager for approximately one week. The DM stated uncooked meats should have been stored under ready-to-eat and prepared food items. The DM stated she was responsible for putting away food items in the freezer and refrigerator. The DM stated this was a task she did herself. The DM stated she was unaware the pork loins were stored above ready-to-eat food items and stated she did not see it. The DM stated she would reorganize the freezer to ensure food was stored properly. The DM stated it was important for uncooked meats to be stored properly as it could have caused cross contamination. The DM stated she was unaware the individual condiments did not contain expiration or use by dates on the individual packages. The DM stated as they received new orders, the condiments were rotated, and the new condiments were placed at the bottom of the containers. The DM stated the individual condiments did not usually last more than one month because the residents used them often. The DM stated there was not a way to ensure the individual condiments were rotated since they did not have a date. The DM stated she was unaware the window seal above the kitchen sink contained a thick layer of dirt and grime. The DM stated she was unaware the wall behind the kitchen stove contained a layer of grease, dirt, and grime. The DM stated she observed the wall and floor beside the refrigerator, and she was aware of the dirt and grime build-up. The DM stated she was not aware the ice scoop was left inside the ice container. The DM stated the dietary staff had a cleaning schedule, but it had not been updated recently as the dietary staff have been short-handed recently. The DM stated it was her expectation that all areas in the kitchen were deep cleaned regularly and maintained through daily cleaning. The DM stated she planned to work on a deep cleaning schedule as soon as possible. The DM stated it was important to maintain a clean and sanitary kitchen to ensure residents did not get sick. The DM stated all dietary staff received training on storing and labelling food items in the kitchen as well as ensuring the kitchen area was clean and sanitary to prevent food borne illnesses. The DM stated all food items must be labeled and dated as consuming expired or outdated items may cause residents to get sick. The DM stated she would ensure all items were dated as soon as possible. The DM stated she planned to rearrange the freezer as soon as possible to ensure there were no items stored improperly and to prevent cross contamination. During an interview on 09/16/2025 at 3:05 PM the ADM stated it was her expectation that the kitchen was clean and sanitary. The ADM stated the DM was responsible for ensuring the kitchen was clean. The ADM stated the DM should have had a cleaning schedule for all dietary staff. The ADM stated the DM was responsible for ensuring food was stored properly and food items were labeled and dated with an expiration or used by date. The ADM stated the DM, and all dietary staff received training on cleanliness and sanitation as well as proper food storage. The ADM stated uncooked pork should not have been stored above ready-to-eat food items as it could result in cross contamination, leading to food borne illnesses. The ADM stated all food items, including condiments, should contain an expiration or used by date. The ADM stated residents could become sick if the kitchen is not clean and sanitary and food items were not stored properly. Record review of the facility's policy titled, Sanitation, dated October 2008, revealed the following: Policy Statement:The food service area shall be maintained in a clean and sanitary manner.Policy Interpretation and Implementation:1- All kitchens, kitchen area and dining areas shall be kept clean, free from litter and rubbish and protected f1om rodents, roaches, flies, and other insects.2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions,, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair.16. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime.17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Record review of the facility's policy titled, Food Receiving and Storage, dated October 2017, revealed the following:Policy Statement:Foods shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation:l. Food Services, or other designated staff, will maintain clean food storage areas at all times.7. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated ( use by date). Such foods will be rotated using a first in - first out system.13. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables, and other ready-to-eat foods

Based on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 3 of 30 days (8/30/2025, 9/4/2025, and 9/13/2025) reviewed for RN coverage.- The facility failed to ensure that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week on 8/30/2025, 9/4/2025, and 9/13/2025. This failure could place residents at risk of not having adequate qualified personnel in case of a health crisis. Findings include:Record review of facility document titled Punch details- Report, revealed on 8/30/2025 the facility had RN coverage for 3.5 hours. On 9/4/2025 the facility had RN coverage for 7.02 hours. On 9/13/2025 the facility did not have any documented RN coverage. During an interview on 9/16/2025 at 12:29pm with the DON she stated she was responsible for ensuring the facility had RN coverage. She stated one of those days, the RN for that day was delayed at the airport and was unable to provide coverage for the rest of the day. She stated on 9/13/2025 she had been sick and was unable to provide coverage and she was unable to find anyone to come in. She stated she did expect her RN staff to provide coverage for the entire 8 hours they are on schedule and not to clock out early. She stated she was always available for coverage and was available by phone if needed. She stated the RN coverage was required for RN assessments, or physician orders that require an RN's scope of practice. She stated the facility had hired another RN that would be covering the weekends. During an interview on 9/16/2025 at 3:01pm with the ADM, she stated the DON was responsible for ensuring the facility had RN coverage. She stated RN coverage was required to ensure quality care for residents. She stated a potential negative outcome of not having the RN coverage could be residents not having their daily care overseen by an RN. She stated she was not aware there had been days with low or no RN coverage. Record review of facility policy titled Departmental Supervision dated 8/2006, revealed; .an RN nurse supervisor/charger nurse is responsible for the supervision of all nursing department activities including the supervision of direct care staff for 8 consecutive hours per 24-hour period beginning at midnight.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 1 of 16 (Resident # 37) residents reviewed for abuse and neglect.- The facility did not report to the State Agency when Resident #37, was found unresponsive and not breathing in her room on 8/3/2025. On 8/9/2025 the DON was made aware that EMS reported food in Resident #37 airway, as a possible cause for Resident #37's medical emergency. This failure could place residents at risk of abuse, neglect and eliminate the opportunity for a timely investigation by the State Agency. Findings include: Record review of Resident #37s undated face sheet, revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #37 had a medical history of absence of right and left leg below the knee (amputation below the knee), gastro esophageal reflux disease (a condition where stomach contents flow back up into the esophagus, causing irritation and various symptoms), bipolar disorder (a chronic mental health condition characterized by extreme mood swings), schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder), muscle wasting (a condition characterized by the loss of muscle mass and strength), lack of coordination, insomnia (persistent problems falling and staying asleep), obesity (excessive body fat accumulation that can negatively impact health), muscle weakness, anxiety and type two diabetes. Record review of Resident #37's annual MDS dated [DATE], Section C- Cognitive Patterns revealed a BIMS score of 7 which indicated Resident #37 had severe cognitive impairment. Section K - Swallowing/Nutritional status revealed Resident #37 did not have signs and symptoms of a possible swallowing disorder. Section GG- Functional Abilities revealed Resident #37 required setup or clean-up assistance with eating. Record review of Resident #37's care plan dated 8/12/2025 did not reveal residents had any swallowing difficulty or required direct supervision during meals. Record review of Resident #37's physician orders revealed an order for a reduced concentrated sweets diet, regular texture/consistency and double portions, with an order start date of 9/23/2024. Record review of Resident #37's nutritional risk and dietary assessment dated [DATE], revealed Resident #37 did not have symptoms related to a swallowing disorder. Record review of Resident #37's progress notes revealed an entry dated 8/3/2025 at 5:20pm Resident [#37] was observed lying on her mat in her room unresponsive with no heart rate or respirations. CPR initiated. 911 called by CNA [unknown CNA]. After four cycles of CPR, AED placed on resident's chest. After analyzing, no shock advised, continue CPR. CPR continued x 22 minutes when first responder arrived and continued CPR. EMS here at 5:45pm and took over CPR and transferred resident to stretcher x 3 assist and exited facility with CPR in progress. Paperwork given to EMS and left facility at 1800 [6:00pm], signed by LVN A [agency nurse]. Record review of Resident #37's progress notes revealed an entry dated 8/9/2025 at 3:37pm, Spoke with [MDI], Resident [#37] passed away. Looks like cause of death will be choking. EMS found food in her airway. [MDI] will be doing a record review before final cause of death will be determined signed by the DON. Record review of EMS report dated 8/3/2025 revealed EMS arrived at the facility at 5:42pm. At 5:43pm, the summary of findings did not reveal any external abnormalities to Resident #37's head, neck, bilateral eyes, front and back torso, pelvis, abdomen, or peripheral extremities. EMS report revealed Resident #37 had no pulse and no respirations upon EMS arrival. EMS report revealed upon first look foreign body noted in the upper airway.removed a large piece of possible meat like gray foreign body obstruction from the upper airway with [NAME] forceps (angled surgical tongs used to guide breathing tubes into the windpipe) .ETT (a tube inserted into the windpipe for ventilation and airway protection) was then able to pass. At 5:52pm, EMS reported Resident #37 had a pulse of 80, a blood sugar of 68, and a blood pressure of 90/XX [diastolic not obtained], no respirations noted. At 6:07pm, EMS reported Resident #37 had a blood pressure of 173/126, a pulse of 80, and respiratory rate 18 with mechanical ventilation (a medical procedure that assists or takes over breathing for a patient who is unable to breathe adequately on their own). Resident #37 did not obtain consciousness and was transported to a local hospital. During an interview on 9/16/2025 at 10:35 AM with VPOO, she stated they had not reported the incident with Resident #37 to the State Agency as they were unable to determine if the resident had choked at the facility or at the hospital. She stated Resident #37 was at the hospital for a few days after she was found unresponsive in her room. She stated the facility had performed CPR and there had been no indication Resident #37 had choked at that time. She stated they had worked with the medical examiner and were told they did not have any fault in her death and had nothing to worry about. During an interview on 9/16/2025 at 12:29 with the DON, she stated on 8/3/2025 she was notified of the incident with Resident #37 by LVN A, who was no longer at the facility. She stated the agency nurse told them they had been passing food trays out to the residents. She stated LVN A had gone in to check on Resident #37 and she had found her unresponsive, and they began CPR. The DON stated EMS was called and when they arrived, they took over CPR and Resident #37 was transported to the hospital. She stated at that time there had been no reports of food being in Resident #37's airway. The DON Stated she was not sure when she spoke to the MDI (Medicolegal Death Investigator, who assist with the investigation of reported deaths to the Medical Examiner's Office), but she was told Resident #37s had passed away after a few days on palliative care at the hospital. She stated the MDI had asked some questions about how the resident was found and what had transpired. She stated the MDI told her, this case would be accidental and there would be no autopsy performed. She stated the MDI did mention EMS reporting food being in her throat but that the food could have come up during CPR. She stated she was not aware of food being in her airway when she was found and she had not seen the EMS report. The DON stated there was nothing that suggested Resident #37 had fallen, or that it was negligent on the facilities part. She stated the facility, and staff did everything the way it was supposed to happen. She stated there was no question whether the facility was negligent. The DON stated Resident #37 was able to feed herself and did not require supervision. She stated Resident #37 did not have a history of swallowing impairments or dysphagia (medical term for difficulty swallowing food or liquids). She stated Resident #37 did not have any signs of end of life and was not on hospice. The DON stated there was no neglect or delay in CPR to report that the facility had not done their job. The DON stated Resident #37 had not fallen and no one had gone into Resident #37s room and harmed her; she was found unresponsive. The DON stated she did not believe the incident was suspicious due to Resident #37s history health problems, and therefore did not believe it would be something that needed to be reported. The DON stated the MDI did not report it as a suspicious death but more of an incident. She stated EMS was able to get her back and Resident #37 lived a few more days at the hospital. She stated she believed that once they spoke to the MDI, the facility felt they were not negligent. During an interview on 9/16/2025 at 3:13 with the ADM, she stated she was not the ADM at the time of that incident. She stated the potential negative outcome of not reporting incidents to state agencies could be harm to the residents. She stated without knowing all the facts of the incident or being here during that time, it was difficult to determine why the incident was not reported to the State Agency. She stated if any resident is found unresponsive and it was unwitnessed, it should be reported.During an interview on 9/17/2025 at 10:02AM with the MDI, she stated on 8/9/2025 the hospital reported to her Resident #37's death. She stated the deceased [Resident #37] was found unresponsive and slumped over in her room. She stated EMS had reported food in the airway at the time of intubation. The MDI stated food in the airway does not mean the resident choked. She stated the food in the airway could have been from CPR or regurgitating (vomiting) after she became unresponsive. She stated after reviewing Resident #37s medical history, there was nothing that indicated she was at risk for choking on her food. She stated she could only speculate on what happened such as a stroke (stroke occurs when the blood supply to part of the brain is blocked or reduced), or an infarct (a small, localized area of dead tissue resulting from failure of blood supply). She stated when she reviewed the EMS report, there were no signs of her choking, only that they had found food when intubating but that could have been from CPR. The MDI stated she did not suspect any trauma or abuse that contributed to this incident. She stated there were no suspicions or evidence of foul play and Resident #37s had been released to a funeral home with no autopsy. The MDI stated she never instructed the facility not to notify the State Agency, only that she had not suspected the facility was negligent. She stated she did speak to Resident #37's family and explained her findings and they had no concerns over her care at the facility and did not have any other questions in regard to the incident. Record review of undated facility policy titled Allegations of Abuse, Neglect, Exploitations, or Mistreatment revealed Purpose: Ensure alleged violations related to mistreatment, exploitation, neglect or abuse, including injuries of unknown source and misappropriation of resident property and the results of all investigations are thoroughly investigated and reported to the proper authorities within required time frames.2. All alleged violations, whether oral or in writing, must be immediately reported to the administrator of this facility and to other official in accordance with State law through established procedures (including to the state survey and certification agency.Definitions: alleged violations is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source.injuries of unknown source- an injury should be classified when both of the following criteria are met: the source of the injury was not observed by any person or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury.

Based on observation, interview and record review the facility failed to implement written policies and procedures that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of known source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Administrator for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure a safe environment free from physical and verbal abuse for Resident #1 when LVN D grabbed and pulled Resident #1 from behind the nurse's station, and Resident #1 was observed with redness on 07/13/25, and with bruises to both hands and wrists on 07/14/25. During this incident LVN D said to the resident three times that her daddy was dead. The noncompliance was identified as PNC. The IT began on 07/13/25 and ended on 07/14/25. The facility had corrected the noncompliance before the survey began on 07/15/25. These failures could affect all residents by placing them at risk of continued abuse, physical harm, pain, mental anguish, emotional distress, and serious harm. Findings include:Record review of Resident #1's face sheet, dated 07/17/25, revealed an [AGE] year-old-female who was originally admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia mild, with mood disturbance (cognitive decline with changes in behavior), insomnia (trouble sleeping), anxiety disorder ( excessive worry feelings of fear), disorientation (lost sense of direction), glaucoma (vision loss), schizoaffective disorder bipolar type (mental health condition episodes mania and depression), intermittent explosive disorder (physical and/or verbal outburst), lack of coordination (unsteadiness), muscle wasting (decrease in strength), muscle weakness (lack of movement), depression (sadness), difficulty in walking (abnormal walking pattern). Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE] revealed: Section C Brief Interview for Mental Status (BIMS) score revealed a score of 3 which indicated the resident's cognition was impaired. Section E Behavior indicated Resident 1 had potential behavior of psychosis that included hallucinations and delusions. And she exhibited physical behaviors directed towards others every 1 to 3 days, verbal behaviors directed towards others every 4 to 6 days, and wandering behavior that occurred every 4 to 6 days. Record review of Resident #1's care plan, dated 06/25/2025, revealed: Focus: Resident #1 had episodes of verbal/physical aggression. Date initiated 05/10/2024Intervention: Assist me to phone [family member] during episodes of agitation. Give me as many choices as possible about care and activities. Monitor for physical/verbally aggressive q shift. Document observed behavior and attempted interventions in behavior log. Focus: Resident #1 is an elopement risk/wanderer r/t disoriented to place, wander risk score 11. Date initiated 12/27/2024 date revised 06/25/2025. Intervention: Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, I prefer having snacks. Date initiated 12/27/2024 revised date 12/24/2025. Record review of Resident #1's progress notes, dated 07/14/2025 - 07/16/2025 revealed: On 07/14/2025 at 1:03 PM, the DON documented a Late Entry, because she was notified of Resident #1 having bruises to both wrists from an incident that occurred the on 07/13/25. The DON went to assess Resident #1 and found her to have bruising to both wrists. Resident #1 was asked if she was in pain from the bruising and she stated no. Notified the MD and emergency contact. The MD gave an order to get an x-ray to both wrists. Hospice was notified 07/16/2025 at 3:29 PM, the DON documented spoke with Hospice staff about bruising on [Resident #1's] bilateral wrist. Per Hospice staff, the bruising to her wrists were not there Friday (07/11/2025). Per Hospice staff, she spent about 30 to 40 minutes talking with [Resident #1]. Monday (07-14-2025) Hospice staff did not know about bruising because [Resident #1] had her hands under her head and refused a shower. Noted resident is frequently wearing long sleeves. Record review of the x-ray report dated 07/14/2025 for Resident #1 revealed the right had wrist no acute abnormalities. The left wrist had osteopenia ( body doesn't make new bone as quickly as it reabsorbs old bone) and degenerative changes. Record review of Resident #1's physician's progress note dated 07/15/2025 revealed staff reported new onset bruising to bilateral ( having or relating to two sides; affecting both sides) FA (forearms). Record review of Resident #1's physician's orders dated 07/17/25 revealed Resident #1 was not prescribed blood thinners at the time of the incident. Observation on 07/15/25 at 7:30 AM indicated the nurses' cart was next to the display case that contained the reporting number for abuse and/or neglect and included the Administrator's phone number. Observation on 07/15/25 at 9:30 am of the facility's video recording dated 07/13/25 at 6:07 PM revealed LVN D was at the medication cart that was next to and in front of the nurse' station, when Resident #1 passed behind her and went into the nurses' station. LVN D said to Resident #1 You can't go back there. and Resident #1 replied I can too. LVN D said You cannot. and Resident #1 replied My daddy own's this place. LVN D said Look lady as she grabbed Resident #1's left wrist, and Resident #1 responded by swinging her right hand at LVN D and stated, Leave me alone. LVN D said Stop. LVN D released Resident #1's right hand and placed something LVN D was holding in her hand on the nurses' desk. LVN D grabbed Resident #1's wrists with her hands and started pulling her out from behind the nurses' station. CNA C then approached LVN D and Resident #1 and said, [Resident #1] get out from back there; you can't be back there. LVN D continued to pull Resident #1 as Resident #1 resisted, kicked, and said to LVN D Turn loose my hands. LVN D pulled Resident #1 into the hallway and around the cabinet, which was out of camera view, and CNA C walked along side of them. LVN D could be heard saying I'm not going to fight with you. CNA B approached the nurses' station and said to Resident D Stop, and then CNA B used the medication cart to block the entry way into the nurses' station. Resident #1 could be heard saying My daddy's the one who owns this place. and LVN D responded He doesn't own it anymore because he's dead. Resident #1 replied He's not dead and LVN D said He is. LVN D, who was in front of the camera, walked into the hallway backwards holding Resident #1's wrist, and released her wrists as she passed in front of the nurses' station. Resident #1 followed her and said (Dad's name) is my daddy and he is not dead. Resident 1 kept saying to LVN D, Shut up and I don't want to hear it anymore. Resident #2 who was sitting approximately 3 feet away from LVN D, yelled out Leave her alone. Then CNAs B and C approached LVN D and Resident #1. Resident #1 lifted her arm as if to hit LVN D, walked one step away from LVN D, then walked back and grabbed LVN D's hand. LVN D said Stop, and grabbed Resident #1's wrists, and said Stop. I'm not gonna hit you. You're not strong enough. I'm not gonna let you hit me so you might as well keep walking. CNA A walked up to Resident #1, extended her hand to Resident #1, who jerked her hand back, and CNA A grabbed her by her right wrist and said come with me, as LVN D said You're not goanna win this fight. Resident #1 complied and walked off with CNA A. During an interview on 07/15/25 at 8:30 AM with the ADM indicated on 07/14/25 at 12 pm CNA A alleged LVN D had caused bruising to Resident #1's wrist on 07/13/25 at approximately 6:00 pm. ADM said on 07/14/25 at approximately 12 pm, she observed Resident #1 with bruising to her wrists, and turned in a self-reported incident on 07/14/25 at 1:55 pm per the Submission Report. The ADM said on 07/14/25 at approximately 12 pm, she observed the video recording dated 07/13/25 at approximately 6:08 pm that indicated Resident #1 entered the nurses' station and LVN D pulled her by her wrists out of the area. The ADM said LVN D told the resident her father was dead 2 or 3 times, which escalated Resident #1's behavior. ADM said she reported the incident as required per her policies and procedures, and she spoke to Resident #1, who could not recall how she sustained the bruising that was observed on Resident #1's wrists. ADM directed LVN F to assess Resident #1 obtain physician's order for an x-ray, and to document his findings. ADM notified LVN D's agency that LVN D could no longer work at the facility. ADM said she recognized that CNAs A, B, and C failed to report the incident of abuse to her or the DON. ADM said on 07/15/23 she conducted Safe Surveys with the facilities residents, including Resident #1, who did not recall being abused. ADM said she immediately in-serviced her staff on shift, and staff who were not at the facility would be in-service before working on the floor. These in-services provided on 05/17/25 included Coping with Agitation, Aggression, and Sundowning in Alzheimer and Disease, and Abuse, Neglect, Exploitation and Misappropriation Prevention Program. The ADM said the nurses and CNAs were receive disciplinary actions against them and she would continue her investigation. ADM said the Medical Director and Resident #1's responsible party were notified. ADM indicated the MD viewed the recording on 07/15/25 and directed her to terminate the contract with the agency that employs LVN D, and that he did not want any of their staff in the building. Prior to the incident on 07/13/25, ADM said she had in serviced the facility's staff and informed them that she was accessible to them twenty-four hours a day, seven days a week. In addition, ADM said prior to the incident she had a form posted next to the reporting guidelines in the hallway next to the nurses' station that included her phone number, and it was there when the incident occurred between LVN D and Resident #1. Record review of the facility's in-service provided 07/15/25 Coping with Agitation, Aggression, and Sundowning in Alzheimer and Disease indicated staff should be patient and try not to show frustration and to avoid arguing, gentle touching to calm down, and take deep breaths and count to 10. Staff should focus on an abject or activity to distract, and/or provide a snack and/or beverage. This in-service included protecting yourself and other if needed, and if the resident becomes aggressive, stay at a safe distance until the behavior stops. Talk to a doctor if aggressive behaviors worsen and consider medications that may help. Record review of the facility's in-service provided 07/15/25 and dated Revised 2021, Abuse, Neglect, Exploitation and Misappropriation Prevention Program indicated Resident have the right to be free from abuse and neglect. This included develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents. Establish and maintain a culture of compassion and caring for all resident and particularly those with behavioral, cognitive or emotional problems. Record Review of Resident Safety Survey provided on 07/15/25 indicated the facility's residents were asked the following. I1. Do you feel safe?2. Have you witnessed any abuse (physical or verbal)?3. Does staff knock and introduce themselves when entering your room?4. Do you know who o report alleged abuse to? There were no negative findings on these reports, including Resident #1. Observation on 07/15/25 at 9:50 AM of Resident #1 indicated she had three inches by three inches of bruising that wrapped around her right and left wrists.During an interview on 07/15/25 at 9:51 AM with Resident #1 indicated she could not recall how she sustained the bruising to her wrists. During an interview on 07/15/25 at 12:31 pm with HR indicated the agency is responsible for ensuring staff are trained to work for nursing homes before placing them on the agency portal. HR said if the facility needs a staff, she will apply the request on the porta. This allows the agency staff to accept the request through their portal. HR said the facility is not responsible for their training because the agency is responsible for their training. If the facility had known that LVN D had not been trained in Dementia, she would not have been allowed to work at the facility. Since this incident, HR said the Medical Director has requested the agency's contract terminated, and their staff not be allowed to care for the facility's residents. During an interview on 07/15/25 at 12:52 pm with CNA H, who works 6 am to 6 pm shift, indicated on 07/14/25 she was in-service on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. CNA H said before this incident on 07/13/25 involving LVN D and Resident #1, the ADM in-serviced her that she was available 24 hours a day seven days a week, and her phone number was posted on the bulletin board next to the A&N phone number. CNA H said when Resident #1 is upset, she will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. CNA H said she would not grab a resident by their wrist and force them to leave the area. CNA H said the nurse and CNAs are the ones that updates her with changes to a resident's care plan.Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA H had signed these in-services on 07/14/25. Record Review of the Counseling Notice for CNA C signed and dated on 7/15/25 and signed by the DON revealed, CNA C received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of the Counseling Notice for CNA A signed and dated on 7/15/25 and signed by the DON revealed, CNA A received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of the Counseling Notice for LVN E signed and dated on 7/15/25 and signed by the DON revealed, LVN E received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of undated text messages at 4:17 PM from the facility ADM to the staffing agency revealed that the staffing agency acknowledged that dementia training was not mandatory unless the staffing agency was notified that it should be and moving forward the agency would document as a requirement. Record Review of an email dated 7/15/25 from the ADM to the staffing agency revealed that effective 7/15/25 the facility would no longer be using the staffing agency. During an interview on 07/15/25 at 1:15 pm with CNA G, who works from 6 am to 4:30 pm, indicated he was in-service on 07/14/25 on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. CNA G said before 07/13/25 he was working but left before the incident occurred between LVN D and Resident #1. CNA G said he received an in-service from the ADM, who informed him her phone number was posted on the bulletin board next to the A&N phone number. CNA G said when Resident#1 is upset, he will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. CNA G said she would not grab a resident by their wrist and force them to leave the area. CNA G said if a resident's plan is changed, he will be informed by the nurse and CNAs. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA G had signed these in-services on 07/14/25. During an interview on 07/15/25 at 2:09 pm with LVN F, who works from 6 am to 6 pm, indicated on 07/14/25 the ADM asked him to assess Resident #1, obtain orders to X-ray her arms, inform the physician and family, and to document his findings. LVN F said he observed Resident #1 had two-to-three-inch bruising to her wrists but did not document this assessment until later in the day because he took his break and because a resident had a fall he was dealing with. LVN F said he was issued a disciplinary [NAME] for not document his assessment. LVN F said he obtained the order for Resident #1's X-rays, which were negative for fractures. LVN F said during shift report on 07/13/25 at approximately 6 am, LVN E did not inform him that Resident #1 had hit LVN D, and that she had assessed her. LVN F said Resident#1 can get aggressive; however, he will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. LVN F said these steps are in Resident #1's care plan. LVN F said he would not grab a resident by their wrist and force them to leave the area. LVN F said if a resident's plan is changed, he will be informed by the DON or outgoing nurse, and he will share this information with his CNAs. LVN F said in the future he will document his assessments on the resident's progress notes and skin assessment. indicated he was in-service on 07/14/25 on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. LVN F said before 07/13/25 he was in-service by the ADM that she could be reached 24 hours a day seven day a week, and her phone number was posted on the bulletin board next to the A&N phone number. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated LVN F had signed these in-services on 07/14/25.During an interview on 07/15/25 at 12:31 pm with HR indicated they use an agency, which is a third party, when they need a nurse or CNA to work at the facility due to a facility staff not being able to work. HR said the agency is responsible for ensuring their staff are trained to work at a nursing home, before placing them on the agency portal. HR said if she needs a staff, she will place her request on the portal, and the interested nurse or CNA will accept the request. HR said if she had known LVN D was not up to date on her training she never would have accepted her request to work at the facility. HR, said due to the incident with LVN D abusing Resident 1, the MD has terminated their contract with this agency. During an interview on 07/15/25 at 2:23 pm with CNA A, who works 6 am to 6 pm, indicated on 07/13/25 at approximately 6 pm, she witnessed LVN D direct Resident #1 to throw away cups the cups she had taken from the medication cart, and she complied. CNA A said she head LV D say to Resident #1 she did not belong there, and Resident #1 began yelling. CNA A said she approached Resident #1, who was in front of the nurses' station and tried to hit LVN D. LVN D grabbed resident #1's hands as Resident #1 yelled at LVN D that her daddy owned the facility. CNA A said LVN D said to resident #1 she could say what she wanted but she was protecting herself from Resident #1. Hitting her. CNA A said she intervened by extending her hand between LVN D and Resident #1, who swatted her hand but then allowed CNA A to hold her hand and follow her towards her room. CNA A said before getting into Resident #1's room, she stopped, pulled up her sleeves, and said look what that lady did to me. CNA A said she witnessed Resident #1's wrist were red. CNA A indicated on 07/14/25 Resident #1's hospice aide questions whey Resident #1 had bruises to her hands and wrists. CNA A replied that there was an incident between Resident #1 and LVN D, and the hospice aide question if this had been reported, and CNA A said yes to the ADM. CNA A said she on 07/14/25 she was in-service on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. CNA A said before this incident on 07/13/25 involving LVN D and Resident #1, the ADM in-serviced her that she was available 24 hours a day seven days a week, and her phone number was posted on the bulletin board next to the A&N phone number. CNA A said when Resident #1 is upset, she will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. CNA A said she would not grab a resident by their wrist and force them to leave the area. CNA A said the nurse and CNAs are the ones that updates her with changes to a resident's care plan. CNA A said she intervened to protect Resident #1; however, she failed to report to the ADM immediately. Instead, CNA A said she reported this incident to the ADM on 07/14/25 and was issued a disciplinary action against her. CNA A said on 07/13/25 she did not report the incident between LVN D and Resident #1 because she was distracted due to having a disagreement with a coworker over dividing the rooms which cause her to be distracted, it was shift change, and she was changing briefs and answering call lights. CNA A said when Resident #1 was upset and aggressive, LVN D should have asked one of the CNAs to assist her, because Resident #1 is familiar with the CNAs. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA A had signed these in-services on 07/14/25.Record Review of the Counseling Notice for CNA C signed and dated on 7/15/25 and signed by the DON revealed, CNA C received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of the Counseling Notice for CNA A signed and dated on 7/15/25 and signed by the DON revealed, CNA A received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of the Counseling Notice for LVN E signed and dated on 7/15/25 and signed by the DON revealed, LVN E received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of undated text messages at 4:17 PM from the facility ADM to the staffing agency revealed that the staffing agency acknowledged that dementia training was not mandatory unless the staffing agency was notified that it should be and moving forward the agency would document as a requirement. Record Review of an email dated 7/15/25 from the ADM to the staffing agency revealed that effective 7/15/25 the facility would no longer be using the staffing agency. During an interview on 07/17/25 at 7:33 am with LVN I, who worked 6 pm to 6 am indicated she was in-service on 07/14/25 on preventing A&N and how to address residents with Alzheimer and Dementia, per in-service forms. LVN I said the phones numbers for reporting A&N are posted next to the A&N poster by the nurses' station. LVN I said the ADM was accessible 24/7 for reporting A&N. LVN I said she is responsible for 2 CNAs during the night shift and for updating them with changes to a resident' care plan or significant changes. LVN I said Resident #1 likes to go into the nurses' station but can be redirected or given snacks so she can comply with leaving the nurses' station, which is part of her plan.Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated LVN I had signed these in-services on 07/14/25.During an interview on 07/17/25 at 9:59 am with the DON indicated that what should have happened ( when LVN D abused Resident #1), staff involved should have reported the incident as soon as it happened. Staff should have intervened and then reported the incident. She stated staff are trained to intervene and stop the incident and then report the incident to the ADM, who is the abuse coordinator. The DON stated the staff should have reported immediately and not have waited for several hours to report. The DON stated staff did not follow the facility policy to report abuse immediately, which could have allowed injury, mental or physical abuse to continue. The DON stated to her knowledge Resident #1 is not on any blood thinners, but she is fragile and has thin skin and easy to bruise. The DON stated that the ADM should have been informed immediately because residents have the right to be protected. The DON stated that talking about Resident #1's dad will escalate her behaviors but offering her a snack will help to calm her behaviors. The DON stated that had staff notify her or the ADM when the incident happened, they would have gone to the facility and sent staff home and initiated the investigation. The DON stated Resident #1 doesn't know how the bruising happened and continues to say she doesn't know who did that to her. The DON stated staff reported the incident the next day (07/14/25) because that is when the bruises appeared. The ADM called LVN's agency and told them not to send the nurse back. She stated that they started in-servicing staff on abuse and reporting abuse and working with residents with behaviors. Review on 07/15/25 of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated DON had signed these in-services on 07/14/25.Record review on 07/17/25 of LVN D's timesheet dated 07/13/25 indicated she worked at the facility 10 hours and 43 minutes (07/13/25 at 7 am until 12:00 am). During an interview on 07/17/25 at 10:14 AM with LVN D indicated she started her shift on 07/13/25 at 7:00 AM and ended her shift at 12:00 AM. LVN D said at approximately 7 PM, Resident #1 went behind the nurses' station, and was rambling and grabbing stuff off the nurses' desk. LVN D said she told Resident #1 she could not be there, and walked towards Resident #1, who started fighting with her. LVN D said she caught Resident #1's wrist to keep her from hitting her and someone used a medication cart to prevent her from returning to the nurses' station. LVN D said she absolutely grabbed Resident #1's wrist; however, prior to that incident she had asked (unable to recall who she asked) why Resident #1 had bruises on her wrist. LVN D said she was positive she did not cause the bruises. LVN D said in the past Resident #1 would go into the nurses' station often; however, she did not do anything, unless Resident #1 took items from the nurses' desk. LVN D said she knew Resident #1 had a care plan; however, she never has nor did it cross her mind to review the care plan. LVN D said she did not know the care plan included interventions to address Resident #1's behaviors. LVN D said she did not call Resident #1's family member nor did she offer her a drink and/or snack when she became upset. LVN D said she did not document Resident #1's incident or her behaviors, and did not notify the physician, responsible party, Director of Nurses, (DON), and the Administrator, because Resident #1 did not have a change of condition and she did not see it as an escalated change. LVN D said that was Resident #1's normal behavior. LVN D said she was trained in addressing residents with Dementia and/or Alzheimer's but could not recall if it included holding residents by their hands or wrists. LVN D said in the moment of the incident she told Resident #1 You are not going to hit me, I'm stronger than you are. LVN D said she had not had training on elderly aggression. LVN D said when a resident is aggressive, she should offer the resident something to avert their attention, let them be if they are not hurting themselves or others, offer medications, and offer snacks. LVN D said she did not grab Resident 1's wrist, she caught her wrist, which was not appropriate but it depended on the situation. LVN D said the first time she put space between her and Resident #1 was when she was going by the medication cart, the second time was when the CNA directed her to leave, and the third time there was distance between her and Resident #1 until, Resident #1 lunged at me. LVN D said she recalled a resident (Resident #2) in the area but could not recall which one. LVN D said Resident #1 was not within reach of a resident. LVN D said Resident #1 has a history of talking about her deceased dad, and she (LVN D) told her he was dead because she was looking for her dad, and Resident #1 was saying she did not have to leave the nurses' station because her dad built the facility and he owns it. During an interview on 07/17/25 at 10:56 AM with Resident #2, who had been sitting approximately 5 feet from the nurses' station and per video yelled out leave her alone, indicated she could not recall the incident involving LVN D and Resident #1. Record review on 07/18/25 at 3 pm of CNA C's written withes statement indicate on 07/13/25 she witnessed LVN D holding Resident #1's by her wrists and attempting to redirect her. CNA C said LVN D was making verbal comments about Resident #1's dad being dead. Then Resident #1 became combative and that's when the CNAs took resident to her room. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA C had signed these in-services on 07/14/25.During an interview on 07/18/25 at 12:50 pm with CNA B, who works 6 pm to 6 am and 6 am to 6 pm shifts, indicated she was in-service but cannot recall the date, because she works for an agency, which requires her to be at numerous facilities. CNA B said prior to the incident on 07/13/25, between LVN D and Resident #1, she had been in-serviced on preventing A&N, and how to address residents with Alzheimer and Dementia through her required CNA training. CNA B said she knew she could call the ADM anytime of the day or night and that her number was posted on the bulletin board in the facility, and if not, she could ask for her number. CNA B said on 07/13/25 at approximately 6 PM, she heard LVN D say to Resident #1 she could not go there (behind the nurses' station). CNA B said when LVN D grabbed Resident #1's wrists and pulled her from behind the nurses' station. CNA B said intervened by using the medication cart to block the entrance to the nurses' station and asking Resident #1 two or three times to go with her to her room, because she could see that LVN D was holding her wrists. CNA B said Resident #1 pulled her right hand loose and swung at LVN D but missed hitting her. That was when LVN D grabbed her wrists and said If you hit me, I will hit you back. CNA B said she continued to direct Resident #1 to go with her to her room, but she refused. Then CNA A intervened by walking up to LVN D and Resident #1, extending her hand to Resident #1 and asking her to go with her, and Resident #1 complied. CNA B said she walked with CNA A, and Resident #1 towards Resident #1's room, until she stopped in the hallway, pulled her shirt sleeves above her wrists, and said Look what she did to me. CNA B said Resident #1 had redness and bruising (blueish blotches) to her wrists. Afterwards, CNA B left CNA A and Resident #1, who continued to walk to Resident #1's room while holding hands. CNA B s[TRUNCATED]

Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to the abuse coordinator, the facility Administrator for 2 of 5 residents (Resident #1) reviewed for abuse.The facility failed to ensure a safe environment free from physical and verbal abuse for Resident #1 on 7/13/25 at 6:07 PM when LVN D grabbed and pulled Resident #1 from behind the nurse's station, and Resident #1 was observed with redness on 07/13/25, and with bruises to both hands and wrists on 07/14/25. During this incident LVN D said to the resident three times that her daddy was dead. LVN D remained working at the facility for 6 hours the remainder shift on 7/13/25 after the incident and had direct contact with Resident #1.The noncompliance was identified as PNC. The IJ began on 07/13/25 and ended on 07/14/25. The facility had corrected the noncompliance before the survey began on 07/15/25. These failures could affect all residents by placing them at risk of continued abuse, physical harm, pain, mental anguish, emotional distress, and serious harm.Findings include: Record review of Resident #1's face sheet, dated 07/17/25, revealed an [AGE] year-old-female who was originally admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia mild, with mood disturbance (cognitive decline with changes in behavior), insomnia (trouble sleeping), anxiety disorder ( excessive worry feelings of fear), disorientation (lost sense of direction), glaucoma (vision loss), schizoaffective disorder bipolar type (mental health condition episodes mania and depression), intermittent explosive disorder (physical and/or verbal outburst), lack of coordination (unsteadiness), muscle wasting (decrease in strength), muscle weakness (lack of movement), depression (sadness), difficulty in walking (abnormal walking pattern). Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE] revealed: Section C Brief Interview for Mental Status (BIMS) score revealed a score of 3 which indicated the resident's cognition was impaired. Section E Behavior indicated Resident 1 had potential behavior of psychosis that included hallucinations and delusions. And she exhibited physical behaviors directed towards others every 1 to 3 days, verbal behaviors directed towards others every 4 to 6 days, and wandering behavior that occurred every 4 to 6 days.Record review of Resident #1's care plan, dated 06/25/2025, revealed:Focus: Resident #1 had episodes of verbal/physical aggression. Date initiated 05/10/2024Intervention: Assist me to phone [family member] during episodes of agitation. Give me as many choices as possible about care and activities. Monitor for physical/verbally aggressive q shift. Document observed behavior and attempted interventions in behavior log.Focus: Resident #1 is an elopement risk/wanderer r/t disoriented to place, wander risk score 11. Date initiated 12/27/2024 date revised 06/25/2025.Intervention: Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, I prefer having snacks. Date initiated 12/27/2024 revised date 12/24/2025.Record review of Resident #1's progress notes, dated 07/14/2025 - 07/16/2025 revealed: On 07/14/2025 at 1:03 PM, the DON documented a Late Entry, they were notified of Resident #1 having bruises to both wrists from an incident that occurred the day before. The DON went to assess Resident #1 and found her to have bruising to both wrists. Resident #1 was asked if she was in pain from the bruising and she stated no. Notified the MD and emergency contact. The MD gave an order to get an x-ray to both wrists. Hospice was notified 07/16/2025 at 3:29 PM, the DON documented spoke with Hospice staff about bruising on [Resident #1's] bilateral wrist. Per Hospice staff, the bruising to her wrists were not there Friday (07/11/2025). Per Hospice staff, she spent about 30 to 40 minutes talking with [Resident #1]. Monday (07-14-2025) Hospice staff did not know about bruising because [Resident #1] had her hands under her head and refused a shower. Noted resident is frequently wearing long sleeves.Record review of the x-ray report dated 07/14/2025 for Resident #1 revealed the right had wrist no acute abnormalities. The left wrist had osteopenia ( body doesn't make new bone as quickly as it reabsorbs old bone) and degenerative changes. Record review of Resident #1's physician's progress note dated 07/15/2025 revealed staff reported new onset bruising to bilateral ( having or relating to two sides; affecting both sides) FA (forearms). Record review of Resident #1's physician's orders dated 07/17/25 revealed Resident #1 was not prescribed blood thinners at the time of the incident.Observation on 07/15/25 at 7:30 AM indicated the nurses' cart was next to the display case that contained the reporting number for abuse and/or neglect and included the Administrator's phone number. Observation on 07/15/25 at 9:30 am of the facility's video recording dated 07/13/25 at 6:07 PM revealed LVN D was at the medication cart that was next to and in front of the nurse' station, when Resident #1 passed behind her and went into the nurses' station. LVN D said to Resident #1 You can't go back there. and Resident #1 replied I can too. LVN D said You cannot. and Resident #1 replied My daddy own's this place. LVN D said Look lady as she grabbed Resident #1's left wrist, and Resident #1 responded by swinging her right hand at LVN D and stated, Leave me alone. LVN D said Stop. LVN D released Resident #1's right hand and placed something LVN D was holding in her hand on the nurses' desk. LVN D grabbed Resident #1's wrists with her hands and started pulling her out from behind the nurses' station. CNA C then approached LVN D and Resident #1 and said, [Resident #1] get out from back there; you can't be back there. LVN D continued to pull Resident #1 as Resident #1 resisted, kicked, and said to LVN D Turn lose my hands. LVN D pulled Resident #1 into the hallway and around the cabinet, which was out of camera view, and CNA C walked along side of them. LVN D could be heard saying I'm not going to fight with you. CNA B approached the nurses' station and said to Resident D Stop, and then CNA B used the medication cart to block the entry way into the nurses' station. Resident #1 could be heard saying My daddy's the one who owns this place. and LVN D responded He doesn't own it anymore because he's dead. Resident #1 replied He's not dead and LVN D said He is. LVN D, who was in front of the camera, walked into the hallway backwards holding Resident #1's wrist, and released her wrists as she passed in front of the nurses' station. Resident #1 followed her and said (Dad's name) is my daddy and he is not dead. Resident 1 kept saying to LVN D, Shut up and I don't want to hear it anymore. Resident #2 who was sitting approximately 3 feet away from LVN D, yelled out Leave her alone. Then CNAs B and C approached LVN D and Resident #1. Resident #1 lifted her arm as if to hit LVN D, walked one step away from LVN D, then walked back and grabbed LVN D's hand. LVN D said Stop, and grabbed Resident #1's wrists, and said Stop. I'm not gonna hit you. You're not strong enough. I'm not gonna let you hit me so you might as well keep walking. CNA A walked up to Resident #1, extended her hand to Resident #1, who jerked her hand back, and CNA A grabbed her by her right wrist and said come with me, as LVN D said You're not goanna win this fight. Resident #1 complied and walked off with CNA A. During an interview on 07/15/25 at 8:30 AM with the ADM indicated on 07/14/25 at 12 pm CNA A alleged LVN D had caused bruising to Resident #1's wrist on 07/13/25 at approximately 6:00 pm. ADM said on 07/14/25 at approximately 12 pm, she observed Resident #1 with bruising to her wrists, and turned in a self-reported incident on 07/14/25 at 1:55 pm per the Submission Report. The ADM said on 07/14/25 at approximately 12 pm, she observed the video recording dated 07/13/25 at approximately 6:08 pm that indicated Resident #1 entered the nurses' station and LVN D pulled her by her wrists out of the area. The ADM said LVN D told the resident her father was dead 2 or 3 times, which escalated Resident #1's behavior. ADM said she reported the incident as required per her policies and procedures, and she spoke to Resident #1, who could not recall how she sustained the bruising that was observed on Resident #1's wrists. ADM directed LVN F to assess Resident #1 obtain physician's order for an x-ray, and to document his findings. ADM notified LVN D's agency that LVN D could no longer work at the facility. ADM said she recognized that CNAs A, B, and C failed to report the incident of abuse to her or the DON. ADM said on 07/15/23 she conducted Safe Surveys with the facilities residents, including Resident #1, who did not recall being abused. ADM said she immediately in-serviced her staff on shift, and staff who were not at the facility would be in-service before working on the floor. These in-services provided on 05/17/25 included Coping with Agitation, Aggression, and Sundowning in Alzheimer and Disease, and Abuse, Neglect, Exploitation and Misappropriation Prevention Program. The ADM said the nurses and CNAs were to receive disciplinary actions against them and she would continue her investigation. ADM said the Medical Director and Resident #1's responsible party were notified. ADM indicated the MD viewed the recording on 07/15/25 and directed her to terminate the contract with the agency that employs LVN D, and that he did not want any of their staff in the building. Prior to the incident on 07/13/25, ADM said she had in serviced the facility's staff and informed them that she was accessible to them twenty-four hours a day, seven days a week. In addition, ADM said prior to the incident she had a form posted next to the reporting guidelines in the hallway next to the nurses' station that included her phone number, and it was there when the incident occurred between LVN D and Resident #1. Record review of the facility's in-service provided 07/15/25 Coping with Agitation, Aggression, and Sundowning in Alzheimer and Disease indicated staff should be patient and try not to show frustration and to avoid arguing, gentle touching to calm down, and take deep breaths and count to 10. Staff should focus on an object or activity to distract, and/or provide a snack and/or beverage. This in-service included protecting yourself and other if needed, and if the resident becomes aggressive, stay at a safe distance until the behavior stops. Talk to a doctor if aggressive behaviors worsen and consider medications that may help. Record review of the facility's in-service provided 07/15/25 and dated Revised 2021, Abuse, Neglect, Exploitation and Misappropriation Prevention Program indicated Resident have the right to be free from abuse and neglect. This included develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents. Establish and maintain a culture of compassion and caring for all resident and particularly those with behavioral, cognitive or emotional problems. Record Review of Resident Safety Survey provided on 07/15/25 indicated the facility's residents were asked the following.I1. Do you feel safe?2. Have you witnessed any abuse (physical or verbal)?3. Does staff knock and introduce themselves when entering your room?4. Do you know who to report alleged abuse to?There were no negative findings on these reports, including Resident #1.Observation on 07/15/25 at 9:50 AM of Resident #1 indicated she had three inches by three inches of bruising that wrapped around her right and left wrists. During an interview on 07/15/25 at 9:51 AM with Resident #1 indicated she could not recall how she sustained the bruising to her wrists.During an interview on 07/15/25 at 12:31 pm with HR indicated the agency is responsible for ensuring staff are trained to work for nursing homes before placing them on the agency portal. HR said if the facility needs a staff, she will apply the request on the porta. This allows the agency staff to accept the request through their portal. HR said the facility is not responsible for their training because the agency is responsible for their training. If the facility had known that LVN D had not been trained in Dementia, she would not have been allowed to work at the facility. Since this incident, HR said the Medical Director has requested the agency's contract terminated, and their staff not be allowed to care for the facility's residents.During an interview on 07/15/25 at 12:52 pm with CNA H, who works 6 am to 6 pm shift, indicated on 07/14/25 she was in-service on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. CNA H said before this incident on 07/13/25 involving LVN D and Resident #1, the ADM in-serviced her that she was available 24 hours a day seven days a week, and her phone number was posted on the bulletin board next to the A&N phone number. CNA H said when Resident #1 is upset, she will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. CNA H said she would not grab a resident by their wrist and force them to leave the area. CNA H said the nurse and CNAs are the ones that updates her with changes to a resident's care plan.Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA H had signed these in-services on 07/14/25. During an interview on 07/15/25 at 1:15 pm with CNA G, who works from 6 am to 4:30 pm, indicated he was in-service on 07/14/25 on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. CNA G said before 07/13/25 he was working but left before the incident occurred between LVN D and Resident #1. CNA G said he received an in-service from the ADM, who informed him her phone number was posted on the bulletin board next to the A&N phone number. CNA G said when Resident#1 is upset, he will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. CNA G said she would not grab a resident by their wrist and force them to leave the area. CNA G said if a resident's plan is changed, he will be informed by the nurse and CNAs.Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA G had signed these in-services on 07/14/25. During an interview on 07/15/25 at 2:09 pm with LVN F, who works from 6 am to 6 pm, indicated on 07/14/25 the ADM asked him to assess Resident #1, obtain orders to X-ray her arms, inform the physician and family, and to document his findings. LVN F said he observed Resident #1 had two-to-three-inch bruising to her wrists but did not document this assessment until later in the day because he took his break and because a resident had a fall he was dealing with. LVN F said he was issued a disciplinary [NAME] for not document his assessment. LVN F said he obtained the order for Resident #1's X-rays, which were negative for fractures. LVN F said during shift report on 07/13/25 at approximately 6 am, LVN E did not inform him that Resident #1 had hit LVN D, and that she had assessed her. LVN F said Resident#1 can get aggressive; however, he will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. LVN F said these steps are in Resident #1's care plan. LVN F said he would not grab a resident by their wrist and force them to leave the area. LVN F said if a resident's plan is changed, he will be informed by the DON or outgoing nurse, and he will share this information with his CNAs. LVN F said in the future he will document his assessments on the resident's progress notes and skin assessment. indicated he was in-service on 07/14/25 on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. LVN F said before 07/13/25 he was in-service by the ADM that she could be reached 24 hours a day seven day a week, and her phone number was posted on the bulletin board next to the A&N phone number.Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated LVN F had signed these in-services on 07/14/25. During an interview on 07/15/25 at 12:31 pm with HR indicated they use an agency, which is a third party, when they need a nurse or CNA to work at the facility due to a facility staff not being able to work. HR said the agency is responsible for ensuring their staff are trained to work at a nursing home, before placing them on the agency portal. HR said if she needs a staff, she will place her request on the portal, and the interested nurse or CNA will accept the request. HR said if she had known LVN D was not up to date on her training she never would have accepted her request to work at the facility. HR, said due to the incident with LVN D abusing Resident 1, the MD has terminated their contract with this agency. During an interview on 07/15/25 at 2:23 pm with CNA A, who works 6 am to 6 pm, indicated on 07/13/25 at approximately 6 pm, she witnessed LVN D direct Resident #1 to throw away cups the cups she had taken from the medication cart, and she complied. CNA A said she head LV D say to Resident #1 she did not belong there, and Resident #1 began yelling. CNA A said she approached Resident #1, who was in front of the nurses' station and tried to hit LVN D. LVN D grabbed resident #1's hands as Resident #1 yelled at LVN D that her daddy owned the facility. CNA A said LVN D said to resident #1 she could say what she wanted but she was protecting herself from Resident #1. Hitting her. CNA A said she intervened by extending her hand between LVN D and Resident #1, who swatted her hand but then allowed CNA A to hold her hand and follow her towards her room. CNA A said before getting into Resident #1's room, she stopped, pulled up her sleeves, and said look what that lady did to me. CNA A said she witnessed Resident #1's wrist was red. CNA A indicated on 07/14/25 Resident #1's hospice aide questions whey Resident #1 had bruises to her hands and wrists. CNA A replied that there was an incident between Resident #1 and LVN D, and the hospice aide question if this had been reported, and CNA A said yes to the ADM. CNA A said she on 07/14/25 she was in-service on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. CNA A said before this incident on 07/13/25 involving LVN D and Resident #1, the ADM in-serviced her that she was available 24 hours a day seven days a week, and her phone number was posted on the bulletin board next to the A&N phone number. CNA A said when Resident #1 is upset, she will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. CNA A said she would not grab a resident by their wrist and force them to leave the area. CNA A said the nurse and CNAs are the ones that updates her with changes to a resident's care plan. CNA A said she intervened to protect Resident #1; however, she failed to report to the ADM immediately. Instead, CNA A said she reported this incident to the ADM on 07/14/25 and was issued a disciplinary action against her. CNA A said on 07/13/25 she did not report the incident between LVN D and Resident #1 because she was distracted due to having a disagreement with a coworker over dividing the rooms which cause her to be distracted, it was shift change, and she was changing briefs and answering call lights. CNA A said when Resident #1 was upset and aggressive, LVN D should have asked one of the CNAs to assist her, because Resident #1 is familiar with the CNAs. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA A had signed these in-services on 07/14/25.During an interview on 07/17/25 at 9:59 am with the DON indicated that what should have happened ( when LVN D abused Resident #1), staff involved should have reported the incident as soon as it happened. Staff should have intervened and then reported the incident. She stated staff are trained to intervene and stop the incident and then report the incident to the ADM, who is the abuse coordinator. The DON stated the staff should have reported immediately and not have waited for several hours to report. The DON stated staff did not follow the facility policy to report abuse immediately, which could have allowed injury, mental or physical abuse to continue. The DON stated to her knowledge Resident #1 is not on any blood thinners, but she is fragile and has thin skin and easy to bruise. The DON stated that the ADM should have been informed immediately because residents have the right to be protected. The DON stated that talking about Resident #1's dad will escalate her behaviors but offering her a snack will help to calm her behaviors. The DON stated that had staff notify her or the ADM when the incident happened, they would have gone to the facility and sent staff home and initiated the investigation. The DON stated Resident #1 doesn't know how the bruising happened and continues to say she doesn't know who did that to her. The DON stated staff reported the incident the next day (07/14/25) because that is when the bruises appeared. The ADM called LVN's agency and told them not to send the nurse back. She stated that they started in-servicing staff on abuse and reporting abuse and working with residents with behaviors.Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated DON had signed these in-services on 07/14/25.Record review on 07/17/25 of LVN D's timesheet dated 07/13/25 indicated she worked at the facility 10 hours and 43 minutes (07/13/25 at 7 am until 12:00 am). During an interview on 07/17/25 at 10:14 AM with LVN D indicated she started her shift on 07/13/25 at 7:00 AM and ended her shift at 12:00 AM. LVN D said at approximately 7 PM, Resident #1 went behind the nurses' station, and was rambling and grabbing stuff off the nurses' desk. LVN D said she told Resident #1 she could not be there, and walked towards Resident #1, who started fighting with her. LVN D said she caught Resident #1's wrist to keep her from hitting her and someone used a medication cart to prevent her from returning to the nurses' station. LVN D said she absolutely grabbed Resident #1's wrist; however, prior to that incident she had asked (unable to recall who she asked) why Resident #1 had bruises on her wrist. LVN D said she was positive she did not cause the bruises. LVN D said in the past Resident #1 would go into the nurses' station often; however, she did not do anything, unless Resident #1 took items from the nurses' desk. LVN D said she knew Resident #1 had a care plan; however, she never has, nor did it cross her mind to review the care plan. LVN D said she did not know the care plan included interventions to address Resident #1's behaviors. LVN D said she did not call Resident #1's family member nor did she offer her a drink and/or snack when she became upset. LVN D said she did not document Resident #1's incident or her behaviors, and did not notify the physician, responsible party, Director of Nurses, (DON), and the Administrator, because Resident #1 did not have a change of condition, and she did not see it as an escalated change. LVN D said that was Resident #1's normal behavior. LVN D said she was trained in addressing residents with Dementia and/or Alzheimer's but could not recall if it included holding residents by their hands or wrists. LVN D said in the moment of the incident she told Resident #1 You are not going to hit me, I'm stronger than you are. LVN D said she had not had training on elderly aggression. LVN D said when a resident is aggressive, she should offer the resident something to avert their attention, let them be if they are not hurting themselves or others, offer medications, and offer snacks. LVN D said she did not grab Resident 1's wrist, she caught her wrist, which was not appropriate, but it depended on the situation. LVN D said the first time she put space between her and Resident #1 was when she was going by the medication cart, the second time was when the CNA directed her to leave, and the third time there was distance between her and Resident #1 until, Resident #1 lunged at me. LVN D said she recalled a resident (Resident #2) in the area but could not recall which one. LVN D said Resident #1 was not within reach of a resident. LVN D said Resident #1 has a history of talking about her deceased dad, and she (LVN D) told her he was dead because she was looking for her dad, and Resident #1 was saying she did not have to leave the nurses' station because her dad built the facility, and he owns it. During an interview on 07/17/25 at 10:56 AM with Resident #2, who had been sitting approximately 5 feet from the nurses' station and per video yelled out leave her alone, indicated she could not recall the incident involving LVN D and Resident #1. Record review on 07/18/25 at 3 pm of CNA C's written withes statement indicate on 07/13/25 she witnessed LVN D holding Resident #1's by her wrists and attempting to redirect her. CNA C said LVN D was making verbal comments about Resident #1's dad being dead. Then Resident #1 became combative and that's when the CNAs took resident to her room. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA C had signed these in-services on 07/14/25.During an interview on 07/18/25 at 12:50 pm with CNA B, who works 6 pm to 6 am and 6 am to 6 pm shifts, indicated she was in-service but cannot recall the date, because she works for an agency, which requires her to be at numerous facilities. CNA B said prior to the incident on 07/13/25, between LVN D and Resident #1, she had been in-serviced on preventing A&N, and how to address residents with Alzheimer and Dementia through her required CNA training. CNA B said she knew she could call the ADM anytime of the day or night and that her number was posted on the bulletin board in the facility, and if not, she could ask for her number. CNA B said on 07/13/25 at approximately 6 PM, she heard LVN D say to Resident #1 she could not go there (behind the nurses' station). CNA B said when LVN D grabbed Resident #1's wrists and pulled her from behind the nurses' station. CNA B said intervened by using the medication cart to block the entrance to the nurses' station and asking Resident #1 two or three times to go with her to her room, because she could see that LVN D was holding her wrists. CNA B said Resident #1 pulled her right hand loose and swung at LVN D but missed hitting her. That was when LVN D grabbed her wrists and said, If you hit me, I will hit you back. CNA B said she continued to direct Resident #1 to go with her to her room, but she refused. Then CNA A intervened by walking up to LVN D and Resident #1, extending her hand to Resident #1 and asking her to go with her, and Resident #1 complied. CNA B said she walked with CNA A, and Resident #1 towards Resident #1's room, until she stopped in the hallway, pulled her shirt sleeves above her wrists, and said Look what she did to me. CNA B said Resident #1 had redness and bruising (blueish blotches) to her wrists. Afterwards, CNA B left CNA A and Resident #1, who continued to walk to Resident #1's room while holding hands. CNA B said she reported the incident to LVN E, on the night of 07/13/25 at 12 am, because she was the nurse relieving LVN D. CNA B said she did not report the incident to the Administrator, because she was busy answering call lights. CNA B said she should have called the Administrator immediately, because she had been in-serviced and informed that the ADM's phone number was posted next to the bulletin board next to the number for reporting abuse and neglect. CNA B said during the incident she intervened to protect Resident #1 from LVN D by using the medication cart to block the entrance to the nurses' station, after she saw LVN D pulling Resident #1 by her hands out of the nurses' station. Then CNA B said she asked Resident #1 two or three times for her to go with her to her room, but she did not comply. Then CNA A reached her hand out to Resident #1 and asked her to go to her room, and Resident #1 complied because she is very familiar with CNA A. CNA B said since 07/13/25 she had not worked at the facility. CNA B said Resident #1 in the past has been redirected and offered snacks when she has been aggressive, and that works. CNA B said she in updated on residents' care plans by the nurses and CNAs.Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA B had signed these in-services on 07/14/25.Record Review of the Counseling Notice for CNA C signed and dated on 7/15/25 and signed by the DON revealed, CNA C received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of the Counseling Notice for CNA A signed and dated on 7/15/25 and signed by the DON revealed, CNA A received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of the Counseling Notice for LVN E signed and dated on 7/15/25 and signed by the DON revealed, LVN E received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of undated text messages at 4:17 PM from the facility ADM to the staffing agency revealed that the staffing agency acknowledged that dementia training was not mandatory unless the staffing agency was notified that it should be and moving forward the agency would document as a requirement. Record Review of an email dated 7/15/25 from the ADM to the staffing agency revealed that effective 7/15/25 the facility would no longer be using the staffing agency. IA phone call interview on 07/18/25 at 1:20 PM was attempted with LVN E via a voice mail and text message, but she did not return the message. Record review of LVN E's written statement(that was not dated) but provided 07/18/25 indicated Was told in report from nurse (LVN D) that resident (Resident #1) became combative and aggressive while being redirected from nurses' station. CNA stated that nurse was holding resident by the wrist to stop her from hitting. Went and checked for new bruising but none noted at that time, only scattered bruising to BUE (Bilateral Upper Extremities). Was not told that abuse was suspected and did not know of all details until ADM watched camera footage.Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program da[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure a safe environment free from physical and verbal abuse for Resident #1 when LVN D grabbed and pulled Resident #1 from behind the nurse's station, and Resident #1 was observed with redness on 07/13/25, and with bruises to both hands and wrists on 07/14/25. During this incident LVN D said to the resident three times that her daddy was dead. The noncompliance was identified as PNC. The IJ began on 07/13/25 and ended on 07/14/25. The facility had corrected the noncompliance before the survey began on 07/15/25. These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm. Findings include:Record review of Resident #1's face sheet, dated 07/17/25, revealed an [AGE] year-old-female who was originally admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia mild, with mood disturbance (cognitive decline with changes in behavior), insomnia (trouble sleeping), anxiety disorder ( excessive worry feelings of fear), disorientation (lost sense of direction), glaucoma (vision loss), schizoaffective disorder bipolar type (mental health condition episodes mania and depression), intermittent explosive disorder (physical and/or verbal outburst), lack of coordination (unsteadiness), muscle wasting (decrease in strength), muscle weakness (lack of movement), depression (sadness), difficulty in walking (abnormal walking pattern). Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE] revealed: Section C Brief Interview for Mental Status (BIMS) score revealed a score of 3 which indicated the resident's cognition was impaired. Section E Behavior indicated Resident 1 had potential behavior of psychosis that included hallucinations and delusions. And she exhibited physical behaviors directed towards others every 1 to 3 days, verbal behaviors directed towards others every 4 to 6 days, and wandering behavior that occurred every 4 to 6 days. Record review of Resident #1's care plan, dated 06/25/2025, revealed: Focus: Resident #1 had episodes of verbal/physical aggression. Date initiated 05/10/2024Intervention: Assist me to phone [family member] during episodes of agitation. Give me as many choices as possible about care and activities. Monitor for physical/verbally aggressive q shift. Document observed behavior and attempted interventions in behavior log. Focus: Resident #1 is an elopement risk/wanderer r/t disoriented to place, wander risk score 11. Date initiated 12/27/2024 date revised 06/25/2025. Intervention: Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, I prefer having snacks. Date initiated 12/27/2024 revised date 12/24/2025. Record review of Resident #1's progress notes, dated 07/14/2025 - 07/16/2025 revealed: On 07/14/2025 at 1:03 PM, the DON documented a Late Entry, because she was notified of Resident #1 having bruises to both wrists from an incident that occurred the on 07/13/25. The DON went to assess Resident #1 and found her to have bruising to both wrists. Resident #1 was asked if she was in pain from the bruising and she stated no. Notified the MD and emergency contact. The MD gave an order to get an x-ray to both wrists. Hospice was notified on 07/16/2025 at 3:29 PM, the DON documented spoke with Hospice staff about bruising on [Resident #1's] bilateral wrist. Per Hospice staff, the bruising to her wrists were not there Friday (07/11/2025). Per Hospice staff, she spent about 30 to 40 minutes talking with [Resident #1]. Monday (07-14-2025) Hospice staff did not know about bruising because [Resident #1] had her hands under her head and refused a shower. Noted resident is frequently wearing long sleeves. Record review of the x-ray report dated 07/14/2025 for Resident #1 revealed the right had wrist no acute abnormalities. The left wrist had osteopenia ( body doesn't make new bone as quickly as it reabsorbs old bone) and degenerative changes. Record review of Resident #1's physician's progress note dated 07/15/2025 revealed staff reported new onset bruising to bilateral ( having or relating to two sides; affecting both sides) FA (forearms). Record review of Resident #1's physician's orders dated 07/17/25 revealed Resident #1 was not prescribed blood thinners at the time of the incident. Observation on 07/15/25 at 7:30 AM indicated the nurses' cart was next to the display case that contained the reporting number for abuse and/or neglect and included the Administrator's phone number. Observation on 07/15/25 at 9:30 am of the facility's video recording dated 07/13/25 at 6:07 PM revealed LVN D was at the medication cart that was next to and in front of the nurse' station, when Resident #1 passed behind her and went into the nurses' station. LVN D said to Resident #1 You can't go back there. and Resident #1 replied I can too. LVN D said You cannot. and Resident #1 replied My daddy own's this place. LVN Dsaid Look lady as she grabbed Resident #1's left wrist, and Resident #1 responded by swinging her right hand at LVN D and stated, Leave me alone. LVN D said Stop. LVN D released Resident #1's right hand and placed something LVN D was holding in her hand on the nurses' desk. LVN D grabbed Resident #1's wrists with her hands and started pulling her out from behind the nurses' station. CNA C then approached LVN D and Resident #1 and said, [Resident #1] get out from back there; you can't be back there. LVN D continued to pull Resident #1 as Resident #1 resisted, kicked, and said to LVN D Turn loose my hands. LVN D pulled Resident #1 into the hallway and around the cabinet, which was out of camera view, and CNA C walked along side of them. LVN D could be heard saying I'm not going to fight with you. CNA B approached the nurses' station and said to Resident D Stop, and then CNA B used the medication cart to block the entry way into the nurses' station. Resident #1 could be heard saying My daddy's the one who owns this place. and LVN D responded He doesn't own it anymore because he's dead. Resident #1 replied He's not dead and LVN D said He is. LVN D, who was in front of the camera, walked into the hallway backwards holding Resident #1's wrist, and released her wrists as she passed in front of the nurses' station. Resident #1 followed her and said (Dad's name) is my daddy and he is not dead. Resident 1 kept saying to LVN D, Shut up and I don't want to hear it anymore. Resident #2 who was sitting approximately 3 feet away from LVN D, yelled out Leave her alone. Then CNAs B and C approached LVN D and Resident #1. Resident #1 lifted her arm as if to hit LVN D, walked one step away from LVN D, then walked back and grabbed LVN D's hand. LVN D said Stop, and grabbed Resident #1's wrists, and said Stop. I'm not gonna hit you. You're not strong enough. I'm not gonna let you hit me so you might as well keep walking. CNA A walked up to Resident #1, extended her hand to Resident #1, who jerked her hand back, and CNA A grabbed her by her right wrist and said come with me, as LVN D said You're not goanna win this fight. Resident #1 complied and walked off with CNA A. During an interview on 07/15/25 at 8:30 AM with the ADM indicated on 07/14/25 at 12 pm CNA A alleged LVN D had caused bruising to Resident #1's wrist on 07/13/25 at approximately 6:00 pm. ADM said on 07/14/25 at approximately 12 pm, she observed Resident #1 with bruising to her wrists, and turned in a self-reported incident on 07/14/25 at 1:55 pm per the Submission Report. The ADM said on 07/14/25 at approximately 12 pm, she observed the video recording dated 07/13/25 at approximately 6:08 pm that indicated Resident #1 entered the nurses' station and LVN D pulled her by her wrists out of the area. The ADM said LVN D told the resident her father was dead 2 or 3 times, which escalated Resident #1's behavior. ADM said she reported the incident as required per her policies and procedures, and she spoke to Resident #1, who could not recall how she sustained the bruising that was observed on Resident #1's wrists. ADM directed LVN F to assess Resident #1 obtain physician's order for an x-ray, and to document his findings. ADM notified LVN D's agency that LVN D could no longer work at the facility. ADM said she recognized that CNAs A, B, and C failed to report the incident of abuse to her or the DON. ADM said on 07/15/23 she conducted Safe Surveys with the facilities residents, including Resident #1, who did not recall being abused. ADM said she immediately in-serviced her staff on shift, and staff who were not at the facility would be in-service before working on the floor. These in-services provided on 05/17/25 included Coping with Agitation, Aggression, and Sundowning in Alzheimer and Disease, and Abuse, Neglect, Exploitation and Misappropriation Prevention Program. The ADM said the nurses and CNAs were receive disciplinary actions against them and she would continue her investigation. ADM said the Medical Director and Resident #1's responsible party were notified. ADM indicated the MD viewed the recording on 07/15/25 and directed her to terminate the contract with the agency that employs LVN D, and that he did not want any of their staff in the building. Prior to the incident on 07/13/25, ADM said she had in serviced the facility's staff and informed them that she was accessible to them twenty-four hours a day, seven days a week. In addition, ADM said prior to the incident she had a form posted next to the reporting guidelines in the hallway next to the nurses' station that included her phone number, and it was there when the incident occurred between LVN D and Resident #1. Record review of the facility's in-service provided 07/15/25 Coping with Agitation, Aggression, and Sundowning in Alzheimer and Disease indicated staff should be patient and try not to show frustration and to avoid arguing, gentle touching to calm down, and take deep breaths and count to 10. Staff should focus on an abject or activity to distract, and/or provide a snack and/or beverage. This in-service included protecting yourself and other if needed, and if the resident becomes aggressive, stay at a safe distance until the behavior stops. Talk to a doctor if aggressive behaviors worsen and consider medications that may help. Record review of the facility's in-service provided 07/15/25 and dated Revised 2021, Abuse, Neglect, Exploitation and Misappropriation Prevention Program indicated Resident have the right to be free from abuse and neglect. This included develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents. Establish and maintain a culture of compassion and caring for all resident and particularly those with behavioral, cognitive or emotional problems. Record Review of Resident Safety Survey provided on 07/15/25 indicated the facility's residents were asked the following. 1. Do you feel safe?2. Have you witnessed any abuse (physical or verbal)?3. Does staff knock and introduce themselves when entering your room?4. Do you know who o report alleged abuse to? There were no negative findings on these reports, including Resident #1. Observation on 07/15/25 at 9:50 AM of Resident #1 indicated she had three inches by three inches of bruising that wrapped around her right and left wrists.During an interview on 07/15/25 at 9:51 AM with Resident #1 indicated she could not recall how she sustained the bruising to her wrists. During an interview on 07/15/25 at 12:31 pm with HR indicated the agency is responsible for ensuring staff are trained to work for nursing homes before placing them on the agency portal. HR said if the facility needs a staff, she will apply the request on the porta. This allows the agency staff to accept the request through their portal. HR said the facility is not responsible for their training because the agency is responsible for their training. If the facility had known that LVN D had not been trained in Dementia, she would not have been allowed to work at the facility. Since this incident, HR said the Medical Director has requested the agency's contract terminated, and their staff not be allowed to care for the facility's residents. During an interview on 07/15/25 at 12:52 pm with CNA H, who works 6 am to 6 pm shift, indicated on 07/14/25 she was in-service on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. CNA H said before this incident on 07/13/25 involving LVN D and Resident #1, the ADM in-serviced her that she was available 24 hours a day seven days a week, and her phone number was posted on the bulletin board next to the A&N phone number. CNA H said when Resident #1 is upset, she will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. CNA H said she would not grab a resident by their wrist and force them to leave the area. CNA H said the nurse and CNAs are the ones that updates her with changes to a resident's care plan.Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA H had signed these in-services on 07/14/25. During an interview on 07/15/25 at 1:15 pm with CNA G, who works from 6 am to 4:30 pm, indicated he was in-service on 07/14/25 on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. CNA G said before 07/13/25 he was working but left before the incident occurred between LVN D and Resident #1. CNA G said he received an in-service from the ADM, who informed him her phone number was posted on the bulletin board next to the A&N phone number. CNA G said when Resident#1 is upset, he will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. CNA G said she would not grab a resident by their wrist and force them to leave the area. CNA G said if a resident's plan is changed, he will be informed by the nurse and CNAs. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA G had signed these in-services on 07/14/25. During an interview on 07/15/25 at 2:09 pm with LVN F, who works from 6 am to 6 pm, indicated on 07/14/25 the ADM asked him to assess Resident #1, obtain orders to X-ray her arms, inform the physician and family, and to document his findings. LVN F said he observed Resident #1 had two-to-three-inch bruising to her wrists but did not document this assessment until later in the day because he took his break and because a resident had a fall he was dealing with. LVN F said he was issued a disciplinary [NAME] for not document his assessment. LVN F said he obtained the order for Resident #1's X-rays, which were negative for fractures. LVN F said during shift report on 07/13/25 at approximately 6 am, LVN E did not inform him that Resident #1 had hit LVN D, and that she had assessed her. LVN F said Resident#1 can get aggressive; however, he will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. LVN F said these steps are in Resident #1's care plan. LVN F said he would not grab a resident by their wrist and force them to leave the area. LVN F said if a resident's plan is changed, he will be informed by the DON or outgoing nurse, and he will share this information with his CNAs. LVN F said in the future he will document his assessments on the resident's progress notes and skin assessment. indicated he was in-service on 07/14/25 on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. LVN F said before 07/13/25 he was in-service by the ADM that she could be reached 24 hours a day seven day a week, and her phone number was posted on the bulletin board next to the A&N phone number. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated LVN F had signed these in-services on 07/14/25. During an interview on 07/15/25 at 12:31 pm with HR indicated they use an agency, which is a third party, when they need a nurse or CNA to work at the facility due to a facility staff not being able to work. HR said the agency is responsible for ensuring their staff are trained to work at a nursing home, before placing them on the agency portal. HR said if she needs a staff, she will place her request on the portal, and the interested nurse or CNA will accept the request. HR said if she had known LVN D was not up to date on her training she never would have accepted her request to work at the facility. HR, said due to the incident with LVN D abusing Resident 1, the MD has terminated their contract with this agency. During an interview on 07/15/25 at 2:23 pm with CNA A, who works 6 am to 6 pm, indicated on 07/13/25 at approximately 6 pm, she witnessed LVN D direct Resident #1 to throw away cups the cups she had taken from the medication cart, and she complied. CNA A said she head LV D say to Resident #1 she did not belong there, and Resident #1 began yelling. CNA A said she approached Resident #1, who was in front of the nurses' station and tried to hit LVN D. LVN D grabbed resident #1's hands as Resident #1 yelled at LVN D that her daddy owned the facility. CNA A said LVN D said to resident #1 she could say what she wanted but she was protecting herself from Resident #1. Hitting her. CNA A said she intervened by extending her hand between LVN D and Resident #1, who swatted her hand but then allowed CNA A to hold her hand and follow her towards her room. CNA A said before getting into Resident #1's room, she stopped, pulled up her sleeves, and said look what that lady did to me. CNA A said she witnessed Resident #1's wrist were red. CNA A indicated on 07/14/25 Resident #1's hospice aide questions whey Resident #1 had bruises to her hands and wrists. CNA A replied that there was an incident between Resident #1 and LVN D, and the hospice aide question if this had been reported, and CNA A said yes to the ADM. CNA A said she on 07/14/25 she was in-service on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. CNA A said before this incident on 07/13/25 involving LVN D and Resident #1, the ADM in-serviced her that she was available 24 hours a day seven days a week, and her phone number was posted on the bulletin board next to the A&N phone number. CNA A said when Resident #1 is upset, she will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. CNA A said she would not grab a resident by their wrist and force them to leave the area. CNA A said the nurse and CNAs are the ones that updates her with changes to a resident's care plan. CNA A said she intervened to protect Resident #1; however, she failed to report to the ADM immediately. Instead, CNA A said she reported this incident to the ADM on 07/14/25 and was issued a disciplinary action against her. CNA A said on 07/13/25 she did not report the incident between LVN D and Resident #1 because she was distracted due to having a disagreement with a coworker over dividing the rooms which cause her to be distracted, it was shift change, and she was changing briefs and answering call lights. CNA A said when Resident #1 was upset and aggressive, LVN D should have asked one of the CNAs to assist her, because Resident #1 is familiar with the CNAs. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA A had signed these in-services on 07/14/25.Record Review of the Counseling Notice for CNA C signed and dated on 7/15/25 and signed by the DON revealed, CNA C received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of the Counseling Notice for CNA A signed and dated on 7/15/25 and signed by the DON revealed, CNA A received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of the Counseling Notice for LVN E signed and dated on 7/15/25 and signed by the DON revealed, LVN E received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of undated text messages at 4:17 PM from the facility ADM to the staffing agency revealed that the staffing agency acknowledged that dementia training was not mandatory unless the staffing agency was notified that it should be and moving forward the agency would document as a requirement. Record Review of an email dated 7/15/25 from the ADM to the staffing agency revealed that effective 7/15/25 the facility would no longer be using the staffing agency. During an interview on 07/17/25 at 7:33 am with LVN I, who worked 6 pm to 6 am indicated she was in-service on 07/14/25 on preventing A&N and how to address residents with Alzheimer and Dementia, per in-service forms. LVN I said the phones numbers for reporting A&N are posted next to the A&N poster by the nurses' station. LVN I said the ADM was accessible 24/7 for reporting A&N. LVN I said she is responsible for 2 CNAs during the night shift and for updating them with changes to a resident' care plan or significant changes. LVN I said Resident #1 likes to go into the nurses' station but can be redirected or given snacks so she can comply with leaving the nurses' station, which is part of her plan. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated LVN I had signed these in-services on 07/14/25.During an interview on 07/17/25 at 9:59 am with the DON indicated that what should have happened ( when LVN D abused Resident #1), staff involved should have reported the incident as soon as it happened. Staff should have intervened and then reported the incident. She stated staff are trained to intervene and stop the incident and then report the incident to the ADM, who is the abuse coordinator. The DON stated the staff should have reported immediately and not have waited for several hours to report. The DON stated staff did not follow the facility policy to report abuse immediately, which could have allowed injury, mental or physical abuse to continue. The DON stated to her knowledge Resident #1 is not on any blood thinners, but she is fragile and has thin skin and easy to bruise. The DON stated that the ADM should have been informed immediately because residents have the right to be protected. The DON stated that talking about Resident #1's dad will escalate her behaviors but offering her a snack will help to calm her behaviors. The DON stated that had staff notify her or the ADM when the incident happened, they would have gone to the facility and sent staff home and initiated the investigation. The DON stated Resident #1 doesn't know how the bruising happened and continues to say she doesn't know who did that to her. The DON stated staff reported the incident the next day (07/14/25) because that is when the bruises appeared. The ADM called LVN's agency and told them not to send the nurse back. She stated that they started in-servicing staff on abuse and reporting abuse and working with residents with behaviors. Review on 07/15/25 of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated DON had signed these in-services on 07/14/25.Record review on 07/17/25 of LVN D's timesheet dated 07/13/25 indicated she worked at the facility 10 hours and 43 minutes (07/13/25 at 7 am until 12:00 am). During an interview on 07/17/25 at 10:14 AM with LVN D indicated she started her shift on 07/13/25 at 7:00 AM and ended her shift at 12:00 AM. LVN D said at approximately 7 PM, Resident #1 went behind the nurses' station, and was rambling and grabbing stuff off the nurses' desk. LVN D said she told Resident #1 she could not be there, and walked towards Resident #1, who started fighting with her. LVN D said she caught Resident #1's wrist to keep her from hitting her and someone used a medication cart to prevent her from returning to the nurses' station. LVN D said she absolutely grabbed Resident #1's wrist; however, prior to that incident she had asked (unable to recall who she asked) why Resident #1 had bruises on her wrist. LVN D said she was positive she did not cause the bruises. LVN D said in the past Resident #1 would go into the nurses' station often; however, she did not do anything, unless Resident #1 took items from the nurses' desk. LVN D said she knew Resident #1 had a care plan; however, she never has nor did it cross her mind to review the care plan. LVN D said she did not know the care plan included interventions to address Resident #1's behaviors. LVN D said she did not call Resident #1's family member nor did she offer her a drink and/or snack when she became upset. LVN D said she did not document Resident #1's incident or her behaviors, and did not notify the physician, responsible party, Director of Nurses, (DON), and the Administrator, because Resident #1 did not have a change of condition and she did not see it as an escalated change. LVN D said that was Resident #1's normal behavior. LVN D said she was trained in addressing residents with Dementia and/or Alzheimer's but could not recall if it included holding residents by their hands or wrists. LVN D said in the moment of the incident she told Resident #1 You are not going to hit me, I'm stronger than you are. LVN D said she had not had training on elderly aggression. LVN D said when a resident is aggressive, she should offer the resident something to avert their attention, let them be if they are not hurting themselves or others, offer medications, and offer snacks. LVN D said she did not grab Resident 1's wrist, she caught her wrist, which was not appropriate but it depended on the situation. LVN D said the first time she put space between her and Resident #1 was when she was going by the medication cart, the second time was when the CNA directed her to leave, and the third time there was distance between her and Resident #1 until, Resident #1 lunged at me. LVN D said she recalled a resident (Resident #2) in the area but could not recall which one. LVN D said Resident #1 was not within reach of a resident. LVN D said Resident #1 has a history of talking about her deceased dad, and she (LVN D) told her he was dead because she was looking for her dad, and Resident #1 was saying she did not have to leave the nurses' station because her dad built the facility and he owns it. During an interview on 07/17/25 at 10:56 AM with Resident #2, who had been sitting approximately 5 feet from the nurses' station and per video yelled out leave her alone, indicated she could not recall the incident involving LVN D and Resident #1. Record review on 07/18/25 at 3 pm of CNA C's written witnesss statement indicate on 07/13/25 she witnessed LVN D holding Resident #1's by her wrists and attempting to redirect her. CNA C said LVN D was making verbal comments about Resident #1's dad being dead. Then Resident #1 became combative and that's when the CNAs took resident to her room. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA C had signed these in-services on 07/14/25.During an interview on 07/18/25 at 12:50 pm with CNA B, who works 6 pm to 6 am and 6 am to 6 pm shifts, indicated she was in-service but cannot recall the date, because she works for an agency, which requires her to be at numerous facilities. CNA B said prior to the incident on 07/13/25, between LVN D and Resident #1, she had been in-serviced on preventing A&N, and how to address residents with Alzheimer and Dementia through her required CNA training. CNA B said she knew she could call the ADM anytime of the day or night and that her number was posted on the bulletin board in the facility, and if not, she could ask for her number. CNA B said on 07/13/25 at approximately 6 PM, she heard LVN D say to Resident #1 she could not go there (behind the nurses' station). CNA B said when LVN D grabbed Resident #1's wrists and pulled her from behind the nurses' station. CNA B said intervened by using the medication cart to block the entrance to the nurses' station and asking Resident #1 two or three times to go with her to her room, because she could see that LVN D was holding her wrists. CNA B said Resident #1 pulled her right hand loose and swung at LVN D but missed hitting her. That was when LVN D grabbed her wrists and said If you hit me, I will hit you back. CNA B said she continued to direct Resident #1 to go with her to her room, but she refused. Then CNA A intervened by walking up to LVN D and Resident #1, extending her hand to Resident #1 and asking her to go with her, and Resident #1 complied. CNA B said she walked with CNA A, and Resident #1 towards Resident #1's room, until she stopped in the hallway, pulled her shirt sleeves above her wrists, and said Look what she did to me. CNA B said Resident #1 had redness and bruising (blueish blotches) to her wrists. Afterwards, CNA B left CNA A and Resident #1, who continued to walk to Resident #1's room while holding hands. CNA B said she reported the incident to LVN E, on the night of 07/13/25 at 12 am, because she was the nurse relieving LVN D. CNA B said she did not report the incident to the Administrator, because she was busy answering call lights. CNA B said she should have called the Administrator immediately, because she had been in-serviced and informed that the ADM's phone number was posted next to the bulletin board next to the number for reporting abuse and neglect. CNA B said during the incident she intervened to protect Resident #1 from LVN D by using the medication cart to block the entrance to the nurses' station, after she saw LVN D pulling Resident #1 by her hands out of the nurses' station. Then CNA B said she asked Resident #1 two or three times for her to go with her to her room, but she did not comply. Then CNA A reached her hand out to Resident #1 and asked her to go to her room, and Resident #1 complied because she is very familiar with CNA A. CNA B said since 07/13/25 she had not worked at the facility. CNA B said Resident #1 in the past has been redirected and offered snacks when she has been aggressive, and that works. CNA B said she in updated on residents' care plans by the nurses and CNAs. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA B had signed these in-services on 07/14/25.A phone call interview on 07/18/25 at 1:20 PM was attempted with LVN E via a voice mail and text message, but she did not return the message. Record review of LVN F's written statement(that was not dated) but prov[TRUNCATED]

Based on observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 1 of 3 residents (Residents #32) reviewed for infection control. The facility failed to ensure CNA A utilized proper hand hygiene during incontinence care for Resident #32. This failure could place residents at risk for infection and cross contamination. The findings include: Record review of Resident #32's undated face sheet revealed an [AGE] year-old male originally admitted on [DATE]. Resident #32 had a medical history of malignant neoplasm of prostate (an abnormal growth of tissue that can spread into nearby tissues and other parts of the body), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and atrial fibrillation (a common type of irregular heart rhythm). Record review of Resident #32's quarterly MDS assessment dated [DATE], revealed a BIMs score of 15 which indicated Resident #32 was cognitively intact. Section H- Bladder and Bowel revealed Resident #32 had an indwelling catheter. Record review of Resident #32's care plan last revised on 8/14/2024, revealed Resident #32 had a foley catheter with the following intervention Catheter care every shift to be performed by CNA. Date Initiated: 01/31/2024. Record review of Resident #32's physician orders revealed, Catheter care every shift to be performed by CNA every shift, with a start date of 1/19/2024. During an observation on 8/19/2024 at approximately 10:15AM, CNA A washed his hands and donned PPE (gloves and gown) outside of the resident's room. CNA A entered the room and assisted Resident #32 with his pants. CNA A unfastened Resident #32's brief and cleaned the resident's foley and front. CNA A assisted Resident #32 to turn onto his right side and tucked the dirty brief under the resident. CNA grabbed the clean brief with contaminated gloves and placed it under Resident #32. CNA A assisted resident to turn to his left side and removed the dirty brief. CNA cleaned Resident #32's bottom with wet wipes. CNA A applied barrier cream onto resident's bottom. CNA A turned Resident #32 onto his back and fastened his brief. CNA A removed his dirty gloves and gown and utilized ABHS. CNA A failed to change gloves and utilize hand hygiene during incontinence care. During an interview on 8/19/2024 at 1:15pm with CNA A, he stated the infection preventionist was the DON and ADM. He stated he had been trained on handwashing during incontinence care but did not remember the last one. He stated the potential negative outcomes of not changing gloves and utilizing handwashing during incontinence care could be skin breakdown, bed sores, skin discoloration, or cross contamination between residents. He stated handwashing should be performed before resident care and immediately after. CNA A stated glove changes should occur if the gloves were visibly soiled. He stated during the care he realized he had grabbed the clean brief with dirty gloves, and he had been nervous during the incontinence care. During an interview with the DON on 8/20/2024 at 10:52 AM, she stated she was the infection preventionist. She stated handwashing training is done monthly and yearly. She stated handwashing compliance is monitored by the nurses and herself and they track UTI rates. She stated the potential negative outcome of not utilizing proper hand hygiene could be infection. She stated handwashing should be done before they go into the resident's room, when they go from dirty to clean, and when they exit the room. She stated handwashing should always occur between glove changes. She stated handwashing is monitored by observation. During an interview with the ADM on 8/20/24 at 12:05 pm, he stated the DON was the infection preventionist. He stated handwashing training is done as needed and yearly. The ADM stated competencies are conducted annually to monitor for compliance. The ADM stated the risk of not utilizing proper hand hygiene during incontinence care is potential for contamination. He stated glove changes should occur after cleaning the soiled area and before switching to a clean area. He stated staff are trained on handwashing or to use ABHS in between glove changes. Record review of facility policy titled Handwashing/Hand Hygiene, revealed . Indications for Hand Hygiene . d. After touching a resident. e. after touching the resident's environment. f. before moving from work on a soiled body site to a clean body site on the same resident and g. immediately after glove removal .Applying and removing gloves . 4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand folding it into the first glove. 5. perform hand hygiene.

Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, on facility grounds in 1 of 2 parking lots (front entrance parking lot) in that: The facility failed to ensure the trash was emptied into the dumpster for five hours. This failure could attract unwanted pests and cause the facility to have an unsightly appearance. The findings included: On 8/19/24 at 9:45 AM, an observation was made of a trashcan located near the front entrance in the front parking lot. The trashcan was observed to be full of trash which prevented the lid from closing. The trash items observed were Styrofoam food containers and cups, fast food bags, and other miscellaneous trash. On 8/19/24 at 12:29 PM, an observation was made of a trashcan located near the front entrance in the front parking lot. The trashcan was observed to be full of trash which prevented the lid from closing. The trash items observed were Styrofoam food containers and cups, fast food bags, and other miscellaneous trash. On 8/19/24 at 2:45 PM, an observation was made of a trashcan located near the front entrance in the front parking lot. The trashcan was observed to be full of trash which prevented the lid from closing. The trash items observed were Styrofoam food containers and cups, fast food bags, and other miscellaneous trash. On 8/20/24 at 12:57 PM, an interview was conducted with the Maintenance and Housekeeping Supervisor, and he stated he was aware that the trashcan by the front entrance was full. He stated he saw it around 10:00 AM as he walked by it, but he was in the middle of repairing something else and did not take it to the dumpster at that time. He stated trashcans were not supposed to be overflowing with trash that prevent the lid from closing. He stated he has since spoken to the housekeeping staff to include checking trashcan outside and on the patio's every morning. He stated he expected housekeeping staff to throw trash immediately when they notice it was full or overflowing. He stated he expected all other staff to let housekeeping staff know when they see any trashcans were full or overflowing so it can be thrown out. He stated he was responsible for training housekeeping staff about requirements for trash. He stated most of his housekeeping staff were new and were still in the process of being trained. He stated he did not know when the last time housekeeping staff received that training if hired prior to him becoming the Maintenance and Housekeeping Supervisor nine months ago. He stated he did not know of a potential negative outcome that could occur from trashcans being left full and overflowing with trash. On 8/20/24 at 1:45 PM, an interview was conducted with the Regional Director/Interim Administrator, and he stated facility policy was that all litter must be disposed of properly and timely. He stated he saw the trashcan by the front entrance was full as he walked a visitor out of the facility, and he told staff to throw it out. He stated there was currently not a system to ensure that trashcan was checked regularly, but he would create a check-off list for housekeeping staff to add checking trashcans in the parking lot, as the current list only included checking trashcans inside the facility. He stated he expected staff to get rid of trash as soon as they had seen it. He stated housekeeping staff were trained; however, he was not sure when each member received the training as it would depend on who their supervisor was when they were hired. He stated potential negative outcomes were that it was unsightly and could invite pests. Record review of the facility policy titled Grounds, Revised May 2008, revealed the following documentation, Policy Statement. Facility grounds shall be maintained in a safe and attractive manner. Policy Interpretation and Implementation. 1. Maintenance shall be responsible for keeping the grounds free of litter. 2. Lawns shall be mowed on a weekly basis during the grass cutting season. Shrubs shall be trimmed as needed. 3. Areas around the buildings (i.e., sidewalks, patios, gardens, etc.) shall be maintained in a safe and orderly manner at all times.

Based on interviews and record review, the facility failed to ensure residents had the right to be free from sexual abuse for 3 (Resident #3, Resident #4 and Resident #6) of 9 residents reviewed for abuse. 1. The facility failed to put protective measures in place on 05/11/24 to protect Resident #4 from sexual abuse after knowing Resident #2 had displayed inappropriate sexual behavior with Resident #3. 2. The facility failed to put protective measures in place on 06/02/24 to protect Resident #3 in place from sexual abuse after knowing Resident #5 had a history of inappropriate sexual behavior. 3. The facility failed to put protective measures in place on 06/02/24 to protect Resident #6 in place from sexual abuse after knowing Resident #5 had a history of inappropriate sexual behavior. On 06/07/24 at 5:00 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 06/09/24 at 3:30 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure caused additional residents to be sexually abused and potentially placed other residents at risk for sexual abuse. Findings Include: 1. Findings for the facility's failure to put protective measures in place on 05/11/24 to protect Resident #4 from sexual abuse after knowing Resident #2 had displayed inappropriate sexual behavior included: Record review of Resident #2's face sheet, dated 06/05/24, revealed a [AGE] year-old-male that was readmitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember), depressive disorder (constant feelings of sadness), mood disorder (emotional deficit), and blindness to the right eye. Record review of Resident #2's Quarterly Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. Section B Hearing, Speech, and Vision revealed that Resident #2 had clear speech, makes himself understood, and understands others. His vision is impaired, and he does not wear corrective lenses. Section E Behavior revealed that he had not had any incidents of physical or verbal behavior. Record review of Resident #2's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a blank BIMS score. Section E Behavior revealed that he had had delusions, physical behaviors such as hitting, kicking, pushing, scratching, grabbing, and abusing others. Resident # 2 had exhibited verbal behaviors such as threatening others, screaming, and cursing at others. Resident #2 had other behavioral symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, smearing food or bodily wastes, or verbal/vocal symptoms like screaming and disruptive sounds. Resident #1 exhibited wandering behavior 1-3 days. Record review of Resident #2 care plan, dated 05/01/24 revealed the following: Resident #2 wanders in other residents' rooms and gets into their beds at times and had the following interventions: Resident #2 required assistance out of rooms that were not his and staff could use snacks if needed. Resident #2 was an elopement risk/wanderer and had the following interventions: Distract Resident #2 from wandering by offering pleasant diversions. Resident #2 prefer having snacks. Followed by [name of psych care]. Notify their MD/NP of any escalation in wandering behaviors, ineffectiveness, or side effects of psychiatric medications. Monitor the resident's location throughout shifts. Document wandering behavior and attempted diversional interventions in behavior log. Resident #2 had episodes of verbal and physical aggression r/t dementia with the following interventions: Give me as many choices as possible about care and activities. Monitor for physically/verbally aggressive behavior q shift. Document observed behavior and attempted interventions in behavior log. Monitor/document/report PRN any s/sx of Resident #2 posing danger to self and others. Resident #2 had impaired visual function r/t cataracts and glaucoma. Resident #2 was blind in his right eye with the following interventions: Arrange consultation with eye care practitioner as required. Monitor/document/report PRN any s/sx of acute eye problems: Change in ability to perform ADLs, decline in mobility, sudden visual loss, pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. Place frequently used items on my left side so I may see them. Record review of Resident #2's progress notes revealed the following: Record review of on 05/11/24 at 12:12 AM LVN G documented: Data: Resident observed by CNA H reported to this nurse observed resident with pants unzipped and PENIS in Resident #3's hand. Action: Resident removed from Resident #3's room w/o incident. Resident #3 appears to have been asleep during entire incident. No physical injuries noted at this time. Response: Resident in his room and placed on 1-1 monitoring per DON instructions. Roommate moved to different room as this nurse considers this a HIGH RISK INCIDENT. DON & Administrator notified. Record review of on 05/11/24 at 03:23 PM The DON documented: Received orders from NP may administer Lorazepam 1ml now and then every 8 hours as needed. DON gave orders to charge nurse may use emergency restraint for safety of resident and others. Record review of on 05/11/24 at 05:27 PM the DON documented: Spoke with Family Member L about incident and orders to give Lorazepam 2mg/ml injection every 8 hours as needed x 14 days. Voiced understanding and gives verbal consent at this time for medication. Also discussed that he would be going back to the behavior support center on Monday and facility would be actively looking for alternate long-term placement for resident. Voiced understanding and consents for referrals to be sent to other facilities. Record review of on 05/11/24 at 05:27 PM LVN B documented: Staff alerted this nurse that this male resident was found in female resident's bed with his hands in the female's pants. Upon entering room male resident is found in bed with female resident with his hand on resident's waist. Told resident he needed to get out of bed. RT refused and put his arm around female resident. Male resident immediately removed from female's bed and taken to his own room. Resident became aggressive with staff refusing to leave bed causing CNAs to fall. Administration notified. Physician A, the DON notified. New order for Ativan 2mg/ml injection. Injection administered. Resident continues to try to go into other female rooms. Record review on 05/31/24 at 01:07 PM The DON documented: Resident returned from behavioral center via their facility van. Notified Physician A of return and medications. Notified the NP of return and reconciled psychotropic medications. Notified family Member L of return and went over psych medications and no issues or concerns at this time. Record review of on 06/02/24 at 03:26 AM LVN M documented: Follow-up on readmission, resident continues to urinate on floor. Reminded resident to use urinal. Resident voiced understanding. Resident also continues to wander. Resident breathing even and unlabored. No complaints voiced. Record review of on 06/02/24 at 07:35 PM The DON documented: Notified by charge nurse that resident was wandering in rooms and becoming aggressive when staff was trying to redirect. Contacted the NP and new orders received to increase Seroquel to 50mg 3 times daily, Xanax 0.25mg every 6 hours as needed x 14 days, and Zyprexa 10mg IM every 12 hours as needed x 14days. Notified Family Member L of resident behavior and new orders. Voiced understanding and no issues or concerns at this time. Record review of Resident #2's monitoring sheets revealed the following: Resident #2 was monitored every 30 minutes starting 05/08/24 at 11:30 AM until 5/10/24 at 6:00 PM. (No abnormal behavior reported during this monitoring time.) No time monitoring accounted for 05/10/24 at 11:00 PM- 12:00 AM. Resident #2 was monitored on 05/11/24 from 1:00 AM-5:45 AM. (No abnormal behavior notated during this time. No time monitoring accounted for 12:00 AM-1:00 AM.) Resident #2 was monitored on 05/11/24 from 6:30 AM-4:00 PM. (No abnormal behavior notated during this time. No time monitoring accounted for 4:30 PM-6:00 PM) Record review of Resident #3's face sheet, dated 06/05/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (memory loss), cognitive communication deficit (difficulty communicating), fracture to neck and left femur, anxiety disorder (increased worry), and major depressive disorder (increased sadness). Record review of Resident #3's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 01, which indicated the resident's cognition was severely impaired. Section B. Ability to understand others revealed that she had clear speech, sometimes could make herself understood, and sometimes could understand others. Record review of Resident #3's care plan dated 6/5/24 revealed the following: Resident #3 was dependent on staff for emotional, intellectual, physical, and social needs related to cognitive deficits. Resident #3 required assistance to ADLs related to Alzheimer's disease, had impaired cognitive function/impaired thought processes related to Alzheimer's, had a mood problem related to depression, and had potential for psychosocial well-being related to trauma. Record review of Resident #3's progress notes revealed the following: 05/11/24 at 01:27 AM LVN G documented: Resident #2 observed in resident's room with Penis in her hand attempting what appears to ejaculate himself. Resident Immediately stopped by staff and removed to his room. Placed on 1-1 monitoring with instructions by DON NOT to be left out of staff sight at any time. No apparent injuries not upon physical inspection with female CNA present. DON to notify PCP & family. Record review of Resident #4's face sheet, dated 06/05/24, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis that included Alzheimer's disease (memory loss). Record review of Resident #4's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section B. Ability to understand others revealed that she had clear speech, could make herself understood, and could understand others. Record review of Resident #4's care plan dated 4/29/24 revealed the following: Resident #4 was dependent on staff for emotional, intellectual, physical, and social needs related to cognitive deficits. Resident 41 had impaired cognitive function related to Alzheimer's disease. Record review of Resident #4's progress notes revealed the following: 05/11/24 at 05:32 PM LVN B documented: Staff alerted this nurse that Resident #2 was found in female resident's bed with his hands in female's pants. Upon entering room male resident is found in bed with female resident with his hand on resident's waist. Male resident immediately removed from female's bed and taken to his own room. Female resident assessed for injury, no visible injury noted. Administration notified. DON to speak with family regarding incident. During an interview on 06/05/24 at 1:49 PM, CNA E stated that one night, when he worked the night shift (unsure of the date and exact time), Resident #2 exposed himself to Resident #3. He said he did not see it but was told by CNA H that Resident #2 had his penis in Resident #3's hand and was jerking off. He said because of that incident, Resident #2 was placed on 1:1 and was checked every 15 minutes by the night staff. He said Resident #3 was not in her right mind and would have been unable to consent. He said Resident #3 may have a BIMs score of 0. He said prior to the incident involving Resident #3, Resident #2 was not on any close monitoring. He said that when Resident #3 was in the dining room and wanted to return to his room, they would assist him, but after he was in his room, they did not do additional monitoring. During an interview on 06/05/24 at 2:57 PM, LVN G stated that on 05/11/24, he was working the night shift. He said he heard a young lady yell out. He said it was the female CNA but did not know her name. He said he was on break. He said the female CNA reported that Resident #2 had a particular part of his anatomy in Resident #3's hand. LVN G stated they assisted in getting Resident #2 out of Resident #3's room. He stated when he walked in, he did not see Resident #2's penis in Resident #3's hand but did see his penis out. He said he had not seen Resident #2 do the sexual act in the past, but that Resident #2 would expose himself and urinate on the floor. He stated that, because of the incident, he reported it to the DON and was instructed to place Resident #2 on 1:1 monitoring. He stated he would sit in the hall and ensure Resident #2 did not go into other rooms. LVN G said that Resident #3 was catatonic (immobile) and could not defend herself. LVN G did not confirm that the DON or the ADM provided specifics to what was expected regarding placing Resident #2 on 1:1 monitoring. During an interview on 06/05/24 at 4:04 PM, the ADM stated she was told but could not remember who told her that Resident #2 was standing over Resident #3 with his penis out and Resident #3's hand was on Resident #2's. The ADM stated she was not told that Resident #2 was masturbating. She said in addition to being notified about Resident #3, she was informed later that day (05/11/24) by LVN B that Resident #2 had gotten into bed with Resident #4 and had his hand near her privates. She said she had read the progress notes since the state surveyor exited on 05/09/24. She said she did not report or investigate both incidents of inappropriate sexual behavior because, in both incidents, all residents involved had dementia. The ADM stated that Resident #2 was placed on 1:1 during the second incident involving Resident #4 because Resident #2 became aggressive. The ADM stated that Resident #2 was not put on 1:1 during the first incident involving Resident #3 because he was not aggressive, and this was the first time he displayed this behavior. During an interview on 06/05/24 at 4:24 PM, the DON stated when the inappropriate sexual incidents were reported to her, she reported it to the ADM as she was the abuse coordinator. She said she had not completed any specific training with staff regarding Resident #2's behavior after the first incident. During an interview on 06/05/24 at 5:14 PM, the NP stated she was aware of and had been notified about the inappropriate sexual touching between Resident #2 and #4. She said that she had charted in her notes that the DON was concerned about the behavior of Resident #2. The NP reported that the DON reported to her that Resident #2 was found in the room of a defenseless resident (Resident #3), and he placed his penis in her hand, and was stroking his penis. The NP then said it was reported to her that Resident #2 was found in the room of another female resident on a separate incident and became combative with staff. The NP stated that she permitted the nursing staff to administer Ativan to Resident #2 during the first incident with Resident #3. During an interview on 06/06/24 at 5:04 AM, CNA N stated she had observed Resident #2 go into a female resident's room but always redirected him when she was on shift. She stated that when he would attempt to go into residents' rooms (male and female), she would report it to her charge nurse. She said she could not tell exact dates and times but that it had happened more than once that she had to redirect Resident #2 out of other rooms. CNA N said his behavior for wandering was constant when he was awake. During an interview on 06/06/24 at 9:47 AM, CNA H stated the incident between Resident #2 and #3 occurred on 05/10/24 around 11:00 PM. She said she was told to go and check on another resident by LVN G. While doing so, she observed Resident #2 in Resident #3's room. When she got closer, she was able to see that he had his penis out, and Resident #3's hand was cuffed under Resident #2's penis. She said Resident #2 had his hand under hers and was masturbating (rubbing it up and down). CNA H said she yelled for help, and LVN G and CNA E assisted her. CNA H said the two male staff could get Resident #2 out of Resident #3's room without any issues. CNA H stated that administration instructed them to watch Resident #2. CNA H said all staff took turns watching Resident #2 every two hours and sat outside his door. CNA H said they told the oncoming shift what happened, and that Resident #2 was on 1:1 supervision. Before the incident on her shift, CNA H said she had not been given any specific instructions regarding Resident #2. She stated that they did pass the information the following shift. CNA H said LVN G had reported the incident between Resident #2 and Resident #4. During an interview on 06/06/24 at 11:47 AM, the Dietary [NAME] stated she assisted in 1:1 monitoring with Resident #2 before the incident on 05/11/24 with Resident #3. The Dietary [NAME] stated that when she watched Resident #2, he continued to display wandering and had to be redirected. She said during her monitoring, she did observe him pull out his penis and urinate on the floor. She said this occurred while he was in his room during the night shift. The Dietary [NAME] said she suggested during the morning meeting (before the incidents on 05/11/24) that Resident #2 be moved closer to the nurses' station for better observation. The Dietary [NAME] said the ADM looked at her, looked at the whiteboard that had the room assignments, and continued the meeting. The Dietary [NAME] said she does not have the ability to change rooms for residents and that this was the duty and responsibility of the ADM and the DON. The dietary [NAME] said outside of monitoring no additional efforts were made to supervise Resident #2's behaviors. During an interview on 06/06/24 at 12:25 PM, the DON stated she did not see the discrepancy in the monitoring sheet that showed that Resident #2 was not monitored from the alleged time of the incident on 05/10/24 from 11:00 AM until 05/11/24 1:00 AM. She said the person in charge of staying with Resident #2 during the first incident would have been LVN G. During the second incident that involved Resident #2 and #4; she was unaware of why there was a gap in the monitoring sheet from 4:00-6:00 PM. The DON said she did not see the gap and, since she had seen it, had not followed up or questioned why there was a gap. The DON said there should have been a staff assigned 1:1 with Resident #2 on 05/11/24 and this could have prevented the incident with Resident #4. She said that once she was notified about the incident between Resident#2 and #4, she realized that there was not a 1:1 staff with Resident #2. The DON stated that normally, staff call administration when staff do not show up, and that she was unaware of why the staff did not call on 05/11/24 when the monitor tech did not show up. The DON said the only interventions that have been put in place for Resident #2 were medication adjustments and redirection from staff. She said those interventions had not been successful. The DON said no specific interventions were put in place for the night shift even though it had been identified previously that Resident #2 tended to have increased behaviors at night. The DON said it had been discussed at morning meetings that they would like to hire more staff. The DON stated that Resident #2 did exhibit wandering during the days before his inappropriate sexual behavior. The DON said inappropriate sexual behavior was new, and this was why she told LVN G to watch him. The DON said she was unsure if the oncoming shift after the first incident was notified of the 1:1 monitoring expectation and that she did not follow up to see if this was done. The DON stated she did not come up to the facility after the instructions for 1:1 was given. She said that usually, in special supervision circumstances, the ADM would come to the facility because she lives in town, and the DON does not. She said that she did not remember discussing with the ADM about the ADM coming to implement formal training for Resident #2's inappropriate sexual behavior. The DON said that regarding the incident with Resident #2, the potential negative outcome was that other incidents could also occur if this was another resident. The DON said she never expected the sexual incident because he never displayed that type of behavior. The DON said she was unaware that he had sexual tendencies. She said the system the facility had in place for monitoring was the 1:1 for the 72 hours when he returned from any behavior support. The DON said she had never observed any sexual behavior or his continued wandering behavior in person. She said all staff were responsible for keeping abuse from happening. The DON said the staff handled everything correctly regarding Resident #2 and his inappropriate sexual behavior with Resident #3 and #4. The DON said the purpose addressing resident behaviors was to protect the residents and to follow policy. During an interview on 06/06/24 at 1:16 PM, The ADM stated no one ever relayed to her that they considered the inappropriate sexual contact a high-risk situation. The ADM said she vaguely remembered talking about moving Resident #2's room but that the way the facility was set up had all of the females and the males together. The ADM stated moving Resident #2 would have placed him among the female residents. The ADM stated she was unaware of who monitored Resident #2 from 05/10/24 at 11:00 PM until 05/11/24 at 1:00 AM. The ADM stated she did not have the monitoring sheets and that the DON had those sheets. The ADM stated the DON was responsible for reviewing those sheets. The ADM said she sometimes reviewed them to ensure they were completed, but not regularly. The ADM said Resident #2 was not supervised because there was supposed to be a monitor tech at the facility, but they did not show up. The ADM stated that staff were trained on what to do if someone does not show up for their shift but were unaware that the staff on 05/11/24 during the day shift was aware that there was supposed to be someone for 1:1 with Resident #2. The ADM said they usually do 1:1 monitoring with any resident for 72 hours after being released from a behavior support center. She said Resident #2 was released on 05/10/24 from 1:1 supervision after being admitted back to the facility on [DATE]. The ADM stated that Resident #2 had no issues during his monitoring period. The ADM said if he had problems, staff would have reported them to her. She stated that staff had been trained to report concerns but that she did not have any written documentation to show that staff had been trained to report incidents while observing 1:1 with Resident #2. The ADM said that it was a verbal instruction given when Resident #2 was placed under 1:1 supervision on 05/11/24 after the incident with Resident #4. The ADM said no formal training was conducted. The ADM stated regarding Resident #2, the inappropriate sexual behavior was new. She said that before, Resident #2 had aggression toward staff and other residents. The ADM said she was unaware of Resident #2's tendency for sexual behavior. The ADM stated she was unaware that Resident #2 was not under 1:1 supervision when he acted inappropriately sexually against Resident #4. The system to monitor behaviors and prevent abuse specifically involved close monitoring and monitoring tech assistance. The ADM said that not addressing a resident's inappropriate sexual behavior and supervising the residents correctly could result in harm to other residents. During an interview on 06/06/24 at 2:30 PM, Resident #4 stated she kind of remembered being touched by a man. She was unable to specify a date, time, or person. During an interview on 06/06/24 at 7:26 PM, the Regional Director stated the ADM was responsible for all activities in the facility He said he would expect for the ADM and the DON to follow facility policies. During an interview on 06/07/24 at 9:00 AM, Resident #2 stated he did not touch anyone. He stated that the staff treated him well at the facility, and he was able to move around the facility without staff. He said that all the residents liked him and celebrated him. He was unable to clarify what he meant by celebrate. During an interview on 06/07/24 at 12:00 PM, LVN B stated that she did not observe what happened. She stated what she noted in the resident's progress notes was what she saw. She said that the medication aide notified her but that he no longer worked at the facility. LVN B said she assessed the situation and observed Resident #2's hands in Resident #4's pants. LVN B said they told Resident #2 that he needed to stop and get out. LVN B stated that when she tried to redirect Resident #2 out of the room, which was when Resident #2 became aggressive. LVN B said Resident #2 was kicking, and it was difficult because Resident #4's bed was low and on the ground. LVN B said Resident #2 was trying to kick and fight the Medication Aide. LVN B said she was upset about the incident. She said it was not passed on that he needed to be 1:1 the night before. LVN B was made aware of the incident with Resident #3, and she was told that she had to do close monitoring. She said she would set her timer and check on him every 30 minutes. She said it would have been impossible for her to sit with him 1:1, and she was the only charge nurse. LVN B said she does not know why she did not completely sign off on the monitoring form between 4:00 PM and 6:00 PM. LVN B confirmed that the initials by the 4:00-6:00 PM blank hours were hers. LVN B said on 05/11/24 during her shift (day 6:00 AM-6:00 PM), she or her staff did not sit 1:1 with Resident #2. LVN B said she would peek in on Resident #2 when she could, but she was the only nurse for all of the residents at the facility. During an interview on 06/07/24 at 12:11 PM, CNA K stated that she did physically see Resident #2's hand in Resident #4's pants. She said Resident #2's right hand was in Resident #4's brief. CNA K said Resident #2's nails were extremely long and gross. CNA K said Resident #4 was not doing anything during this incident. CNA K said Resident #4 had no emotion on her face, but her eyes were open. She said that 05/11/24 Resident #2 was all over the facility and not on special 1:1 supervision. CNA K said no monitor techs were on duty that day (05/11/24). During an interview on 06/07/24 at 12:17 PM, CNA J stated that she does not know much about the incident that occurred on 05/11/24 with Resident #2 and Resident #4. She said that the Medication Aide was the one who observed Resident #2 touching Resident #4. CNA J said they had not been notified that Resident #2 was on 1:1 and were not trained to do anything different with Resident #2. 2. Findings for the facility's failure to put protective measures in place on 06/02/24 to protect Resident #3 from sexual abuse after knowing Resident #5 had a history of inappropriate sexual behavior included: Record review of Resident #3's progress notes revealed the following: 05/11/24 at 01:27 AM LVN G documented: Resident #2 observed in resident's room with Penis in her hand attempting what appears to ejaculate himself. Resident Immediately stopped by staff and removed to his room. Placed on 1-1 monitoring with instructions by DON NOT to be left out of staff sight at any time. No apparent injuries not upon physical inspection with female CNA present. DON to notify PCP & family. Record review of Resident #5's face sheet, dated 06/09/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses that included other sexual dysfunction (difficulty with sexual response), intermittent explosive disorder (impulsive and aggressive outbursts), insomnia (difficulty sleeping), age related cognitive decline, and cognitive communication deficit (difficulty communicating). Record review of Resident #5's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 07, which indicated the resident's cognition was severely impaired. Section B. Ability to understand others revealed that she had clear speech, could usually make herself understood, and usually understood others. Section E Behavior revealed that he had no documented behavior outside of wandering that occurred 1-3 days. Record review of Resident #5's care plan dated 6/02/24 revealed the following: Resident #5 occasionally attempted to be sexually inappropriate with staff and other residents. Resident #5 occasionally stated he was a killer and a rapist. Resident #5 had impaired cognitive function. Record review of Resident #5's progress notes revealed the following: On 06/02/24 at 02:20 PM LVN Q documented: LATE ENTRY Data: Resident #5 was kissing another resident (unidentified) on the lips. Action: Stopped the resident and sent him to his room and informed him not to be kissing other female residents. Response: WCTM this shift. 06/02/24 at 08:50 PM LVN Q documented: LATE ENTRY Data: Resident #5 was seen by a staff member touching and kissing on another resident (unidentified) in the dining room. Action: Removed the resident away from the other resident and informed him to keep his hands to himself. Response: WCTM this shift. On 06/09/24 at 02:56 PM the DON documented: Family members x 3 here to see [Resident #5]. Family would like facility to attempt referrals closer to their area. They would like referrals sent to multiple facilities. Informed Family that we would start referral process on Monday. Record review of Resident #5's monitoring sheets revealed the following: No time monitoring accounted for the following dates: 06/02/2024. Resident #5 was monitored every 15 minutes starting 06/09/24 at 12:00 AM until 11:45 PM (No abnormal behavior reported during this monitoring time). Resident #5 was monitored every 15 minutes starting 06/10/24 at 12:00 AM until 12:45 PM (No abnormal behavior reported during this monitoring time). During an interview on 06/09/24 at 11:23 AM, the DON stated as a result of the IJ, they were able to identify two other incidents that involved inappropriate sexual touching that was not investigated or reported. This occurred with Residents #5, and #3. She stated they identified the incident when they were following their removal plan and reviewing progress notes for potential residents that could be affected. The DON stated they immediately placed Resident #5 on Red supervision, notified Physician A, assessed all residents involved (Resident # 5 and #3), notified the family of both residents, and trained staff. The DON stated that she did not have details of what happened but that they had started the process of investigating. During an interview on 06/09/24 at 12:46 PM, the Dietary [NAME] stated she was present for the incident with Resident #5 and #4. The Dietary [NAME] said she was unsure of the date but that it happened a week before the interview. The Dietary [NAME] said the incident with Resident #4 involved Resident #5 touching and rubbing Resident #4's breast in the dining room. She said she reported this to LVN B and the ADM. She said she was unaware that anything had been done about those incidents. She said that before the IJ Resident #5 was not on any special level of supervision, but since the IJ had been placed on a special level. During an interview on 06/09/24 at 2:00 PM, Residen [TRUNCATED]

Based on observation, interviews and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse and neglect for 4 (Resident #1, Resident #3, Resident #4, and Resident #6) of 9 residents reviewed for abuse and neglect. The facility failed to implement their abuse and neglect policy when: 1. The facility failed to investigate the fall incident that occurred with Resident #1 while in the care of CNA E on 05/30/24. CNA E failed to notify the nurse of the fall. Resident #1 sustained a hip fracture. 2. The facility failed to report to the state agency and investigate a sexual incident that occurred on 05/10/24 between Resident #2 and Resident #3. 3. The facility failed to report to the state agency and investigate a sexual incident that occurred on 05/11/24 between Resident #2 and Resident #4. 4. The facility failed to notify Family Member C of the inappropriate sexual incident that involved Resident #3. 5. The facility failed to report to the state agency and investigate a sexual incident that occurred on 06/02/24 between Resident #5 and Resident #3. 6. The facility failed to report to the state agency and investigate a sexual incident that occurred on 06/02/24 between Resident #5 and Resident #6. On 06/07/24 at 5:00 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 06/09/24 at 3:30 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The failures placed resident at risk for continued abuse and neglect and a decline in quality of life, harm and mental anguish. Findings included: 1. Findings for fall incident that occurred on 05/30/24 with Resident #1 and CNA E included: Record review of Resident #1's face sheet, dated 06/05/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), major depressive disorder, anxiety (increased feelings of fear, dread, and uneasiness), and cognitive communication deficit (difficulty understanding and communicating). Record review of Resident #1's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 04, which indicated the resident's cognition was severely impaired. Section B Hearing, Speech, and Vision revealed that Resident #1 had slurred speech, could make himself understood, and usually understood others. Section GG Functional Abilities and Goals indicated the Resident #1 was dependent and this could mean that the resident did all the effort or that he required the assistance of 2 or more helpers to complete the activity of tub or shower transfer. Record review of Resident #1 Care Plan, dated 05/29/24, revealed the following: Resident #1 had an ADL self-care performance deficit r/t to limited range of motion due to CVA. Resident #1's self-performance fluctuated r/t confusion, but he usually requires assistance with ADLs. Resident #1 required 1-2 staff for showering/bath and shower/tub transfer Resident #1 required two+ person physical assists. Resident #1 used a mechanical lift for transfers with a minimum of two staff present unless transferring with therapy/ restorative. Resident #1 was at risk for falls r/t balance problem. Ensuring Resident #1 frequently used items were within reach. Resident #1 had osteoporosis and was at risk for fractures. Record review of Resident #1's progress notes revealed the following: 05/30/24 at 1:10 AM LVN F documented: Xray results show positive intertrochanteric hip fracture (upper thigh hip fracture) to left hip. Physician A notified and received orders to send [Resident #1] to ER to evaluate. Notified [Family Member A] POA. EMS here to transport resident to local hospital. Report called in to ER. ADM and DON notified as well. 05/30/24 at 1:43 AM the DON documented: 5:38 PM was notified by charge nurse that resident was c/o left hip pain. Instructed charge nurse to notify [Physician A]. Nurse received orders to obtain x-rays to left hip. Notified administrator of resident c/o left hip pain. Then instructed night nurse to notify as soon as x-ray results received. Received notification at 10:25 pm from night charge nurse that x-ray showed a left acute intertrochanteric hip fracture (upper thigh hip fracture). Immediately notified administrator of findings. 06/03/24 at 9:29 PM the LVN F documented: Resident readmitted to facility following hospitalization following fall on 5/30 resulting in intertrochanteric hip fracture (upper thigh hip fracture) to left hip. Dynamic hip screw surgery to left hip. Resident weight bearing as tolerated. During an interview on 06/05/24 at 12:07 PM, Family Member D stated on 05/30/24 she visited with Resident #1. She stated that he had received a shower that morning from CNA E. She said during the day, around the time they played Bingo, Resident #1 started complaining that his butt hurt. She said she thought maybe he was constipated. She said that when the CNAs (CNA J and CNA K) went to put him in bed, he started complaining of pain. She said Resident #1 pointed to his left side and said, Hurt hurt. She said she waited until the CNAs left to notify RN I to ask Resident #1 what happened because he was complaining more than earlier. Resident #1 told me that he fell in the shower that morning with CNA E. She said Resident #1 said he fell and hit his head. She said CNA E was in the room when Resident #1 fell but he did not see Resident #1 fall because his back was to Resident #1. CNA E was shutting the bathroom door when Resident #1 fell . Family Member D said she asked if Resident #1 had reported to anyone that he had fallen and if the nurse knew. She said Resident #1 said no. She said Resident #1 explained that it was an accident, that he did not want to get CNA E in trouble, and that he liked him. She said she spoke with CNA E after Resident #1's fall (unknown date and time), and he said he was sorry and acknowledged the fall. She said CNA E told her that he told the ADM and therapy. She stated she was not notified of the fall and was at the facility when CNA E showered Resident #1. She said she would have liked to have been told so that she could have had Resident #1 checked out immediately. During an interview on 06/09/24 at 12:22 PM, Resident #1 stated that he fell in the shower while showering. Resident #1 said CNA E was in the restroom, but his back was to him. Resident #1 said he fell to the floor and hit his head. Resident #1 said CNA E picked him up and put him in the wheelchair. Resident #1 said no other staff helped CNA E pick him up. Resident #1 said that a nurse did not check him. Resident #1 said no one from the administration came and talked to him about the incident. Resident #1 said he was in pain when he left the shower room but did not report it because he did not want to get CNA E in trouble. During an interview on 06/05/24 at 1:49 PM, CNA E stated the incident with Resident #1 occurred on Thursday (05/30/24). CNA E stated he had just completed Resident #1's shower. He stated Resident #1 appeared to be standing fine. He said Resident #1's leg buckled, and as Resident #1 was holding on to the grab bar, he swiveled and hit the wall. He said Resident #1 never completely hit the ground. CNA E stated he called for assistance with Resident #1. CNA E stated he called CNA J and CNA K. CNA E stated he and CNA J and CNA K finished getting Resident #1 dressed and placed Resident #1 in his wheelchair. CNA E stated he asked Resident #1 how he was doing and was told by Resident #1 that he was ok. CNA E stated he had reported what happened to the ADM and the PTA directly after the incident. CNA E stated that he reported to the ADM that the fall was not a complete fall to the ground. CNA E could not recall if he told the ADM that Resident #1 had hit the wall. He stated Resident #1 did not complain of pain or show any signs of discomfort. When he demonstrated to Family Member D what happened, CNA E stated that his head hit the wall. CNA E stated he did not have the nurse look at Resident #1 because he felt he did the correct thing when he reported the incident to the ADM. CNA E stated the ADM told him that the incident was not reportable, so he did not tell anyone else. He said although Resident #1's care plan says to use the mechanical lift, he was a physical transfer. He said the fall might have happened around 11:30 AM on 05/30/24. During an interview on 06/05/24 at 2:08 PM, RN I stated that he was unsure when the fall incident happened with Resident #1 but was in the middle of the week. RN I said he did not know anything about it until the end of his shift. He said CNA K came to him and alerted him that Resident #1 was in pain the same day Resident #1 fell . He said he was told by Resident #1 that he had a fall in the shower earlier that day, and he had hit his head and his hip. RN I said Resident #1 said he did not want to get CNA E in trouble. RN I said while Resident #1 was telling him, he was crying. RN I stated he notified the DON, and the DON was surprised that CNA E had not told the nursing staff anything about the incident. RN I said he was frustrated because although the incident was communicated to the PTA and the ADM, it was not communicated to him as the charge nurse, and a delay in treatment occurred. He stated that once he became aware of this, he assessed and notified Physician A. RN. I stated that x-rays were ordered, but he did not receive the results on his shift. RN I said he spoke with CNA E and inquired why he was not notified. RN I said CNA E said he could not find RN I and apologized for not reporting the incident to RN I. RN I explained that his license could be on the line and treatment for Resident #1 could be delayed. RN I said that CNA E stated he was doing therapy in the shower to promote movement, and Resident #1 gave out. RN I said that CNA E told him that Resident #1 never hit the ground, but that differed from what Resident #1 told him. He stated he was told by Resident #1 that he fell to the ground. RN I said it was vital that he was notified when fall incidents occurred so that the residents were assessed at the time of injury. RN I said during his assessment of Resident #1, he saw issues with his range of motion and the apparent pain that Resident #1 was expressing. RN I said failure to report the incident to him could compromise resident safety, and with Resident #1 hitting his head, it could have been a more significant issue. RN I said during his assessment he did not see any problems with Resident #1's mental status. RN I stated he did not talk to the PTA or the ADM about the incident as they were already gone for the day and not in the facility. During an interview on 06/05/24 at 3:10 PM, CNA J stated she was not assisting Resident #1 the day he fell . She said she and her partner (CNA K) heard the call light go off in the shower room. She said that when they saw what was happening, CNA E requested that they bring Resident #1's wheelchair. CNA J stated she did observe Resident #1, and CNA E. CNA J stated that CNA E was holding Resident #1 up. She said CNA E did not appear to need assistance. CNA J said she and her partner provided the wheelchair and walked away. She said she nor her partner provided any assistance then. CNA J stated that around 4:30-4:45 PM that same day, the call light in Resident #1's room went off, and they were told by Resident #1 and Family Member D to place Resident #1 in bed. CNA J said they (her and CNA K) transferred Resident #1, and he complained that his leg was hurting. After the transfer, CNA J said they reported the leg pain to RN I. During an interview on 06/05/24 at 3:41 PM, CNA K stated that when Resident #1 fell , she and her partner, CNA J, were not working directly with Resident #1. CNA K said she was working the floor with other residents. She said she and her partner heard the lights go off in the shower room. CNA K said CNA E asked for Resident #1's wheelchair. CNA K stated they provided him with the wheelchair and walked back out of the shower room. She said no additional assistance was provided. She said Resident #1 was being held up by CNA E. She said when she and her partner were in the restroom, CNA E did not look like he needed help. She said that the encounter was before lunch. She said that at around 4:40 PM, Resident #1's call light went off, and she and CNA J went to see what he needed. She said Resident #1 wanted to be transferred to bed, and during the transfer with her and CNA J, Resident #1 expressed that he was in pain. She stated they completed the transfer and got him comfortable. She said she and her partner immediately notified RN I. CNA K stated that RN I went to Resident #1's room, which was all she knew happened. During an interview on 06/05/24 at 4:04 PM, the ADM stated she did not consider Resident #1's incident a fall because CNA E told her that Resident #1 did not fall to the ground. The ADM said CNA E told her that during a transfer, CNA E held Resident #1 up, straightened Resident #1 up, and was able to place him in his wheelchair. The ADM stated she did not talk to Resident #1 about the incident. She stated that she did not because when she was told about the incident, Resident #1 was present in the dining room. The ADM said she was unaware if the presence of CNA E could have influenced Resident #1 to speak up. She said she did not investigate the incident further after CNA E reported it. She said she later heard that CNA J and CNA K were transferring Resident #1, and Resident #1 complained of pain. She stated she was confused that Resident #1 would have been in any pain because earlier that day, he never voiced any pain concerns. The ADM said she did not know if he was in pain because she did not know how he could sit 6-7 hours in pain. She said she would have thought if he was in pain, he would have said something. She also said she did not consider it a fall because the DOR told her that if a fall occurred during restorative or therapy, it was not considered a fall. During an interview on 06/05/24 at 4:24 PM, the DON stated she received a call on 05/30/24 from RN I around 5:28 PM or 5:30 PM. RN I said Resident #1 was complaining of pain and stated he had fallen. The DON said she called CNA E, and CNA E told her Resident #1 did not fall. She said CNA E said he reported it to the ADM and the PTA directly after the incident. The DON said she was told by CNA E that Resident #1's legs buckled, and that CNA E held Resident #1 up. The DON said that she was told CNAs J and K helped CNA E with Resident #1. The DON said she interviewed CNA J and CNA K and confirmed that they observed CNA E holding Resident #1 up and that they got the wheelchair. The DON said she did not confirm if they helped with the transfer. The DON said she did not speak with Resident #1 because he had already gone to the hospital. The DON stated she had not spoken with Resident #1 since he returned from the hospital. The DON stated that she understood that since CNA E had been trained, he could transfer Resident #1 alone. During an interview on 06/06/24 at 4:56 AM, LVN F stated she worked the night shift when Resident #1 fell . She stated it was passed to her during the report that Resident #1 fell while in the shower room. LVN F said that x-rays had been ordered, and she received the report around 10:00 PM on 05/30/24 that Resident #1 had a positive fracture. LVN F stated RN I told her he was not informed about the incident when it happened. LVN F stated she spoke with Resident #1, and he was able to say to her that he had fallen in the shower, but he did not provide any additional information. During an interview on 06/06/24 at 11:00 AM, the PTA stated that on 05/30/24, CNA E approached him. The PTA said CNA E was doing restorative on Resident #1, and he slipped. The PTA said CNA E stated that he had already reported the incident to the ADM. The PTA stated that CNA E had not given him any additional information. The PTA said that when he was told about the incident, he was not told it was in the shower. The PTA stated that he had not seen Resident #1's care plan and could not verify what it entailed, but two people to transfer was for safety especially when using the mechanical lift. He stated that if the care plan stated that there needed to be two people, then there should be two people, and staff should not deviate from that. The PTA stated that therapists could transfer with one person, and sometimes, it depended on if a female or male was doing the transfer. He did not specify why gender would make a difference. The PTA said he spoke with Resident #1, and all Resident #1 kept saying was fall, fall. During an interview on 06/06/24 at 12:25 PM, the DON stated she was unaware that Resident #1 had fallen in the shower. The DON said she was made aware when the nurse called about Resident #1's pain. The DON stated that the restorative aide had been trained to report the incident to therapy and the nurse (that included the DON). The DON confirmed that CNA E was a restorative aide. She said Resident #1 had improved in his health and strength. The DON said it was her understanding that Resident #1 could be transferred with one person if it was a restorative aide. The DON said that regarding the incident with Resident #1, the potential negative outcome was that similar incidents could also occur with other residents. The DON said the potential negative outcome of not reporting Resident #1's fall to the nurse staff, not following their policy, and not investigating the incident was the charge nurse would not be made aware of the incident, and there could be a negative outcome for the resident if something internally would have been wrong with the resident. The DON said she was responsible for incident/accident prevention, but the ADM was responsible for investigations and reporting. The DON said the purpose of reporting incidents and investigating incidents of alleged abuse and neglect was to protect the residents and to follow policy. The DON said the facility system to monitor was to follow their policy. The DON said she was unaware of why they did not follow the policy. During an interview on 06/06/24 at 1:16 PM, the ADM stated that not reporting falls to the nurse, investigating incidents, and/or following their facility abuse policy could cause continued harm to the residents. The ADM said she was made aware of the incident regarding Resident #1 after CNA E told her about it. The ADM said she was unaware that Resident #1 was in pain and did not interview Resident #1. She said the system was implemented to monitor that falls were reported to the appropriate people, incidents were investigated, and ANE policies were followed by training staff on the facility policy. The ADM said she did not investigate the incident because she did not consider the incident a fall since it happened with therapy. The ADM stated she expected all staff to follow the care plan. The ADM said she did not look at the care plan to confirm that CNA E's transfer was correct. During an interview on 06/06/24 at 4:00 PM, the DOR stated that she had been notified during a morning meeting that Resident #1 had a fall. The DOR said she could not remember in particular the details. The DOR said she did not remember the date of the morning meeting. The DOR said she believed it was the day after the fall incident because they typically screened every fall. The DOR said all she knew was that it had something to do with the shower and that Resident #2's knee buckled. The DOR said doing restorative in the shower was normal and that CNA E had been specifically trained to do restorative with Resident #1. The DOR said Resident #1 required two people for transfer, but a restorative could transfer Resident #2's with one person. The DOR said that because CNA E was a male, he was allowed to transfer Resident #1 with one person, but if the staff were smaller, they would recommend that the staff use two people. The DOR said nursing would ultimately make the decision. 2. Findings for sexual incident that occurred on 05/10/24 between Resident #2 and Resident #3 include: Record review of Resident #2's face sheet, dated 06/05/24, revealed a [AGE] year-old-male that was readmitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember), depressive disorder (constant feelings of sadness), mood disorder (emotional deficit), and blindness to the right eye. Record review of Resident #2's Quarterly Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. Section B Hearing, Speech, and Vision revealed that Resident #2 had clear speech, made himself understood, and understands others. His vision was impaired, and he did not wear corrective lenses. Section E Behavior revealed that he had not had any incidents of physical or verbal behaviors. Record review of Resident #2's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a blank BIMS score. Section E Behavior revealed that he had had delusions, physical behaviors such as hitting, kicking, pushing, scratching, grabbing, and abusing others. Resident #2 had exhibited verbal behaviors such as threatening others, screaming, and cursing at others. Resident #2 had other behavioral symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, smearing food or bodily wastes, or verbal/vocal symptoms like screaming and disruptive sounds. Resident #1 exhibited wandering behavior 1-3 days. Record review of Resident #2 care plan, dated 05/01/24 revealed the following: [Resident #2] wanders in other residents' rooms and gets into their beds at times and had the following interventions: [Resident #2] required assistance out of rooms that were not his and staff could use snacks if needed. [Resident #2] was an elopement risk/wanderer and had the following interventions: Distract [Resident #2] from wandering by offering pleasant diversions. [Resident #2] prefer having snacks. Followed by [name of psych care]. Notify their MD/NP of any escalation in wandering behaviors, ineffectiveness, or side effects of psychiatric medications. Monitor the resident's location throughout shifts. Document wandering behavior and attempted diversional interventions in behavior log. [Resident #2] had episodes of verbal and physical aggression r/t dementia with the following interventions: Give me as many choices as possible about care and activities. Monitor for physically/verbally aggressive behavior q shift. Document observed behavior and attempted interventions in behavior log. Monitor/document/report PRN any s/sx of [Resident #2] posing danger to self and others. [Resident #2] had impaired visual function r/t cataracts and glaucoma. Resident #2 was blind in his right eye with the following interventions: Arrange consultation with eye care practitioner as required. Monitor/document/report PRN any s/sx of acute eye problems: Change in ability to perform ADLs, decline in mobility, sudden visual loss, pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. Place frequently used items on my left side so I may see them. Record review of Resident #2's progress notes revealed the following: Record review on 05/11/24 at 12:12 AM LVN G documented: Data: Resident observed by CNA H reported to this nurse observed resident with pants unzipped and PENIS in Resident #3's hand. Action: Resident removed from Resident #3's room w/o incident. Resident #3 appears to have been asleep during entire incident. No physical injuries noted at this time. Response: Resident in his room and placed on 1-1 monitoring per DON instructions. Roommate moved to different room as this nurse considers this a HIGH RISK INCIDENT. DON & Administrator notified. Record review on 05/11/24 at 03:23 PM The DON documented: Received orders from NP may administer Lorazepam 1ml now and then every 8 hours as needed. DON gave orders to charge nurse may use emergency restraint for safety of resident and others. Record review on 05/11/24 at 05:27 PM the DON documented: Spoke with Family Member L about incident and orders to give Lorazepam 2mg/ml injection every 8 hours as needed x 14 days. Voiced understanding and gives verbal consent at this time for medication. Also discussed that he would be going back to the behavior support center on Monday and facility would be actively looking for alternate long-term placement for resident. Voiced understanding and consents for referrals to be sent to other facilities. Record review on 05/11/24 at 05:27 PM LVN B documented: Staff alerted this nurse that this male resident was found in female resident's bed with his hands in the female's pants. Upon entering room male resident is found in bed with female resident with his hand on resident's waist. Told resident he needed to get out of bed. RT refused and put his arm around female resident. Male resident immediately removed from female's bed and taken to his own room. Resident became aggressive with staff refusing to leave bed causing CNAs to fall. Administration notified. Physician A, the DON notified. New order for Ativan 2mg/ml injection. Injection administered. Resident continues to try to go into other female rooms. Record review on 05/31/24 at 01:07 PM The DON documented: Resident returned from behavioral center via their facility van. Notified Physician A of return and medications. Notified the NP of return and reconciled psychotropic medications. Notified family Member L of return and went over psych medications and no issues or concerns at this time. Record review on 06/02/24 at 03:26 AM LVN M documented: Follow-up on readmission, resident continues to urinate on floor. Reminded resident to use urinal. Resident voiced understanding. Resident also continues to wander. Resident breathing even and unlabored. No complaints voiced. Record review of on 06/02/24 at 07:35 PM The DON documented: Notified by charge nurse that resident was wandering in rooms and becoming aggressive when staff was trying to redirect. Contacted the NP and new orders received to increase Seroquel to 50mg 3 times daily, Xanax 0.25mg every 6 hours as needed x 14 days, and Zyprexa 10mg IM every 12 hours as needed x 14days. Notified Family Member L of resident behavior and new orders. Voiced understanding and no issues or concerns at this time. Record review of Resident #2's monitoring sheets revealed the following: Resident #2 was monitored every 30 minutes starting 05/08/24 at 11:30 AM until 5/10/24 at 6:00 PM. (No abnormal behavior reported during this monitoring time.) No time monitoring accounted for 05/10/24 at 11:00 PM- 12:00 AM. Resident #2 was monitored on 05/11/24 from 1:00 AM-5:45 AM. (No abnormal behavior notated during this time. No time monitoring accounted for 12:00 AM-1:00 AM.) Resident #2 was monitored on 05/11/24 from 6:30 AM-4:00 PM. (No abnormal behavior notated during this time. No time monitoring accounted for 4:30 PM-6:00 PM) Record review of Resident #3's face sheet, dated 06/05/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (memory loss), cognitive communication deficit (difficulty communicating), fracture to neck and left femur, anxiety disorder (increased worry), and major depressive disorder (increased sadness). Record review of Resident #3's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 01, which indicated the resident's cognition was severely impaired. Section B. Ability to understand others revealed that she had clear speech, sometimes could make herself understood, and sometimes could understand others. Record review of Resident #3's care plan dated 6/5/24 revealed the following: Resident #3 was dependent on staff for emotional, intellectual, physical, and social needs related to cognitive deficits. Resident #3 required assistance to ADLs related to Alzheimer's disease, had impaired cognitive function/impaired thought processes related to Alzheimer's, had a mood problem related to depression, and had potential for psychosocial well-being related to trauma. Record review of Resident #3's progress notes revealed the following: On 05/11/24 at 01:27 AM LVN G documented: [Resident #2] observed in resident's room with Penis in her hand attempting what appears to ejaculate himself. Resident Immediately stopped by staff and removed to his room. Placed on 1-1 monitoring with instructions by DON NOT to be left out of staff sight at any time. No apparent injuries not upon physical inspection with female CNA present. DON to notify PCP & family. During an interview on 06/05/24 at 1:49 PM, CNA E stated that one night, when he worked the night shift (unsure of the date and exact time), Resident #2 exposed himself to Resident #3. He said he did not see it but was told by CNA H that Resident #2 had his penis in Resident #3's hand and was jerking off. He said as a result of that incident, Resident #2 was placed on 1:1 and was checked every 15 minutes by the night staff. He said Resident #3 was not in her right mind and would have been unable to consent. He said Resident #3 may have a BIMs of 0 (severe cognitive impairment). He said prior to the incident involving Resident #3, Resident #2 was not on any close monitoring. He said that when Resident #3 was in the dining room and wanted to return to his room, they would assist him, but after he was in his room, they did not do additional monitoring. During an interview on 06/05/24 at 2:57 PM, LVN G stated that on 05/11/24, he was working the night shift. He said he heard a young lady yell out. He said it was the female CNA but did not know her name. He said he was on break. He said the female CNA reported that Resident #2 had a particular part of his anatomy in Resident #3's hand. LVN G stated they assisted in getting Resident #2 out of Resident #3's room. He stated when he walked in, he did not see Resident #2's penis in Resident #3's hand but did see his penis out. He said he had not seen Resident #2 do the sexual act in the past, but that Resident #2 would expose himself and urinate on the floor. He stated that, because of the incident, he reported it to the DON and was instructed to place Resident #2 on 1:1 monitoring. He stated he would sit in the hall and ensure Resident #2 did not go into other rooms. LVN G said that Resident #3 was catatonic (immobile) and could not defend herself. During an interview on 06/05/24 at 4:04 PM, the ADM stated she did not report the incident that involved inappropriate sexual contact that occurred with Residents #2 and #3 because all parties had dementia. She said she focused on if the act was willful. She said Resident #3 was asleep and did not know what was happening. She said she was told but could not remember who told her that Resident #2 was standing over Resident #3 with his penis out and Resident #3's hand was on Resident #2's penis. The ADM stated she was not told that Resident #2 was masturbating. The ADM stated that Resident #2 was not put on 1:1 during the first incident involving Resident #3 because he was not aggressive, and that was the first time he displayed this behavior. During an interview on 06/05/24 at 4:24 PM, the DON stated when the inappropriate sexual incident between Residents #2 and #3 were reported to her, she reported it to the ADM as she was the abuse coordinator. The DON stated the ADM confirmed with the Regional Director that it did not have to be reported because the residents had dementia. The DON said the Regional Director provided documentation to support the de [TRUNCATED]

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury to the administer of the facility and to other officials including the State Survey Agency in accordance with State law through established procedures for 5 of 9 residents (Residents #2, #3, #4, #5 and #6) reviewed for abuse and neglect. 1. The facility failed to report a sexual incident which occurred on 05/10/24 between Resident #2 and Resident #3. 2. The facility failed to report a sexual incident which occurred on 05/11/24 between Resident #2 and Resident #4. 3. The facility failed to report a sexual incident which occurred on 06/02/24 between Resident #5 and Resident #3. 4. The facility failed to report a sexual incident which occurred on 06/02/24 between Resident #5 and Resident #6. These failures could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. Findings Include: 1. Findings for the facility failure to report a sexual incident which occurred on 05/10/24 between Resident #2 and Resident #3. Record review of Resident #2's face sheet, dated 06/05/24, revealed a [AGE] year-old-male that was readmitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember), depressive disorder (constant feelings of sadness), mood disorder (emotional deficit), and blindness to the right eye. Record review of Resident #2's Quarterly Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. Section B Hearing, Speech, and Vision revealed that Resident #2 had clear speech, makes himself understood, and understands others. His vision is impaired, and he does not wear corrective lenses. Section E Behavior revealed that he had not had any incidents of physical or verbal behavior. Record review of Resident #2's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a blank BIMS score. Section E Behavior revealed that he had had delusions, physical behaviors such as hitting, kicking, pushing, scratching, grabbing, and abusing others. Resident # 2 had exhibited verbal behaviors such as threatening others, screaming, and cursing at others. Resident #2 had other behavioral symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, smearing food or bodily wastes, or verbal/vocal symptoms like screaming and disruptive sounds. Resident #1 exhibited wandering behavior 1-3 days. Record review of Resident #2 care plan, dated 05/01/24 revealed the following: Resident #2 wanders in other residents' rooms and gets into their beds at times and had the following interventions: Resident #2 required assistance out of rooms that were not his and staff could use snacks if needed. Resident #2 was an elopement risk/wanderer and had the following interventions: Distract Resident #2 from wandering by offering pleasant diversions. Resident #2 prefer having snacks. Followed by [name of psych care]. Notify their MD/NP of any escalation in wandering behaviors, ineffectiveness, or side effects of psychiatric medications. Monitor the resident's location throughout shifts. Document wandering behavior and attempted diversional interventions in behavior log. Resident #2 had episodes of verbal and physical aggression r/t dementia with the following interventions: Give me as many choices as possible about care and activities. Monitor for physically/verbally aggressive behavior q shift. Document observed behavior and attempted interventions in behavior log. Monitor/document/report PRN any s/sx of Resident #2 posing danger to self and others. Resident #2 had impaired visual function r/t cataracts and glaucoma. Resident #2 was blind in his right eye with the following interventions: Arrange consultation with eye care practitioner as required. Monitor/document/report PRN any s/sx of acute eye problems: Change in ability to perform ADLs, decline in mobility, sudden visual loss, pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. Place frequently used items on my left side so I may see them. Record review of Resident #2's progress notes revealed the following: Record review of on 05/11/24 at 12:12 AM LVN G documented: Data: Resident observed by CNA H reported to this nurse observed resident with pants unzipped and PENIS in Resident #3's hand. Action: Resident removed from Resident #3's room w/o incident. Resident #3 appears to have been asleep during entire incident. No physical injuries noted at this time. Response: Resident in his room and placed on 1-1 monitoring per DON instructions. Roommate moved to different room as this nurse considers this a HIGH RISK INCIDENT. DON & Administrator notified. Record review of on 05/11/24 at 03:23 PM The DON documented: Received orders from NP may administer Lorazepam 1ml now and then every 8 hours as needed. DON gave orders to charge nurse may use emergency restraint for safety of resident and others. Record review of on 05/11/24 at 05:27 PM the DON documented: Spoke with Family Member L about incident and orders to give Lorazepam 2mg/ml injection every 8 hours as needed x 14 days. Voiced understanding and gives verbal consent at this time for medication. Also discussed that he would be going back to the behavior support center on Monday and facility would be actively looking for alternate long-term placement for resident. Voiced understanding and consents for referrals to be sent to other facilities. Record review of on 05/11/24 at 05:27 PM LVN B documented: Staff alerted this nurse that this male resident was found in female resident's bed with his hands in the female's pants. Upon entering room male resident is found in bed with female resident with his hand on resident's waist. Told resident he needed to get out of bed. RT refused and put his arm around female resident. Male resident immediately removed from female's bed and taken to his own room. Resident became aggressive with staff refusing to leave bed causing CNAs to fall. Administration notified. Physician A, the DON notified. New order for Ativan 2mg/ml injection. Injection administered. Resident continues to try to go into other female rooms. Record review on 05/31/24 at 01:07 PM The DON documented: Resident returned from behavioral center via their facility van. Notified Physician A of return and medications. Notified the NP of return and reconciled psychotropic medications. Notified family Member L of return and went over psych medications and no issues or concerns at this time. Record review of on 06/02/24 at 03:26 AM LVN M documented: Follow-up on readmission, resident continues to urinate on floor. Reminded resident to use urinal. Resident voiced understanding. Resident also continues to wander. Resident breathing even and unlabored. No complaints voiced. Record review of on 06/02/24 at 07:35 PM The DON documented: Notified by charge nurse that resident was wandering in rooms and becoming aggressive when staff was trying to redirect. Contacted the NP and new orders received to increase Seroquel to 50mg 3 times daily, Xanax 0.25mg every 6 hours as needed x 14 days, and Zyprexa 10mg IM every 12 hours as needed x 14days. Notified Family Member L of resident behavior and new orders. Voiced understanding and no issues or concerns at this time. Record review of Resident #2's monitoring sheets revealed the following: Resident #2 was monitored every 30 minutes starting 05/08/24 at 11:30 AM until 5/10/24 at 6:00 PM. (No abnormal behavior reported during this monitoring time.) No time monitoring accounted for 05/10/24 at 11:00 PM- 12:00 AM. Resident #2 was monitored on 05/11/24 from 1:00 AM-5:45 AM. (No abnormal behavior notated during this time. No time monitoring accounted for 12:00 AM-1:00 AM.) Resident #2 was monitored on 05/11/24 from 6:30 AM-4:00 PM. (No abnormal behavior notated during this time. No time monitoring accounted for 4:30 PM-6:00 PM) Record review of Resident #3's face sheet, dated 06/05/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (memory loss), cognitive communication deficit (difficulty communicating), fracture to neck and left femur, anxiety disorder (increased worry), and major depressive disorder (increased sadness). Record review of Resident #3's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 01, which indicated the resident's cognition was severely impaired. Section B. Ability to understand others revealed that she had clear speech, sometimes could make herself understood, and sometimes could understand others. Record review of Resident #3's care plan dated 6/5/24 revealed the following: Resident #3 was dependent on staff for emotional, intellectual, physical, and social needs related to cognitive deficits. Resident #3 required assistance to ADLs related to Alzheimer's disease, had impaired cognitive function/impaired thought processes related to Alzheimer's, had a mood problem related to depression, and had potential for psychosocial well-being related to trauma. Record review of Resident #3's progress notes revealed the following: 05/11/24 at 01:27 AM LVN G documented: Resident #2 observed in resident's room with Penis in her hand attempting what appears to ejaculate himself. Resident Immediately stopped by staff and removed to his room. Placed on 1-1 monitoring with instructions by DON NOT to be left out of staff sight at any time. No apparent injuries not upon physical inspection with female CNA present. DON to notify PCP & family. During an interview on 06/05/24 at 1:49 PM, CNA E stated that one night, when he worked the night shift (unsure of the date and exact time), Resident #2 exposed himself to Resident #3. He said he did not see it but was told by CNA H that Resident #2 had his penis in Resident #3's hand and was jerking off. He said as a result of that incident, Resident #2 was placed on 1:1 and was checked every 15 minutes by the night staff. He said Resident #3 was not in her right mind and would have been unable to consent. He said Resident #3 may have a BIMs of 0. He said prior to the incident involving Resident #3, Resident #2 was not on any close monitoring. He said that when Resident #3 was in the dining room and wanted to return to his room, they would assist him, but after he was in his room, they did not do additional monitoring. During an interview on 06/05/24 at 2:57 PM, LVN G stated that on 05/11/24, he was working the night shift. He said he heard a young lady yell out. He said it was the female CNA but did not know her name. He said he was on break. He said the female CNA reported that Resident #2 had a particular part of his anatomy in Resident #3's hand. LVN G stated they assisted in getting Resident #2 out of Resident #3's room. He stated when he walked in, he did not see Resident #2's penis in Resident #3's hand but did see his penis out. He said he had not seen Resident #2 do the sexual act in the past, but that Resident #2 would expose himself and urinate on the floor. He stated that, because of the incident, he reported it to the DON and was instructed to place Resident #2 on 1:1 monitoring. He stated he would sit in the hall and ensure Resident #2 did not go into other rooms. LVN G said that Resident #3 was catatonic (immobile) and could not defend herself. He said he reported the incident to the DON. During an interview on 06/05/24 at 4:04 PM, the ADM stated she did not report the incident that involved inappropriate sexual contact that occurred with Resident #2 and #3 because all parties had dementia. She said she focused on if the act was willful. She said Resident #3 was asleep and did not know what was happening. She said she was told but could not remember who told her that Resident #2 was standing over Resident #3 with his penis out and Resident #3's hand was on Resident #2's penis. The ADM stated she was not told that Resident #2 was masturbating. The ADM stated that Resident #2 was not put on 1:1 during the first incident involving Resident #3 because he was not aggressive, and this was the first time he displayed this behavior. During an interview on 06/05/24 at 4:24 PM, the DON stated when the inappropriate sexual incident between Residents #2 and #3 were reported to her, she reported it to the ADM as she was the abuse coordinator. The DON stated the ADM confirmed with the Regional Director that it did not have to be reported because the residents had dementia. The DON said the Regional Director provided documentation to support the decision. The DON stated she did not speak up or take any additional action to report the incidents. During an interview on 06/06/24 at 12:25 PM, the DON stated she did not want to say the wrong things and that she could not think of the potential negative outcome when it came to not reporting sexual incidents between residents, specifically the incidents that occurred between Residents #2 and #3. She said she was aware that the sexual incident had not been reported to the HHSC. The DON said the ADM told her that she did not report it based on the instruction given to her by the Regional Director. The DON said she did not observe the sexual incident between Resident #2 and #3. The DON said she was responsible for incident/accident prevention, but the ADM was responsible for reporting. The DON said the purpose of reporting incidents of alleged abuse and neglect was to protect the residents and to follow policy. The DON said the facility system to monitor was to follow their policy. The DON said she was unaware of why they did not follow the policy. The DON said the ADM was responsible for reporting and investigating the incidents. During an interview on 06/06/24 at 1:16 PM, the ADM stated she was aware that she had not reported the sexual incident between Resident #2 and #3. She said the reason she did not report the incident was because after speaking with her Regional Director, who was more experienced, they felt that it was a behavior, not intentional, and abuse did not occur. The ADM said with this being a brand-new behavior for Resident #2, she could see that she did not see anything abnormal, with the conclusion of not reporting the incident of inappropriate sexual behavior. The ADM said her gut feeling was to report the incidents. The ADM said her Regional Director told her the incidents of inappropriate sexual behavior did not have to be reported, and she did not question it. The ADM said she was responsible for reporting all appropriate incidents to HHSC. During an interview on 06/06/24 at 7:26 PM, the Regional Director stated he was notified in the middle of the night on 05/11/24 by the ADM that a resident was found in another resident's room holding his penis. The Regional Director said he was not given the details of who the resident was and the resident using another resident's hand to masturbate. The Regional Director said he was told by the ADM that there was no victim because the resident was blind, wandering, and the other resident was sleeping. The Regional Director stated again that he was not given any details at that time of which residents were involved. The Regional said he did google the flow chart from the internet and sent it to the ADM. The Regional Director said the document he provided showed a person with dementia does not have the willingness to abuse someone. The Regional Director said it was still the expectation that the incident should have been reported. The Regional Director said the purpose of reporting was to ensure no residents were in harm's way. The Regional Director said he never instructed anyone not to report any incidents. The regional director said the ADM was responsible for all activities in the facility. 2. Findings for the facility failure to report a sexual incident which occurred on 05/11/24 between Resident #2 and Resident #4. Record review of Resident #2's progress notes revealed the following: Record review of on 05/11/24 at 12:12 AM LVN G documented: Data: Resident observed by CNA H reported to this nurse observed resident with pants unzipped and PENIS in Resident #3's hand. Action: Resident removed from Resident #3's room w/o incident. Resident #3 appears to have been asleep during entire incident. No physical injuries noted at this time. Response: Resident in his room and placed on 1-1 monitoring per DON instructions. Roommate moved to different room as this nurse considers this a HIGH RISK INCIDENT. DON & Administrator notified. Record review of on 05/11/24 at 03:23 PM The DON documented: Received orders from NP may administer Lorazepam 1ml now and then every 8 hours as needed. DON gave orders to charge nurse may use emergency restraint for safety of resident and others. Record review of on 05/11/24 at 05:27 PM the DON documented: Spoke with Family Member L about incident and orders to give Lorazepam 2mg/ml injection every 8 hours as needed x 14 days. Voiced understanding and gives verbal consent at this time for medication. Also discussed that he would be going back to the behavior support center on Monday and facility would be actively looking for alternate long-term placement for resident. Voiced understanding and consents for referrals to be sent to other facilities. Record review of on 05/11/24 at 05:27 PM LVN B documented: Staff alerted this nurse that this male resident was found in female resident's bed with his hands in the female's pants. Upon entering room male resident is found in bed with female resident with his hand on resident's waist. Told resident he needed to get out of bed. RT refused and put his arm around female resident. Male resident immediately removed from female's bed and taken to his own room. Resident became aggressive with staff refusing to leave bed causing CNAs to fall. Administration notified. Physician A, the DON notified. New order for Ativan 2mg/ml injection. Injection administered. Resident continues to try to go into other female rooms. Record review on 05/31/24 at 01:07 PM The DON documented: Resident returned from behavioral center via their facility van. Notified Physician A of return and medications. Notified the NP of return and reconciled psychotropic medications. Notified family Member L of return and went over psych medications and no issues or concerns at this time. Record review of on 06/02/24 at 03:26 AM LVN M documented: Follow-up on readmission, resident continues to urinate on floor. Reminded resident to use urinal. Resident voiced understanding. Resident also continues to wander. Resident breathing even and unlabored. No complaints voiced. Record review of on 06/02/24 at 07:35 PM The DON documented: Notified by charge nurse that resident was wandering in rooms and becoming aggressive when staff was trying to redirect. Contacted the NP and new orders received to increase Seroquel to 50mg 3 times daily, Xanax 0.25mg every 6 hours as needed x 14 days, and Zyprexa 10mg IM every 12 hours as needed x 14days. Notified Family Member L of resident behavior and new orders. Voiced understanding and no issues or concerns at this time. Record review of Resident #2's monitoring sheets revealed the following: Resident #2 was monitored every 30 minutes starting 05/08/24 at 11:30 AM until 5/10/24 at 6:00 PM. (No abnormal behavior reported during this monitoring time.) No time monitoring accounted for 05/10/24 at 11:00 PM- 12:00 AM. Resident #2 was monitored on 05/11/24 from 1:00 AM-5:45 AM. (No abnormal behavior notated during this time. No time monitoring accounted for 12:00 AM-1:00 AM.) Resident #2 was monitored on 05/11/24 from 6:30 AM-4:00 PM. (No abnormal behavior notated during this time. No time monitoring accounted for 4:30 PM-6:00 PM) Record review of Resident #4's face sheet, dated 06/05/24, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis that included Alzheimer's disease (memory loss). Record review of Resident #4's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section B. Ability to understand others revealed that she had clear speech, could make herself understood, and could understand others. Record review of Resident #4's care plan dated 4/29/24 revealed the following: Resident #4 was dependent on staff for emotional, intellectual, physical, and social needs related to cognitive deficits. Resident 41 had impaired cognitive function related to Alzheimer's disease. Record review of Resident #4's progress notes revealed the following: 05/11/24 at 05:32 PM LVN B documented: Staff alerted this nurse that Resident #2 was found in female resident's bed with his hands in female's pants. Upon entering room male resident is found in bed with female resident with his hand on resident's waist. Male resident immediately removed from female's bed and taken to his own room. Female resident assessed for injury; no visible injury noted. Administration notified. DON to speak with family regarding incident. During an interview on 06/05/24 at 4:04 PM, the ADM stated she did not report the incidents that involved inappropriate sexual contact that occurred with Resident #2 and #4 because all parties had dementia. She said she focused on if the act was willful. She said she was informed later that day (05/11/24) by LVN B that Resident #2 had gotten into bed with Resident #4 and had his hand near her privates. She said she had read the progress notes since the state surveyor exited on 05/09/24. She said she did not report the incident of inappropriate sexual behavior because, in the incident involving Resident #2 and #4, all residents involved had dementia. The ADM stated that Resident #2 was placed on 1:1 during the second incident involving Resident #4 because Resident #2 became aggressive. During an interview on 06/05/24 at 4:24 PM, the DON stated when the inappropriate sexual incident between Residents #2 and #4 were reported to her, she reported it to the ADM as she was the abuse coordinator. The DON stated the ADM confirmed with the Regional Director that it did not have to be reported because the residents had dementia. The DON said the Regional Director provided documentation to support the decision. The DON stated she did not speak up or take any additional action to report the incidents. During an interview on 06/06/24 at 12:25 PM, the DON stated the purpose of reporting incidents of alleged abuse and neglect was to protect the residents and to follow policy. The DON said the facility system to monitor was to follow their policy. The DON said she was unaware of why they did not follow the policy. The DON said the ADM was responsible for reporting the incidents. During an interview on 06/06/24 at 1:16 PM, the ADM did not name any potential negative outcomes for the resident during this interview. The ADM said she was aware that she had not reported the incident. She said the reason she did not report the incident was because after speaking with her Regional Director, who was more experienced, they felt that it was a behavior, not intentional, and abuse did not occur. She said that this was why she did not report the incident. The ADM said with this being a brand-new behavior for Resident #2, she could see that she did not see anything abnormal, with the conclusion of not reporting the incidents of inappropriate sexual behavior. The ADM said her gut feeling was to report the incident. The ADM said her Regional Director told her the incident of inappropriate sexual behavior did not have to be reported, and she did not question it. The ADM said she was responsible for reporting all appropriate incidents to HHSC. During an interview on 06/06/24 at 7:26 PM, the Regional Director stated it was his expectation that the incident should have been reported. The Regional Director said the purpose of reporting was to ensure no residents were in harm's way. The Regional Director said he never instructed anyone not to report any incidents. The Regional Director said the ADM was responsible for all activities in the facility. During an interview on 06/07/24 at 12:00 PM, LVN B stated that she did not observe what happened between Resident #2 and Resident #4. She stated what she noted in the resident's progress notes was what she saw. She said that the medication aide notified her but that he no longer worked at the facility. LVN B said she assessed the situation and observed Resident #2's hands in Resident #4's pants. LVN B said they told Resident #2 that he needed to stop and get out. LVN B stated that when she tried to redirect Resident #2 out of the room, that was when Resident #2 became aggressive. LVN B said Resident #2 was kicking, and it was difficult because Resident #4's bed was low and on the ground. LVN B said Resident #2 was trying to kick and fight the Medication Aide. LVN B said she was upset about the incident. She said it was not passed on that he needed to be 1:1 the night before. LVN B she was instructed that she had to do close monitoring. She said she would set her time and check on him every 30 minutes. She said it would have been impossible for her to sit with him 1:1, and she was the only charge nurse. LVN B said she does not know why she did not completely sign off on the monitoring form between 4:00 PM and 6:00 PM. LVN B confirmed that the initials by the 4:00-6:00 PM blank hours were hers. LVN B said on 05/11/24 during her shift (day 6:00 AM-6:00 PM), she or her staff did not sit 1:1 with Resident #2. LVN B said she would peek in on Resident #2 when she could, but she was the only nurse for all the residents at the facility. LVN B stated she did report the inappropriate sexual incident to the DON and documented in her progress notes. 3. Findings for the facility failure to report a sexual incident which occurred on 06/02/24 between Resident #5 and Resident #3. Record review of Resident #3's progress notes revealed the following: 05/11/24 at 01:27 AM LVN G documented: Resident #2 observed in resident's room with Penis in her hand attempting what appears to ejaculate himself. Resident Immediately stopped by staff and removed to his room. Placed on 1-1 monitoring with instructions by DON NOT to be left out of staff sight at any time. No apparent injuries not upon physical inspection with female CNA present. DON to notify PCP & family. Record review of Resident #5's face sheet, dated 06/09/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses that included other sexual dysfunction (difficulty with sexual response), intermittent explosive disorder (impulsive and aggressive outbursts), insomnia (difficulty sleeping), age related cognitive decline, and cognitive communication deficit (difficulty communicating). Record review of Resident #5's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 07, which indicated the resident's cognition was severely impaired. Section B. Ability to understand others revealed that she had clear speech, could usually make herself understood, and usually understood others. Section E Behavior revealed that he had no documented behavior outside of wandering that occurred 1-3 days. Record review of Resident #5's care plan dated 6/02/24 revealed the following: Resident #5 occasionally attempted to be sexually inappropriate with staff and other residents. Resident #5 occasionally stated he was a killer and a rapist. Resident #5 had impaired cognitive function. Record review of Resident #5's progress notes revealed the following: On 06/02/24 at 02:20 PM LVN Q documented: LATE ENTRY Data: Resident #5 was kissing another resident (unidentified) on the lips. Action: Stopped the resident and sent him to his room and informed him not to be kissing other female residents. Response: WCTM this shift. 06/02/24 at 08:50 PM LVN Q documented: LATE ENTRY Data: Resident #5 was seen by a staff member touching and kissing on another resident (unidentified) in the dining room. Action: Removed the resident away from the other resident and informed him to keep his hands to himself. Response: WCTM this shift. On 06/09/24 at 02:56 PM the DON documented: Family members x 3 here to see [Resident #5]. Family would like facility to attempt referrals closer to their area. They would like referrals sent to multiple facilities. Informed Family that we would start referral process on Monday. Record review of Resident #5's monitoring sheets revealed the following: Resident #5 was monitored every 15 minutes starting 06/09/24 at 12:00 AM until 11:45 PM (No abnormal behavior reported during this monitoring time). Resident #5 was monitored every 15 minutes starting 06/10/24 at 12:00 AM until 12:45 PM (No abnormal behavior reported during this monitoring time). No time monitoring accounted for the following dates: 06/02/2024. During an interview on 06/09/24 at 11:23 AM, the DON stated as a result of the IJ identified on 06/06/24, they were able to identify two other incidents that involved inappropriate sexual touching that was not reported. This occurred with Residents #5, and #3. She stated they identified the incident when they were following their removal plan and reviewing progress notes for potential residents that could be affected. The DON stated they immediately placed Resident #5 on Red supervision, notified Physician A, assessed all residents involved (Resident # 5 and #3), notified the family of both residents, and trained staff. The DON stated that she did not have details of what happened but that they had started the process of investigating. The DON stated they had reported the incident and did not know why the incidents had not been reported. During an interview on 06/09/24 at 12:46 PM, the Dietary [NAME] stated she was present for the incident with Resident #5 and #4. The Dietary [NAME] said she was unsure of the date but that it happened a week before the interview. The Dietary [NAME] said the incident with Resident #4 involved Resident #5 touching and rubbing Resident #4's breast in the dining room. She said she reported this to LVN B and the ADM. 4. Findings for the facility failure to report a sexual incident which occurred on 06/02/24 between Resident #5 and Resident #6. Record review of Resident #5's progress notes revealed the following: On 06/02/24 at 02:20 PM LVN Q documented: LATE ENTRY Data: Resident #5 was kissing another resident (unidentified) on the lips. Action: Stopped the resident and sent him to his room and informed him not to be kissing other female residents. Response: WCTM this shift. 06/02/24 at 08:50 PM LVN Q documented: LATE ENTRY Data: Resident #5 was seen by a staff member touching and kissing on another resident (unidentified) in the dining room. Action: Removed the resident away from the other resident and informed him to keep his hands to himself. Response: WCTM this shift. On 06/09/24 at 02:56 PM the DON documented: Family members x 3 here to see [Resident #5]. Family would like facility to attempt referrals closer to their area. They would like referrals sent to multiple facilities. Informed Family that we would start referral process on Monday. Record review of Resident #5's monitoring s [TRUNCATED]

Based on interview and record reviews the facility failed to have evidence that all violations, in response to abuse, neglect, exploitation or mistreatment, were thoroughly investigated for 6 of 9 residents (Residents #1, #2, #3, #4, #5 and #6) reviewed for abuse and neglect. 1. The facility failed to investigate a fall incident that occurred on 05/30/24 with Resident #1 while in the care of CNA E. 2. The facility failed to investigate a sexual incident that occurred on 05/10/24 between Resident #2 and Resident #3. 3. The facility failed to investigate a sexual incident that occurred on 05/11/24 between Resident #2 and Resident #4. 4. The facility failed to investigate a sexual incident that occurred on 06/02/24 between Resident #5 and Resident #3. 5. The facility failed to investigate a sexual incident that occurred on 06/02/24 between Resident #5 and Resident #6. These failures could place residents at risk of incidents not being thoroughly investigated. The findings included: 1. Findings for the facility's failure to investigate a fall incident that occurred on 05/30/24 with Resident #1 while in the care of CNA E. Record review of Resident #1's face sheet, dated 06/05/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), major depressive disorder, anxiety (increased feelings of fear, dread, and uneasiness), and cognitive communication deficit (difficulty understanding and communicating). Record review of Resident #1's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 04, which indicated the resident's cognition was severely impaired. Section B Hearing, Speech, and Vision revealed that Resident #1 had slurred speech, could make himself understood, and usually understood others. Section GG Functional Abilities and Goals indicated the Resident #1 was dependent and this could mean that the resident did all the effort or that he required the assistance of 2 or more helpers to complete the activity of tub or shower transfer. Record review of Resident #1 Care Plan, dated 05/29/24, revealed the following: Resident #1 had an ADL self-care performance deficit r/t to limited range of motion due to CVA. Resident #1's self-performance fluctuate r/t confusion, but he usually requires assistance with ADLs. Resident #1 required 1-2 staff for showering/bath and shower/tub transfer Resident #1 required two+ person physical assists. Resident #1 used a mechanical lift for transfers with a minimum of two staff present unless transferring with therapy/ restorative. Resident #1 was at risk for falls r/t balance problem. Ensuring Resident #1 frequently used items were within reach. Resident #1 had osteoporosis and was at risk for fractures. Record review of Resident #1's progress notes revealed the following: 05/30/24 at 1:10 AM LVN F documented: Xray results show positive intertrochanteric hip fracture (upper thigh hip fracture) to left hip. Physician A notified and received orders to send Resident #1 to ER to evaluate. Notified Family Member A POA. EMS here to transport resident to local hospital. Report called in to ER. ADM and DON notified as well. 05/30/24 at 1:43 AM the DON documented: 5:38 PM was notified by charge nurse that resident was c/o left hip pain. Instructed charge nurse to notify Physician A. Nurse received orders to obtain x-rays to left hip. Notified administrator of resident c/o left hip pain. Then instructed night nurse to notify as soon as x-ray results received. Received notification at 10:25 pm from night charge nurse that x-ray showed a left acute intertrochanteric hip fracture (upper thigh hip fracture). Immediately notified administrator of findings. 06/03/24 at 9:29 PM the LVN F documented: Resident readmitted to facility following hospitalization following fall on 5/30 resulting in intertrochanteric hip fracture (upper thigh hip fracture) to left hip. Dynamic hip screw surgery to left hip. Resident weight bearing as tolerated. During an interview on 06/05/24 at 12:07 PM, Family Member D stated on 05/30/24, she visited with Resident #1. She stated that he had received a shower that morning from CNA E. She said during the day, around the time they played Bingo, Resident #1 started complaining that his butt hurt. She said she thought maybe he was constipated. She said that when the CNAs (CNA J and CNA K) went to put him in bed, he started complaining of pain. She said Resident #1 pointed to his left side and said, Hurt hurt. She said she waited until the CNAs left to notify RN I to ask Resident #1 what happened because he was complaining more than earlier. Resident #1 told me that he fell in the shower that morning with CNA E. She said Resident #1 said he fell and hit his head. She said CNA E was in the room when Resident #1 fell but he did not see Resident #1 fall because his back was to Resident #1. CNA E was shutting the bathroom door when Resident #1 fell . Family Member D said she asked if Resident #1 had reported to anyone that he had fallen and if the nurse knew. She said Resident #1 said no. She said Resident #1 explained that it was an accident, that he did not want to get CNA E in trouble, and that he liked him. She said she spoke with CNA E after Resident #1's fall (unknown date and time), and he said he was sorry and acknowledged the fall. She said CNA E told her that he told the ADM and therapy. She stated she was not notified of the fall and was at the facility when CNA showered Resident #1. She said she would have liked to have been told so that she could have had Resident #1 checked out immediately. She said no one had come to her and asked her any questions about what Resident #1 had disclosed to her. During an interview on 06/09/24 at 12:22 PM, Resident #1 stated that he fell in the shower while showering. Resident #1 said CNA E was in the restroom, but his back was to him. Resident #1 said he fell to the floor and hit his head. Resident #1 said CNA E picked him up and put him in the wheelchair. Resident #1 said no other staff helped CNA E to pick him up. Resident #1 said that a nurse did not check him. Resident #1 said no one from the administration came and talked to him about the incident. Resident #1 said he was in pain when he left the shower room but did not report it because he did not want to get CNA E in trouble. He said at the time of the interview no one had asked him any questions about what happened in the shower room when he fell . During an interview on 06/05/24 at 1:49 PM, CNA E stated the incident with Resident #1 occurred on Thursday (05/30/24). CNA E stated he had just completed Resident #1's shower. He stated Resident #1 appeared to be standing fine. He said Resident #1's leg buckled, and as Resident #1 was holding on to the grab bar, he swiveled and hit the wall. He said Resident #1 never completely hit the ground. CNA E stated he called for assistance with Resident #1. CNA E stated he called CNA J and CNA K. CNA E stated he and CNA J and CNA K finished getting Resident #1 dressed and placed Resident #1 in his wheelchair. CNA E stated he asked Resident #1 how he was doing and was told by Resident #1 that he was ok. CNA E stated he had reported what happened to the ADM and the PTA directly after the incident. CNA E stated that he reported to the ADM that the fall was not a complete fall to the ground. CNA E could not recall if he told the ADM that Resident #1 had hit the wall. CNA E did not disclose if the ADM had asked any additional questions about the incident. He stated Resident #1 did not complain of pain or show any signs of discomfort. When he demonstrated to Family Member D what happened, CNA E stated that his head hit the wall. CNA E stated he did not have the nurse look at Resident #1 because he felt he did the correct thing when he reported the incident to the ADM. CNA E stated the ADM told him that the incident was not reportable, so he did not tell anyone else. He said although Resident #1's care plan says to use the mechanical lift, he was a physical transfer. He said the fall might have happened around 11:30 AM on 05/30/24. During an interview on 06/05/24 at 2:08 PM, RN I stated that he was unsure when the fall incident happened with Resident #1 but was in the middle of the week. RN I said he did not know anything about it until the end of his shift. He said CNA K came to him and alerted him that Resident #1 was in pain the same day Resident #1 fell . He said he was told by Resident #1 that he had a fall in the shower earlier that day, and he had hit his head and his hip. RN I said Resident #1 said he did not want to get CNA E in trouble. RN I said while Resident #1 was telling him he was crying. RN I stated he notified the DON, and the DON was surprised that CNA E had not told the nursing staff anything about the incident. RN I said he was frustrated because although the incident was communicated to the PTA and the ADM, it was not communicated to him as the charge nurse, and a delay in treatment occurred. He stated that once he became aware of this, he assessed and notified Physician A. RN. I stated that x-rays were ordered, but he did not receive the results on his shift. RN I said he spoke with CNA E and inquired why he was not notified. RN I said CNA E said he could not find RN I and apologized for not reporting the incident to RN I. RN I explained that his license could be on the line and treatment for Resident #1 could be delayed. RN I said that CNA E stated he was doing therapy in the shower to promote movement, and Resident #1 gave out. RN I said that CNA E told him that Resident #1 never hit the ground, but this differed from what Resident #1 told him. He stated he was told by Resident #1 that he fell to the ground. RN I said it was vital that he was notified when fall incidents occurred so that the residents were assessed at the time of injury. RN I said during his assessment of Resident #1, he saw issues with his range of motion and the apparent pain that Resident #1 was expressing. RN I said failure to report the incident to him could compromise resident safety, and with Resident #1 hitting his head, it could have been a more significant issue. RN I said during his assessment he did not see any problems with Resident #1's mental status. RN I stated he did not talk to the PTA or the ADM about the incident as they were already gone for the day and not in the facility. He stated outside of him having concerns about the information not being reported to him no one asked him any additional questions about the incident between Resident #1 and CNA E. During an interview on 06/05/24 at 3:10 PM, CNA J stated she was not assisting Resident #1 the day he fell . She said she and her partner (CNA K) heard the call light go off in the shower room. She said that when they saw what was happening, CNA E requested that we bring Resident #1's wheelchair. CNA J stated she did observe Resident #1, and CNA E. CNA J stated that CNA E was holding Resident #1. CNA J said she and her partner provided the wheelchair and walked away. She said she or her partner did not provide any assistance then. CNA J stated that around 4:30-4:45 PM that same day, the call light in Resident #1's room went off, and they were told by Resident #1 and Family Member D to place Resident #1 in bed. CNA J said they (her and CNA K) transferred Resident #1, and he complained that his leg was hurting. After the transfer, CNA J said they reported the leg pain to RN I. CNA J did not disclose that any additional questions were asked of her by the ADM. During an interview on 06/05/24 at 3:41 PM, CNA K stated that when Resident #1 fell , she and her partner, CNA J, were not working directly with Resident #1. CNA K said she was working the floor with other residents. She said she and her partner heard the lights go off in the shower room. CNA K said CNA E asked for Resident #1's wheelchair. CNA K stated they provided him with the wheelchair and walked back out of the shower room. She said no additional assistance was provided. She said when she and her partner were in the restroom, CNA E did not look like he needed help. She said that the encounter was before lunch. She said that at around 4:40 PM, Resident #1's call light went off, and she and CNA J went to see what he needed. She said Resident #1 wanted to be transferred to bed, and during the transfer with her and CNA J, Resident #1 expressed that he was in pain. She stated they completed the transfer and got him comfortable. She said she and her partner immediately notified RN I. CNA K stated that RN I went to Resident #1's room, which was all she knew happened. CNA K did not disclose if she was asked any additional questions from the ADM about the incident with CNA E and Resident #1. During an interview on 06/05/24 at 4:04 PM, the ADM stated she did not consider Resident #1's incident a fall because CNA E told her that Resident #1 did not fall to the ground. The ADM said CNA E told her that during a transfer, CNA E held Resident #1 up, straightened Resident #1 up, and was able to place him in his wheelchair. The ADM stated she did not talk to Resident #1 about the incident. She stated that she did not because when she was told about the incident, Resident #1 was present in the dining room. The ADM said she was unaware if the presence of CNA E could have influenced Resident #1 not to speak up. She said she did not investigate the incident further after CNA E reported it. She said the only person she spoke with about the incident with Resident #1 was CNA E. She also said she did not consider it a fall because the DOR told her that if a fall occurs during restorative or therapy, it was not considered a fall . During an interview on 06/05/24 at 4:24 PM, the DON stated she received a call 05/30/24 from RN I around 5:28 PM or 5:30 PM. RN I said Resident #1 was complaining of pain and stated he had fallen. The DON said she called CNA E, and CNA E told her Resident #1 did not fall. She said CNA E said he reported it to the ADM and the PTA directly after the incident. The DON said she was told by CNA E that Resident #1's legs buckled, and that CNA E held Resident #1 up. The DON said that she was told CNA J and K helped CNA E with Resident #1. The DON said she interviewed CNA J and CNA K and confirmed that they observed CNA E holding Resident #1 up and that they got the wheelchair. The DON said she did not confirm if they helped with the transfer. The DON said she did not ask any additional or follow up questions after the CNAs confirmed that they observed CNA E holding Resident #1 up. The DON said she did not speak with Resident #1 because he had already gone to the hospital. The DON stated she had not spoken with Resident #1 since he returned from the hospital. The SON did not provide a reason why she had not spoken with Resident #1 about the incident between him and CNA E. The DON stated that she understood that since CNA E had been trained, he could transfer Resident #1 alone. During an interview on 06/06/24 at 11:00 AM, the PTA stated that on 05/30/24, CNA E approached him. The PTA said CNA E was doing restorative on Resident #1, and he slipped. CNA E stated that he had already reported the incident to the ADM. The PTA stated that CNA E had not given him any additional information. The PTA said that when he was told about the incident, he was not told it was in the shower. The PTA stated that he had not seen Resident #1's care plan and could not verify what it entailed, but two people to transfer was for safety especially when using the mechanical lift. He stated that if the care plan stated that there needs to be two people, then there should be two people, and staff should not deviate from that. The PTA stated that therapists could transfer with one person, and sometimes, it depends on a female or male was doing the transfer. The PTA said he spoke with Resident #1, and all Resident #1 kept saying was fall, fall. The PTA did not disclose if the ADM had spoken with him about the incident between Resident #1 and CNA E. During an interview on 06/06/24 at 12:25 PM, the DON stated she was unaware that Resident #1 had fallen in the shower. The DON said she was made aware when the nurse called about Resident #1's pain. The DON stated that the restorative Aide had been trained to report the incident to therapy and the nurse (that included the DON). The DON said that regarding the incident with Resident #1, the potential negative outcome was that similar incidents could also occur with other residents. The DON said the potential negative outcome of not investigating Resident #1's fall was the facility staff would not be following their policy, and there could be a negative outcome for the resident if something internally would have been wrong with the resident. The DON said she was responsible for incident/accident prevention, but the ADM was responsible for investigating incidents. The DON said the purpose of reporting incidents and investigating incidents of alleged abuse and neglect was to protect the residents and to follow policy. The DON said the facility system to monitor was to follow their policy. The DON said she was unaware of why they did not follow the policy. The DON said the ADM was responsible for investigating the incidents. During an interview on 06/06/24 at 1:16 PM, The ADM stated that not investigating incidents could cause continued harm to the residents. The ADM said she was made aware of the incident regarding Resident #1 after CNA E told her about it. The ADM said she was unaware that Resident #1 was in pain and admitted that she did not interview Resident #1. She said the system to monitor investigations was to monitor that falls and to ensure falls were investigated, and ANE policies were followed by training staff on the facility policy. The ADM said she did not investigate the incident because she did not consider the incident a fall since it happened with therapy. 2. Findings for the facility's failure to investigate a sexual incident that occurred on 05/10/24 between Resident #2 and Resident #3 included: Record review of Resident #2's face sheet, dated 06/05/24, revealed a [AGE] year-old-male that was readmitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember), depressive disorder (constant feelings of sadness), mood disorder (emotional deficit), and blindness to the right eye. Record review of Resident #2's Quarterly Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. Section B Hearing, Speech, and Vision revealed that Resident #2 had clear speech, makes himself understood, and understands others. His vision is impaired, and he does not wear corrective lenses. Section E Behavior revealed that he had not had any incidents of physical or verbal behavior. Record review of Resident #2's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a blank BIMS score. Section E Behavior revealed that he had had delusions, physical behaviors such as hitting, kicking, pushing, scratching, grabbing, and abusing others. Resident # 2 had exhibited verbal behaviors such as threatening others, screaming, and cursing at others. Resident #2 had other behavioral symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, smearing food or bodily wastes, or verbal/vocal symptoms like screaming and disruptive sounds. Resident #1 exhibited wandering behavior 1-3 days. Record review of Resident #2 care plan, dated 05/01/24 revealed the following: Resident #2 wanders in other residents' rooms and gets into their beds at times and had the following interventions: Resident #2 required assistance out of rooms that were not his and staff could use snacks if needed. Resident #2 was an elopement risk/wanderer and had the following interventions: Distract Resident #2 from wandering by offering pleasant diversions. Resident #2 prefer having snacks. Followed by [name of psych care]. Notify their MD/NP of any escalation in wandering behaviors, ineffectiveness, or side effects of psychiatric medications. Monitor the resident's location throughout shifts. Document wandering behavior and attempted diversional interventions in behavior log. Resident #2 had episodes of verbal and physical aggression r/t dementia with the following interventions: Give me as many choices as possible about care and activities. Monitor for physically/verbally aggressive behavior q shift. Document observed behavior and attempted interventions in behavior log. Monitor/document/report PRN any s/sx of Resident #2 posing danger to self and others. Resident #2 had impaired visual function r/t cataracts and glaucoma. Resident #2 was blind in his right eye with the following interventions: Arrange consultation with eye care practitioner as required. Monitor/document/report PRN any s/sx of acute eye problems: Change in ability to perform ADLs, decline in mobility, sudden visual loss, pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. Place frequently used items on my left side so I may see them. Record review of Resident #2's progress notes revealed the following: Record review of on 05/11/24 at 12:12 AM LVN G documented: Data: Resident observed by CNA H reported to this nurse observed resident with pants unzipped and PENIS in Resident #3's hand. Action: Resident removed from Resident #3's room w/o incident. Resident #3 appears to have been asleep during entire incident. No physical injuries noted at this time. Response: Resident in his room and placed on 1-1 monitoring per DON instructions. Roommate moved to different room as this nurse considers this a HIGH RISK INCIDENT. DON & Administrator notified. Record review of on 05/11/24 at 03:23 PM The DON documented: Received orders from NP may administer Lorazepam 1ml now and then every 8 hours as needed. DON gave orders to charge nurse may use emergency restraint for safety of resident and others. Record review of on 05/11/24 at 05:27 PM the DON documented: Spoke with Family Member L about incident and orders to give Lorazepam 2mg/ml injection every 8 hours as needed x 14 days. Voiced understanding and gives verbal consent at this time for medication. Also discussed that he would be going back to the behavior support center on Monday and facility would be actively looking for alternate long-term placement for resident. Voiced understanding and consents for referrals to be sent to other facilities. Record review of on 05/11/24 at 05:27 PM LVN B documented: Staff alerted this nurse that this male resident was found in female resident's bed with his hands in the female's pants. Upon entering room male resident is found in bed with female resident with his hand on resident's waist. Told resident he needed to get out of bed. RT refused and put his arm around female resident. Male resident immediately removed from female's bed and taken to his own room. Resident became aggressive with staff refusing to leave bed causing CNAs to fall. Administration notified. Physician A, the DON notified. New order for Ativan 2mg/ml injection. Injection administered. Resident continues to try to go into other female rooms. Record review on 05/31/24 at 01:07 PM The DON documented: Resident returned from behavioral center via their facility van. Notified Physician A of return and medications. Notified the NP of return and reconciled psychotropic medications. Notified family Member L of return and went over psych medications and no issues or concerns at this time. Record review of on 06/02/24 at 03:26 AM LVN M documented: Follow-up on readmission, resident continues to urinate on floor. Reminded resident to use urinal. Resident voiced understanding. Resident also continues to wander. Resident breathing even and unlabored. No complaints voiced. Record review of on 06/02/24 at 07:35 PM The DON documented: Notified by charge nurse that resident was wandering in rooms and becoming aggressive when staff was trying to redirect. Contacted the NP and new orders received to increase Seroquel to 50mg 3 times daily, Xanax 0.25mg every 6 hours as needed x 14 days, and Zyprexa 10mg IM every 12 hours as needed x 14days. Notified Family Member L of resident behavior and new orders. Voiced understanding and no issues or concerns at this time. Record review of Resident #2's monitoring sheets revealed the following: Resident #2 was monitored every 30 minutes starting 05/08/24 at 11:30 AM until 5/10/24 at 6:00 PM. (No abnormal behavior reported during this monitoring time.) No time monitoring accounted for 05/10/24 at 11:00 PM- 12:00 AM. Resident #2 was monitored on 05/11/24 from 1:00 AM-5:45 AM. (No abnormal behavior notated during this time. No time monitoring accounted for 12:00 AM-1:00 AM.) Resident #2 was monitored on 05/11/24 from 6:30 AM-4:00 PM. (No abnormal behavior notated during this time. No time monitoring accounted for 4:30 PM-6:00 PM) Record review of Resident #3's face sheet, dated 06/05/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (memory loss), cognitive communication deficit (difficulty communicating), fracture to neck and left femur, anxiety disorder (increased worry), and major depressive disorder (increased sadness). Record review of Resident #3's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 01, which indicated the resident's cognition was severely impaired. Section B. Ability to understand others revealed that she had clear speech, sometimes could make herself understood, and sometimes could understand others. Record review of Resident #3's care plan dated 6/5/24 revealed the following: Resident #3 was dependent on staff for emotional, intellectual, physical, and social needs related to cognitive deficits. Resident #3 required assistance to ADLs related to Alzheimer's disease, had impaired cognitive function/impaired thought processes related to Alzheimer's, had a mood problem related to depression, and had potential for psychosocial well-being related to trauma. Record review of Resident #3's progress notes revealed the following: 05/11/24 at 01:27 AM LVN G documented: Resident #2 observed in resident's room with Penis in her hand attempting what appears to ejaculate himself. Resident Immediately stopped by staff and removed to his room. Placed on 1-1 monitoring with instructions by DON NOT to be left out of staff sight at any time. No apparent injuries not upon physical inspection with female CNA present. DON to notify PCP & family. During an interview on 06/05/24 at 1:49 PM, CNA E stated that one night, when he worked the night shift (unsure of the date and exact time), Resident #2 exposed himself to Resident #3. He said he did not see it but was told by CNA H that Resident #2 had his penis in Resident #3's hand and was jerking off. He said as a result of that incident, Resident #2 was placed on 1:1 and was checked every 15 minutes by the night staff. He said Resident #3 was not in her right mind and would have been unable to consent. He said Resident #3 may have a BIMs of 0. He said prior to the incident involving Resident #3, Resident #2 was not on any close monitoring. He said that when Resident #3 was in the dining room and wanted to return to his room, they would assist him, but after he was in his room, they did not do additional monitoring. During an interview on 06/05/24 at 2:57 PM, LVN G stated that on 05/11/24, he was working the night shift. He said he heard a young lady yell out. He said it was the female CNA but did not know her name. He said he was on break. He said the female CNA reported that Resident #2 had a particular part of his anatomy in Resident #3's hand. LVN G stated they assisted in getting Resident #2 out of Resident #3's room. He stated when he walked in, he did not see Resident #2's penis in Resident #3's hand but did see his penis out. He said he had not seen Resident #2 do the sexual act in the past, but that Resident #2 would expose himself and urinate on the floor. He stated that, because of the incident, he reported it to the DON and was instructed to place Resident #2 on 1:1 monitoring. He stated he would sit in the hall and ensure Resident #2 did not go into other rooms. LVN G said that Resident #3 was catatonic (immobile) and could not defend herself. He said he reported the incident to the DON. During an interview on 06/05/24 at 4:04 PM, the ADM stated she did not report the incident that involved inappropriate sexual contact that occurred with Resident #2 and #3 because all parties had dementia. She said she focused on if the act was willful. She said Resident #3 was asleep and did not know what was happening. She said she was told but could not remember who told her that Resident #2 was standing over Resident #3 with his penis out and Resident #3's hand was on Resident #2's penis. The ADM stated she was not told that Resident #2 was masturbating. The ADM stated that Resident #2 was not put on 1:1 during the first incident involving Resident #3 because he was not aggressive, and this was the first time he displayed this behavior. During an interview on 06/05/24 at 4:24 PM, the DON stated when the inappropriate sexual incident between Residents #2 and #3 were reported to her, she reported it to the ADM as she was the abuse coordinator. The DON stated the ADM confirmed with the Regional Director that it did not have to be reported because the residents had dementia. The DON said the Regional Director provided documentation to support the decision. The DON stated she did not speak up or take any additional action to investigate the incidents after being told it did not need to be reported. During an interview on 06/06/24 at 12:25 PM, the DON stated she did not want to say the wrong things and that she could not think of the potential negative outcome when it came to not investigating sexual incidents between residents, specifically the incidents that occurred between Residents #2 and #3. She said she was aware that the sexual incident had not been reported to the HHSC. The DON said the ADM told her that she did not report it based on the instruction given to her by the Regional Director. The DON said she did not observe the sexual incident between Resident #2 and #3. The DON said she was responsible for incident/accident prevention, but the ADM was responsible for investigating. The DON said the purpose of investigating incidents of alleged abuse and neglect was to protect the residents and to follow policy. The DON said the facility system to monitor was to follow their policy. The DON said she was unaware of why they did not follow the policy. The DON said the ADM was responsible for investigating the incidents and she did not have a specific reason why the incident was not investigated by the ADM. During an interview on 06/06/24 at 1:16 PM, the ADM stated she was aware that she had not reported the sexual incident between Resident #2 and #3. She said the reason she did not report the incident was because after speaking with her Regional Director, who was more experienced, they felt that it was a behavior, not intentional, and abuse did not occur. The ADM said with this being a brand-new behavior for Resident #2, she could see that she did not see anything abnormal, with the conclusion of not reporting the incident of inappropriate sexual behavior. The ADM said her gut feeling was to report the incidents. The ADM said her Regional Director told her the incidents of inappropriate sexual behavior did not have to be reported, and she did not question it. She said because she was instructed not report the incident, she did not take any additional action to investigate. The ADM said she was responsible for inves [TRUNCATED]

Based on interviews, and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 (Residents #1) residents reviewed for adequate supervision and prevention of accidents. The facility staff (Administrator and DON) failed to adequately address Resident #2's ongoing behavior of entering Resident #1's room. The facility (Administrator and DON) failed to address resident #2's ongoing physical and verbal behavior with appropriate interventions. These failures to put supervision measures in place could result in harm to Resident #2 and the remaining residents in the facility. The findings included: Record review of Resident #1's face sheet, dated 05/08/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnosis to include Cerebral infarction (stroke), major depressive disorder, anxiety (increased feelings of fear, dread and uneasiness), cognitive communication deficit (difficulty understanding and communicating). Record review of Resident #1's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 04, which indicated the resident's cognition was severely impaired. Section B Hearing, Speech and Vision revealed that Resident #1 had slurred speech, could make himself understood and usually understood others. Record review of Resident #1 Care Plan, dated 02/29/24, revealed that he is a max assist, depends on staff for meeting his needs, requires tube feeding, has depression (impaired ability to remember), is on antianxiety medications, and that he was pulled from the bed on 04/25/24. Record review of Resident #1's progress notes revealed the following: 04/25/24 at 05:08 PM LVN A documented: Resident #1 was found on the floor was pulled out of bed by another resident (unidentified) assist Resident #1 back to bed did assessment no injures noted 03/30/24 at 12:49 AM LVN B documented: Other resident (unidentified) tried to pull Resident #1 out of his bed. other resident (unidentified) scratched Resident #1 across his chest x2, under left arm and lower abdomen, also abrasion noted to the right breast area extending to right mid back. immediately separated resident. Other resident (unidentified) was taken to his own room. Record review of Resident #2's face sheet, dated 05/08/24, revealed a [AGE] year-old-male was readmitted to the facility on [DATE] with diagnosis to include dementia (impaired ability to remember), depressive disorder (constant feelings of sadness), mood disorder (emotional deficit), and blindness to the right eye. Record review of Resident #2's Quarterly Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. Section B Hearing, Speech and Vision revealed that Resident #2 has clear speech, makes himself understood and understands others. His vision is impaired, and he does not wear corrective lenses. Section E Behavior revealed that he had not had any incidents of physical or verbal behavior. Record review of Resident #2's Comprehensive Minimum Data Set, dated dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. Section B Hearing, Speech and Vision revealed that Resident #2 has clear speech, makes himself understood and understands others. His vision is impaired, and he does not wear corrective lenses. Section E Behavior revealed that he has had physical behaviors such as hitting, kicking, pushing, scratching, grabbing, abusing others. Resident # 2 has exhibited verbal behaviors such as threatening others, screaming and cursing at others. The behaviors in this section were coded to have gotten worse. Record review of Resident #2 care plan, dated 04/30/24 revealed the following: Focus (Date initiated:04/26/24 Date revised:04/26/24) 4-25-24-I pulled another resident out of bed. Goal I will have no further episodes of aggression through review date. Interventions Placed 1:1 Sent to a behavior support center. Focus (Date initiated:01/22/24 Date revised: 01/22/24) I am an elopement risk/wanderer. Wander risk Goal I will not leave facility unattended through the review date. Interventions Distract me from wandering by offering pleasant diversions. I prefer having snacks. followed by psychiatric services. Notify their MD/NP of any escalation in wandering behaviors, ineffectiveness, or side effects of psychiatric medications. Monitor my location throughout shifts. Document wandering behavior and attempted diversional interventions in behavior log. Focus (Date initiated: 01/22/24 Date revised:01/22/24) I have episodes of verbal and physical aggression r/t dementia. Goal I will not harm self or others through the review date. Interventions Give me as many choices as possible about care and activities. Monitor for physically/verbally aggressive behavior q shift. Document observed behavior and attempted interventions in behavior log. Monitor/document/report PRN any s/sx of me posing danger to self and others. When I become agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Focus (Date initiated:01/22/24 Date revised:01/22/24) I have impaired visual function r/t cataracts and glaucoma. I am blind in my right eye. Goal I will show no decline in visual function through the review date. Interventions Arrange consultation with eye care practitioner as required. Monitor/document/report PRN any s/sx of acute eye problems: Change in ability to perform ADLs, Decline in mobility, Sudden visual loss, Pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. Place frequently used items on my left side so I may see them Record review of Resident #2's progress notes revealed the following: 04/25/24 at 04:55 PM LVN A documented: Resident #2 was found in another residents (unidentified) bed Resident #2 pulled another resident (unidentified) out of bed and stated he (unidentified resident) was in Resident #2 room and bed removed resident (unidentified) out of bed and room Resident #2 did get agitated did get Resident #2 in to own room. 04/24/24 at 08:25 PM the DON documented: 7:37 PM received notification from charge nurse that Resident #2 had pulled another male resident (unidentified) out of his bed to the floor and laid down in his bed. Notified the FNP of incident and received orders that may repeat Lorazepam dose X 1 if ineffective. Notified the PCP of incident and received orders may consult Behavioral Health. 04/23/24 at 11:34 AM the DON documented: Spoke with the FNP about Resident #2 physical aggression last night and swinging walking stick hitting staff. New order received to increase Depakote to 500mg BID and start Xanax 0.25mg every 8 hours as needed x 14 days. 04/23/24 at 1:06 AM LVN A documented: Resident #2 became toward staff called the FNP ordered Lorazepam 2mg he was abusive towards staff did have to redirect Resident #2 04/15/24 at 4:16 AM LVN B documented: Resident #2 continues to wander into other residents' rooms, at shift change he was sitting on bed in room [ROOM NUMBER]b. redirected Resident #2 to his room. 04/04/24 at 05:11 PM LVN B documented: Another resident (unidentified) informed this nurse that this Resident #2 was in his bed. Attempted assist Resident #2 to his room. Resident #2 refused. CNA attempted to redirect Resident #2 to his room. Resident #2 became combative with staff kicking his feet at staff and attempting to swing walking cane. Staff able to remove walking cane from rt hands and redirect to room. Admin notified. 03/30/24 at 12:26 AM LVN B documented: Resident #2 thought he was in room, and someone was in his bed. Resident #2 tried to pull other resident (unidentified) out of his bed. Resident #2 scratched other resident (unidentified) across his chest x2, under left arm and lower abdomen, also abrasion noted to the right breast area extending to right mid back. immediately separated resident. Resident #2 was taken to his own room. 03/30/24 at 05:27 PM LVN D documented: Resident #2 has slept all day and refused to get up for shower or meals. Resident #2 came to staff during the dinner pass demanding a shower. Explained to Resident #2 that we are in the middle of dinner and cannot stop and give showers at this moment. Resident #2 very aggressively started shouting I don't care what time it is I'm going to get a shower now Resident #2 is legally blind and needs assistance in shower but Resident #2 attempting to go into to back shower room. Tried to explain again to Resident #2 that he will have to wait until after dinner for his shower and resident said, I don't care and began pushing this nurse. Resident #2 began opening other residents' rooms trying to find the shower room. Made sure resident did not enter wrong room. Resident #2 eventually turned around and went back to his room. Record review of the provider investigation report, dated 05/01/24, revealed that Resident #2 had a history combativeness, wandering, verbal aggression, physical aggression and was not on any special supervision. Record review of the provider investigation report, 04/29/24, revealed that Resident #2 had a history combativeness, wandering, verbal aggression, physical aggression and was not on any special supervision but that as a result of the incident with Resident #1 was placed on 1:1. Record review of Resident #2's close monitoring log revealed that Resident #2 was monitored every30 minutes on 05/08/24-05/10/24. During an interview on 05/08/24 at 11:42 AM, the ADM stated Resident #2 went into Resident #1's room. The ADM stated Resident #1 and Resident #2's rooms were next to each other. She stated staff heard yelling from Resident #1. She stated when staff entered the room, they observed Resident #1 on the floor, and Resident #2 was in Resident #1's bed. The ADM stated staff redirected Resident #2 to his room, assessed Resident #1 and did not identify any injuries on either resident. The ADM stated she was notified and physically came to the facility to attempt to get additional support from a local behavior support center for Resident #2's behavior. She said Resident #2 was transported to the behavior support center the same night. The ADM stated that Resident #2 had never done this to Resident #1. She stated Resident #1 had a history of aggressive behavior with staff. The ADM said as a result of this incident, on 04/25/24, they conducted training with staff over resident rights, ANE, and that they had consulted with the local behavior support center to conduct training on dealing with aggressive behaviors, but no official date had been set. During an interview on 05/08/24 at 01:34 PM, Resident #2 said he did not recall staff yelling at him, felt safe, had difficulty seeing things, and had no physical incidents with staff or other residents. Resident #2 said he knew where his room was but could not recall a specific room number. He said he did not have any additional concerns. During an interview on 05/08/24 at 1:50 PM, Family Member J stated on 04/25/24, she was notified that Resident #2 had thrown Resident #1 on the floor. Family Member J said she was notified that Resident #1 was assessed, received x-rays, and had no injuries. Family Member J said she spoke with Resident #1 and was told he was not hurting too badly. Family Member J said before the incident on 04/25/24 that she had participated in Resident #1 care plan meeting and specifically had asked what would be done about Resident #2 going into Resident #1 room. Family Member J said it had been suggested that possibly hanging something on Resident #2's door could help Resident #2 find his room. Family Member J said she did not believe that Resident #2 was intentionally targeting Resident #1 but that he was confused. Family Member J said during the care plan meeting, the MDS coordinator, the ADM, the DON, the DM, and the Activities Director were present. She said she brought up the interaction between Resident #1 and Resident #2 because she had been present when Resident #2 would wander into Resident #1 room. Family Member J said she was lucky that Resident #2 had never been violent with her. Family Member J said she had always successfully redirected him out of Resident #1's room. She said the incident on 04/25/24 was not the first time Resident #2 had entered Resident #1's room. Family Member J said the incident on 04/25/24 was the only time she had been notified. Family Member J said she had been told by the staff (LVN A and other CNAs that she could not remember) that there was an incident (did not know the date) where Resident #2 had come into Resident #1's room and tried to pull him off the bed, but was unsuccessful. She said she believe the Social Worker may have mentioned to her about Resident #2 attempting to pull Resident #1 off the bed. Family Member J said that there was an instance (unsure of the date) where she had entered Resident #1's room, and Resident #2 walking cane was behind the dresser in Resident #1's room, indicating he had been there. Family Member J said it was her first time bringing it up to the ADM and DON at the care plan meeting, but she had talked to staff and the nurses numerous times before the care plan meeting. Family Member J said staff had expressed that they were reporting issues, but nothing was being done. Family Member J said that no incidents with Resident #1 and Resident #2 would occur during the day because she or Family Member K would be there during the day. Family Member J said she was there during the day on Monday, Wednesday, Thursday, and Friday. She said Family Member K was at the facility on Wednesday. Family Member J said that before the incident on 04/25/24, nothing had been done to help Resident #2 know where his room was. During an interview on 05/08/24 at 2:02 PM, Resident #1 stated via telephone that Resident #2 had pulled him off the bed, and he did not want it to happen again. During an interview on 05/08/24 at 2:03 PM, Family Member K stated via telephone that she was physically with Resident #1 but that he had a hard time talking because of his stroke. Family Member K said there was an incident where LVN A walked into the room (unsure of the date), and Resident #1 was sideways, hanging onto the bed with one arm. She said she believed there was another incident where Resident #1 tried to protect his feeding tube site. She said she was concerned that this was happening when Resident #1 was sleeping, and that Resident #1 could not defend himself. Family Member K said the staff knew about the incidents and needed to do something. Family Member K said that she had not physically told anyone but was told by Family Member J that she had. During an interview on 05/08/24 at 2:18 PM, CNA F stated she was unsure of the exact dates, but about a month before the interview, She and CNA E had caught Resident #2 in Resident #1 room. CNA F said Resident #2 was confused and had difficulty seeing. CNA F said she did not believe Resident #2 was being mean or awful to Resident #1, but he thought he was in his (Resident #2) room. CNA F stated Resident #1 was yelling. CNA F said when they got to Resident #1's room (she and CNA E), they observed the door closed and the lights off. CNA F said when they turned on the lights, they observed Resident #2 trying to pull Resident #1 off the bed. CNA F stated water was on the floor, and Resident #1's head was on the bed rail. She observed the side table turned over, and Resident #1 was protecting his feeding tube site and crying. CNA F attempted to redirect Resident #2, but he refused to leave. CNA F stated this incident was reported to LVN B. CNA F stated LVN B said she reported the incident to the appropriate parties. CNA F stated a week after that incident (unsure of the exact date), Resident #2 was back in Resident #1's room. CNA F stated that Resident #1 had pushed his call light, and Resident #2 was standing in Resident #1's room when they got to him. CNA F stated that when they attempted to redirect him out of Resident #1's room, Resident #2 stated he wanted his jacket, and they grabbed his hand. Finally, Resident #2 went with them. CNA F stated that there had been a lot of changes in the facility as far as room changes and believed that the separation by gender may have contributed to Resident #2 being confused about where he was going and, in addition, his difficulty being blind. CNA F stated Resident #2 had been moved three or four times. CNA F stated the difficulty they had been having with Resident #2 had been reported to LVN A and LVN B (unsure of the exact time and date). She stated she was under the impression that, as the CNA, she was to report to her charge nurse and that they would proceed further if needed. She said her charge nurses had told her that the incidents with Resident #2 had been reported to higher people. CNA F stated they had wondered when something would be done. CNA F stated she was frustrated with all the incidents that had occurred with Resident #2. She stated that although Resident #2 was not evil and was sweet, his behaviors had worsened, and he had become more confused. CNA F stated that outside of the incidents with Resident #1, Resident #2 had become aggressive with her, and CNA G. CNA F stated that if something had been done, some of the incidents with Resident #2 could have been prevented. During an interview on 05/08/24 at 2:58 PM, CNA E stated she could not remember exact dates and times. CNA E stated the first incident between Resident #1 and #2 might have occurred four months ago. CNA E stated that she and CNA F were doing rounds and heard Resident #1 scream aloud. CNA E stated Resident #2 was in Resident #1 room. CNA E stated she observed Resident #1 halfway off the bed. CNA E stated that Resident #2 had his wife in the room. CNA E stated Resident #1 was halfway off of the bed, and she observed the lower half of Resident #1's body off the bed. CNA E said Resident #1 was holding onto the bed rail with his right arm. CNA E stated the incident where Resident #1 was hanging off the bed was the first incident she had ever seen. She said she reported the incident to the charge nurse but could not remember who it was as they have many charge nurses. CNA E stated there was another incident (unsure of the date and time) where Resident #1 screamed. CNA E stated that Resident #2 scratched Resident #1 during this incident. CNA E stated it happened possibly two months ago. CNA E stated Resident #2 had scratches on his chest and right side. CNA E stated this was reported to LVN B. CNA E stated that she had to scream for assistance during this incident. She stated CNA F came to assist her. CNA E stated that this incident scared her and that things were worsening with Resident #2's behaviors. CNA E stated that Resident #2 was telling her that Resident #1's room was his room and yelling at her. CNA E said she kept telling him it was not his room. CNA E said that after they told LVN B, she (LVN B) would notify the appropriate parties. She said Resident #1 appeared scared and had water in his eyes. She said Resident #1 said it was scary. CNA E said Resident #1 used minimal words such as scary, hurt, and oh man to describe what had happened. CNA E said there was another incident where Resident #2 had become agitated and aggressive with staff; this was when she messaged the DON. CNA E said she did not like what was happening, and it made her sad about what had happened to Resident #1. A record review of text messages sent to the HHSC investigator on 05/08/24 at 3:28 PM from CNA E revealed on 04/23/24 at 3:28 PM that CNA E expressed concern about Resident #2's behavior, not being trained to take care of residents with Resident #2's behaviors, other residents being afraid and the potential for the incident to be worse. The DON responded that Resident #2's medication was adjusted. CNA E expressed concern about what to do when Resident #2 does not take his medication. CNA E expressed in the text message that Resident #2 had several incidents before the aggressive incident with staff. CNA E referenced the incident with Resident #2 protecting his feeding tube and that CNA E had reported the incident to her charge nurse. The DON responded to the concerns by stating that Resident #2's medication was adjusted and that she was unaware what had happened when Resident #2 became aggressive with staff. During an interview on 05/08/24 at 3:29 PM, LVN A stated that she no longer worked at the facility. LVN A stated on 04/25/24 that she did not witness Resident #2 pulling Resident #1 out of the bed. LVN A stated that she had heard Resident #1 scream and thought it was another resident. LVN A said that when she walked down the hallway, one of the CNAs came running towards her. LVN A stated she could not remember the CNAs name. LVN A said she went into Resident #1 room and observed Resident #2 in Resident #1's bed and Resident #1 was on the floor. LVN A said this was not the first interaction between Resident #1 and Resident #2. LVN A stated this was the second time this had happened. LVN A said that during the incident on 04/25/24, Resident #2 yelled at the staff. LVN A stated she raised her voice for Resident #2 to get out of Resident #1's bed. LVN A said that they were finally able to get Resident #2 out of Resident #1 room. LVN A said she notified the DON of the incident. LVN A stated the DON said that she told the ADM and that the ADM was on the way to the facility to send Resident #2 out for behavior support. LVN A said she had experienced Resident #2 becoming agitated with staff on 04/18/24. She stated that the FNP, PCP, DON, and ADM knew about the incident. She said she had been told by other staff that Resident #2 had attempted to pull Resident #1 out of bed before. She said she was unaware of any interventions that had been put in place. During an interview on 05/08/24 at 10:25 PM, CNA I stated on 04/25/24, it was around 7 PM or 9 PM when the residents that smoke go out. CNA I said she observed Resident #1 on the floor. CNA I said she went to get LVN A, and that was when she (LVN A) told Resident #2 to get the fuck out. CNA I said she redirected Resident #2 to his room. CNA I stated she and CNA H placed Resident #1 back in bed. CNA I said after that incident and Resident #2 received a shot of Ativan he came back out and was trying to throw a shoe at Resident #1. CNA I said that most of the time when she worked with Resident #2, he would always try to go into Resident #1's room. CNA I said this occurred at least three times a week. Before the incident on 04/25/24, CNA I said that Resident #2 never made physical contact with Resident #1 on her shift. CNA I said there was nothing ever done that she could recall to alleviate the situation, but the staff had placed gloves on the outer door at one point. She stated she could not provide a picture of the gloves on the door to the HHSC worker. CNA I said that she had been trained to report allegations of ANE immediately. During an interview on 05/08/24 at 10:51 PM, LVN D stated that the incident on 04/25/24 was the second time that Resident #2 had attempted to pull Resident #1 out of bed. She stated she was not present but had received the information in the report as she typically worked the day shift. LVN D said that they had to redirect Resident #2 consistently. LVN D stated that she did not feel that Resident #2 was explicitly targeting Resident #1 but that he was confused as to where his room was. An attempt to contact LVN B was made at 10:57 PM. LVN B said she would contact her DON and ADM and return the call. Additional attempts to speak with LVN B were made on 05/09/24 at 10:29 AM. LVN B did not answer. During an interview on 05/09/24 at 10:21 AM, the FNP stated that she had consistently been seeing Resident #2 for psychiatric services. The FNP said she was making frequent medication adjustments. The FNP said she was only aware of one incident where Resident #2 had pulled a resident out of the bed, but no other incidents had been reported. The FNP said it had been reported that he had become aggressive with staff. During an interview on 05/09/24 at 10:52 AM, the Activity Director stated that she participated in Resident #1's care plan. The Activity Director stated that Family Member J expressed that Resident #2 had wandered into Resident #1's room once or twice. The Activity Director stated they had gloves on the door so Resident #2 knew where his room was. The Activity Director said she does not know what happened to the gloves because they are no longer there. The Activity Director said she was unaware of any other interventions to prevent Resident #2 from entering Resident #1's room. The Activity Director stated she did not feel that Family Member J was upset but did express concern. During an interview on 05/09/24 at 11:00 AM, the DM stated that she participated in Resident #1's care plan. The DM said Family Member J expressed concern about Resident #2 entering Resident #1's room. The DM suggested placing bells or something on Resident #2's door so that he would know which room was his. The DM said Family Member J was concerned that the next time could be worse for Resident #1. The DM stated that before the incident on 04/25/24, Resident #2 had gone into Resident #1's room, but she did not know the date or time. The DM said she was unaware if Resident #2 had been physical with Resident #1. The DM said Family Member J was not upset but concerned. During an interview on 05/09/24 at 11:10 AM, the MDS Coordinator stated that she was aware that Resident #2 had pulled Resident #1 out of the bed only once. The MDS Coordinator said that she was unaware that Resident #1 had increased physical or verbal aggression behaviors. The MDS Coordinator said revising the care plan if the behaviors differ was customary. The MDS Coordinator said that Resident #2 did not understand well and that all staff could do was redirect him with a snack or an activity. The MDS Coordinator stated that she revises the care plan each time there was an MDS update. The MDS Coordinator said the MDS was updated annually, quarterly, and sometimes on an off cycle. The MDS Coordinator said she would also update us if there was a significant change. The MDS Coordinator said she looked over the care plans each time there was a care plan meeting. The MDS Coordinator said she would have revised the care plan if it had been reported to her each time Resident #2 pulled any resident out of bed. The MDS Coordinator said the interventions were what the staff do to care for the resident, and staff should be watching him closely. During an interview on 05/09/24 at 11:27 AM, Resident #1 stated that Resident #2 had been in his room [ROOM NUMBER]-5 times. Resident #1 stated no one had come to him and interviewed him about the incident outside of the HHSC investigator. Resident #1 said that he was afraid when he had to hang onto the bed. Resident #1 said he had told multiple CNAs and nurses that he did not want Resident #2 in his room. Resident #1 said he could not remember the names of the staff he told. Resident #1 said he felt like his problem was never solved. Resident #1 said that three times when Resident #2 came into his room, it got physical; he was pulled off the bed, scratched, and pulled halfway off the bed. Resident #1 said he could not remember the date and time when the incidents happened but that staff knew about it because they had to help him. During an interview on 05/09/24 at 1:07 PM, the ADM clarified that during the initial interview, she stated the incident between Resident #2 and Resident #1 had never happened was because three weeks prior, staff had reported that Resident #2 had gone into the room and scratched Resident #1 and LVN B had redirected Resident #2 out. The ADM stated she was unsure where the scratch was. The ADM stated this type of information was typically reported to the DON. The ADM stated she did not report the incident to the state agency because the nurse had intervened and redirected Resident #2 out of the room. The ADM said she was unaware that Resident #2 had encountered Resident #1 multiple times. The ADM said she was unaware that Resident #2 had attempted to pull Resident #1 out of the bed before the incident on 04/25/24. The ADM said she was unsure of Resident #1's care plan meeting . The ADM said she, the DON, Family Member J, The MDS Coordinator, the ADM, and the Social Worker may have been there. During the care plan meeting, the ADM said Family Member J did not express concerns about Resident #2 coming into Resident #1's room. The ADM said they did discuss potentially placing something on Resident #2's door but never made it official. The ADM said the discussion about Resident #2 did not occur during Resident #1's care plan meeting. The ADM said they were monitoring Resident #2's behavior through psychiatric services and medication adjustments. The ADM stated that the staff had expressed concerns about them getting hurt, but she was unaware of the ongoing issues with Resident #1. She said she was only aware of one incident where Resident #2 had become aggressive with staff. She said she was unaware of any other incidents. The ADM said she knew that most of Resident #2's incidents or behaviors occurred at night. The ADM said she did not implement any other interventions outside of the medication adjustments and monitoring from psychiatric services and notifying the family, PCP, and FNP. The ADM said she was sure the care plan had interventions to address Resident #2's behaviors. The ADM said all interventions and revisions should be dated. The ADM said grievances were for family and residents. The ADM said if staff had a concern, they should be redirected to HR to identify a solution. The ADM said she did not have a system to track staff concerns. The ADM said she was responsible for grievances. The ADM said all staff had been trained to handle grievances as part of ANE and resident rights training. The ADM said she had never interviewed Resident #1 to see if this had happened. The ADM had never delegated to interview Resident #1. The ADM said the night of the incident (04/25/24), she was more concerned with his well-being and what happened. The ADM said part of the investigation process was interviewing key witnesses and residents and finding out what happened. The ADM said the potential negative harm if they do not attempt to prevent incidents and accidents was that harm could come to the residents and staff. The ADM said the care plan had interventions that helped prevent incidents and accidents. The ADM said they usually would have met weekly if they identified a potential problem. The ADM said that her team had not met every week regarding Resident #2. The ADM said the purpose of preventing incidents and accidents was the residents' overall safety. The ADM said that she could have prevented further incidents if she had known about the multiple incidents between Resident #1 and Resident #2. The ADM said she was unaware of the various times. The ADM said the facility staff monitored incident/accident prevention through daily standup meetings, talking to staff, and in-service. The ADM said she had not done anything specific for the night-time staff but that they had received the same ANE and resident rights training. The ADM said she had no formal training regarding preventing incidents/accidents, but they trained the staff through in-services. The ADM said she had not observed Resident #2 go into Resident #1's room but expected her staff to monitor and redirect as much as possible. The ADM said everyone was responsible for preventing incidents and accidents and

Based on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse for 8 of 10 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #10), reviewed for abuse. The facility failed to ensure a safe environment free from abuse for Resident #1 when can D was suspected to have used unnecessary force causing a spiral fracture to Resident #1 on night shift on 04/12/2023. The facility failed to ensure Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10 resided in a safe environment after making allegations of abuse toward CNA D and CNA D was continued to allow to work with all resident's even after prior allegations of abuse. This failure was determined to be an Immediate Jeopardy situation that was identified on 04/14/2023 at 5:51 p.m. While the IJ was removed on 04/17/2023 , the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotion distress, serious harm, and death. Findings include: Resident #1: Record Review of Resident #1's face sheet documented he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was admitted with a diagnosis which includes: dementia without behavioral disturbance, muscle wasting and atrophy (loss or thinning of muscle tissue), difficulty in walking, Record review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] documented that Resident #1's BIMS (Brief Interview for Mental Status) was a 3/15, meaning severe cognitive impairment. Under Section B under Hearing, Speech, and Vision indicated that Resident #1, for ability to hear listed him at a 0, meaning no difficulty in normal conversation, social interaction, or watching tv. Under Section B in B0600 labeled Speech Clarity indicated listed at a 1 meaning that Resident #1 has unclear speech such as slurred or mumbled words. Under B0700 labeled Makes Self Understood Lists Resident #1 at a 1 meaning that Resident #1 is usually understood with difficulty communicating some words or finishing thoughts but is able if prompted or given time. Under B0800 labeled Ability to Understand documents that Resident #1 usually understands meaning misses some part/intent of message but comprehends most conversation. Under B0700 labeled Makes Self Understood is documented at a 1 meaning usually understands: difficulty communication some words or finishing thoughts but is able if prompted or given time. Under Section C for cognitive patterns for C0700 labeled short-term memory is left blank and not completed. Under C0700 labeled long-term memory is left blank and not completed. Under C0800 labeled Memory/Recall Ability is left blank and not completed. Under C01000 labeled Cognitive Skills for Daily Decision Making is left blank and not completed. Under C01300 for Delirium for the question, Is there evidence of an acute change in mental status, labeled as a) meaning no there is not a change in mental status, for inattention is listed as a 0 meaning no behavior is present, for disorganized thinking is listed as a 0 meaning there is no behavior present, for altered level of consciousness is listed as a 0 meaning behavior is not present. Under Section D for Resident Mood Interview under D0200 Resident #1 shows little interest or pleasure doing things displayed at a frequency of 7-11 days, feeling down, depressed, or hopeless at a frequency of 2-6 days, feeling tired or having little energy at a frequency of 2-6 days. Under Section E for E0200 under Behavioral Symptom-Presence and Frequency is documented at a 0 meaning Resident #1 did not exhibit behaviors for physical behavioral symptom directed towards others such as for example (hitting, scratching, pushing, kicking, grabbing, abusing others sexually) , verbal behavioral symptoms directed toward others such as, for example (threatening others, screaming at others, cursing at others), other behavioral symptoms not directed towards others such as, for example (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds). Under B0300 under Overall Presence of Behavioral Symptoms listed at a 0 meaning Resident #1 did not exhibit these behaviors. Under B0500 under Impact on Resident for the questions: put the resident at significant risk for physical illness or injury, significantly interfere with resident care, significantly interfere with the resident's participation in activities or social interactions was blank and incomplete. Under B0600 under Impact on Others for the questions: put others at significant risk for physical injury, significantly intrude on the privacy or activity of others, significantly disrupt care or living environment was left blank and incomplete. Under B0800 under rejection of care is listed as a 0 meaning that Resident #1 did not exhibit this behavior. Under Section E for Wandering labeled has the resident wandered list a 0 indicating that Resident #1 has not displayed this behavior. Under Section G for Functional Status for G0100 labeled a), bed mobility (how resident moves to and from lying positions, turns side to side, and positions body while in bed or alternate sleep furniture) is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) listed as a 2 person assist, b). transfer (how the resident moves between surfaces including to and from bed, wheelchair, and standing position) is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) with a 2 person assist, c). Walk in room is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) with a 1 person assist, e). Locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair) is listed as a 0 indicating Resident #1 does not need assistance. Under G0300 for Balance during Transitions and Walking for a). Moving from seated to standing position is listed as a 1 meaning (not steady, but able to stabilize without staff assistance), b). Walking is listed as a 1 meaning (not steady, but able to stabilize without staff assistance), e). Surface to Surface transfer (transfer between bed and wheelchair) is listed as a 1 meaning (not steady, but able to stabilize without staff assistance). Under G0400 labeled Functional Limitation of Range of Motion for a). Upper extremities is listed as a 0 meaning no impairment. Under G0600 labeled Mobility Devices indicates that Resident #1 uses a wheelchair. Under G0900 labeled Functional Rehabilitation Potential indicates for Direct care staff believe resident is capable of increased independence in at least some ADLs is listed as a 1 meaning yes, they do believe Resident #1 is capable of increased independence. Under Section J for Health Conditions for J0300 for Pain Assessment indicates that Resident #1 has not had any pain or hurting in the past 5 day. Under J1700 for, a). Did the resident have a fall any time in the last month prior to admission/entry or reentry, indicates that Resident #1 was listed as a 1 meaning that he did have a fall prior to admission in the past month, b). Did the resident have a fall any time in the past 2-6 months prior to admission/entry or reentry, is documented as a 1 indicating that Resident #1 has experienced a fall in the past 2-6 months prior to admission in the facility. C). Did the resident have any fracture related to a fall in the past 6 months prior to admission/entry or reentry is listed as a 0 meaning the resident has not experienced a fracture in the past 6 months prior to admission into the facility. Under J1800 labeled Any falls since admission/entry or re-entry prior to assessment indicates a 1 meaning that Resident #1 has experienced a fall prior to admission into the facility. A). No Injuries is listed as a 1 meaning (no evidence of any injury on physical assessment by the nurse or primary care clinician, no complaints of pain or injury by the resident; no change in the resident's behavior is noted after the fall). Record review of Resident #1s Care Plan dated 4/12/2023 revealed Resident #1 had a fracture of the left humerus with the interventions of: non weight bearing to LUE-nursing was to remove from sling 3 times a day to perform elbow extension only PROM. Nursing only to perform. In-service was given on 4/12/2023 to CN from PT on how to perform PROM correctly to prevent further injury. LPN, RN, DON, apply sling and encourage to leave it on assisting as needed for proper placement. Record review of Resident #1s Care Plan dated 04/14/2023 indicated Resident #1 had limited mobility r/t fx of left humerus that limits ADL self-performance. AEB unable to use left arm and requires a restorative nursing program to maintain current level of function with the interventions of: Nursing rehab/restorative: Passive ROM Program #1 extend lower arm flexing elbow 3 sets of 15 with 5 second pause. Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is dependent on staff for meeting emotional, intellectual, physical, and social needs due to cognitive deficits with the interventions of: All staff to converse while providing care, establish and record level of activity and interests by talking with Resident, caregivers, and family on admission and as necessary, needs assistance/escort to activity function. Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is deficit with dementia with the interventions with ADLs as follows: bed mobility: self-performance supervision, bed mobility: support provided with 2 person physical assist, transfer: self-performance supervision, support provided with 2 person physical assist, walk in room: self-performance supervision, support provided with one person assist, locomotion on unit: self-performance independent, support provided no setup or physical help from staff, nurse aides to document most dependent self-performance per shift. Monitor signs and symptoms of ADL decline and notify family, MD, identify causes and solutions. Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is an elopement risk/wanderer with disoriented to place, wander risk is 9, with the interventions of distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, snacks, monitor location throughout shifts. Document wandering behavior and attempted diversional intervention in behavior log. Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 had a cognitive impairment due to dementia with the interventions of ask yes/no questions in order to determine the resident's needs. Cue, reorient and supervise as needed. Need assistance with all decision making. Keep routine consistent and try to provide care givers as much as possible in order to decrease confusion. Present just one thought, idea, question or command at a time. Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 had a communication problem with difficulty making self-understood and difficulty understanding others with the interventions of monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed. Monitor/document frustration level, wait 30 seconds before providing with a word. Speak on an adult level, speaking clearly and slower than normal. Validate message by repeating aloud. Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 is at risk for falls with gait/balance problems with the interventions of: provide with a chair to sit in when wondering in halls, be sure my call light is within reach and remind to use it for assistance as needed. Record Review of Resident #1's Progress notes dated 04/12/2023 at 5:38 am, signed by LVN A revealed: Note Text: Resident #1 woke up and came to nursing station stating he fell asleep on hand, and it was hurting/tingling. Assessed and hand was red with minimal puffiness. Resident #1 walks off and was later found in another Resident's room asleep in an empty bed. Male Aide (CNA D) was notified, and he assisted Resident #1 and he assisted Resident #1 out of room and down hall to his assigned room. LVN A (Nurse) hears Resident #1 yelling really loud and complaining of shoulder pain. LVN A (Nurse) asked Nurse Aide (CNA D) what did he do and he replied nothing, I just lifted him up under his arms and took him to his room. Nurse (LVN A) and Aide went into room to see what was wrong and Resident #1 attempts to hit aide yelled, get away from me in anger. Assessed arm and noticed bruising to lower forearm but Resident #1 had on a long sleeve shirt that would only go up so far. Resident #1 lays down. A few minutes later LVN A hears Resident #1 still moaning in pain. By this time aide (CNA D) reports that he just vomited and needed to leave and go home because he wasn't feeling well. Nurse (LVN A) and only aide (CNA C) present, goes in to check on Resident #1. This time I (LVN A) attempted to take off Resident #1 shirt and he's yelling in pain. I (LVN A) was able to get it off and assessed shoulder. I (LVN A) noticed a crease in arm in-between shoulder and elbow. Softly palpating down arm, Resident #1 guards' arm and a knot is felt and arms appears to be disformed. I (LVN A) had the aide (CNA C) to ask Resident #1 what happened in the room in Spanish, and he replied, He hit me two times. BOM, MD, wife, and Regional Operations Director notified. 911 called and Resident #1 transferred to UMC. During an observation on 04/13/2023 at 12:01 p.m., Resident #1 was sleeping and did not awaken to name being called. Resident #1 had a sling on the left arm. Resident #1 did not appear to be in any distress at this time. During an interview on 04/15/2023 at 12:48 p.m., with Family member 13 stated that the morning that Resident #1 was sent out to the hospital she received a call from LVN A and told her that Resident #1 had a hurt arm and was being sent out to the hospital. Family member 13 stated that LVN A told her that Resident #1 had stated that CNA D had hurt his arm. Family member 13 stated that she immediately felt sick to her stomach because she had been told by Resident #1 on a couple of different occasions that CNA D was mean to him. Family member 13 stated that she had told the staff and Administrator about Resident #1 stating that CNA D was being mean. Family member 13 stated she didn't know if anything had been done about the other times that Resident #1 had complained because she never heard anything from the staff or Administrator about the situations. Family member 13 stated that she would hope that now that something would get done about CNA D hurting Resident #1. Family member 13 stated that it's bad enough that something like this had to happen before something would get done about CNA D hurting Resident #1. Family member 13 stated that BOM had called her later that morning after she had already talked to LVN A and BOM told her that CNA D was transferring Resident #1 to bed and accidentally hurt him. Family member 13 stated that on one of the other times that Resident #1 was saying he was being treated mean, Resident #1 had told her and her brother, He beat me, Resident #1 had told family member 13, That big guy was in a boxing match with me, he beat me. Family member 13 stated that she took her concerns to the Administrator and never heard anything else about it. *Resident #2: Record Review of Resident #2 face sheet documented he is a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 was admitted with a diagnosis which includes: stroke, seizures, difficulty swallowing, facial weakness, major depressive disorder, anxiety disorder, type 2 diabetes, muscle wasting, cognitive communication deficit, lack of coordination, hyperlipidemia (a condition which there are high levels of fat particles (lipids) in the blood). Record review of Resident #2's admission MDS dated [DATE] documented that Resident #2's BIMS was listed as 00 meaning zero points are assigned if the resident didn't repeat words correctly Under B0600 for Speech Clarity indicated that Resident #2 scored 1 meaning Unclear Speech-slurred or mumbled words. Under B0700 for Makes Self Understood indicated that Resident #2 scored 2 for ability to express ideas and wants. meaning sometimes understood ability is limited to making concrete requests. Under B0800 for Ability to Understand Others-understanding verbal content scoring a 2 meaning responds adequately to simple and direct communication only. Under G0110 for Activities of Daily Living Assistance indicates: A). Bed Mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) Resident #2 scored a 3 meaning extensive assistance (resident involved in activity, staff providing weight bearing support) with 2 persons assist. B). Transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), Resident #2 scored a 4 indicating total dependence (full staff performance every time during entire 7-day period). G). Dressing how resident puts on, fastens and takes off all items of clothing, including donning/removing a prosthesis or TED hose. Dressing includes putting on and changing pajamas, Resident scored a 3 indicating extensive assistance (resident involved in activity, staff providing weight bearing support) with 2 persons assist). Resident #2 scored a 3 indicating extensive assistance (resident involved in activity, staff providing weight bearing support) with one person assist. Toilet Use: how resident uses the toilet room, commode, bedpan, or urinal Record review of Resident #2s Care Plan dated on 07/01/2022 indicated the following: Resident #2 has an ADL self-care performance deficit with interventions of: ADL self-performance fluctuates with confusion but usually requires assistance as follows: Bed mobility-self-performance (Total Dependence), Bed mobility: support provided with 2-person physical assist, Transfer: self-performance (total dependence), Transfer-support provided with 2 person physical assist, walk in room- self-performance (activity did not occur), walk in room- support provided ADL activity did not occur, Walk in corridor- self-performance (Activity did not occur), walk in corridor-support provided ADL activity itself did not occur, Locomotion on unit-self performance (total dependence), Locomotion on unit- support provided one person physical assist, Locomotion off unit- self-performance (total dependence), locomotion off unit- support provided with one person physical assist, Dressing: self-performance (Extensive assistance), Dressing: support provided with two person physical assist, Eating: self-performance (Supervision), Eating: support provided with one person physical assist, Toilet use: self-performance (Total dependence), Toilet use: support provided with two person physical assist, Personal hygiene: self-performance (Total dependence), Personal hygiene: support provided with two-person physical assist, Nurse aides to document Resident #2s most dependence self-performance per shift. Monitor for signs and symptoms of ADL decline and notify family, MD, identifying causes and solutions. Monitor/document/report to MD as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Record Review of Resident #2's Progress notes dated 04/15/2023 at 10:57 am, signed by Social Worker revealed: Social worker spoke with Family Member #12 to let her know about the new reporting guidelines for abuse and neglect. She (Family Member #12) asked that it be mailed. She (Family Member #12) may also pick it up today when she is here. The form is also placed in Resident #2's room. During an Observation on 04/13/2023 at 12:08 pm with Sampled Resident #2 revealed: Observed Resident #2 laying in his bed visiting with family member. Observed Resident #2 free from distress. During an Interview with Resident #2 on 04/13/2023 at 12:07 pm. Resident #2 was able to slowly reveal the complaint that he had against CNA D with the help of family member. Resident #2 stated that during care he went to grab side bars and CNA D pushed him hard and motioned to Surveyor where his head was hit on the side bars. Resident #2 stated, He hits me, hard. (CNA D). Resident #2 put his fingers on top of his head and stated, Devil. Surveyor stated who is the Devil, Resident #2 called CNA D by name. Observed Resident #2 began to show signs of anxiety just talking about it and began to tear up in his eyes. Family member #11 had to console Resident #2 to get him to calm down. During an interview on 04/13/2023 at 12:17 p.m., with Family member 12 via telephone for Resident #2, Family Member #11 used her own personal cell phone to reach out to Family member #12 and was happy to share some concerns. Family Member #12 stated that she does have some concerns with CNA D and that she did not have a lot of time because she had to get back to work but would like the opportunity to write down all the concerns and get back with Surveyor in a couple of days. Family Member #12 stated that she was told by Resident #2's old roommate (Resident #9) that he witnessed CNA D tell Resident #2 to stop using the call light so much or the next time he puts him in the Hoyer lift he (CNA D) will leave him there. Family Member #12 stated that the Administrator and BOM both knew that these things were going on and did nothing about it. Family Member #12 stated that she had stressed out so much from worrying about Resident #2 being in the facility when CNA D is working. Family Member #12 stated that she would like to make a written statement to provide to Surveyor about all the things that CNA D did to Resident #2. Record Review of a written Statement provided on 04/15/2023 at 8:00 am, from Family member #12, revealed: To Whom it May Concern: I (Family Member #12) just want to say thank you, my name is (Family Member #12), stated it is unfortunate that they are in the situation that they are in with the facility. Family Member #12 stated that she is willing to share Resident #2 journey at the facility in hopes that something or someone will finally do something to help these residents. Family Member #12 stated that everything had gone fine until the facility had hired CNA D (nights). Family Member #12 stated that she finally became concerned when CNA D had acted in a manner in front of another family member like he didn't like Resident #2 (talking rude to him). Family Member #12 stated that CNA D had a demeanor that he did not have a very caring personality and acted like he didn't want to be there most times. Family Member #12 stated that she had witnessed one of the times that CNA D had been rough with Resident #2 when she walked in when he was providing care and she told CNA D, Hey be easy with him. Family Member #12 stated that it seemed to upset CNA D when she told him because he got an upset look on his face. Family Member #12 stated that as time passed by it got to a point when Resident #2 didn't want family to leave him there alone when CNA D was working. Family Member #12 stated that she finally reported her concerns to the DON and Administrator at the time on October 2022 and she was told that the facility was investigating the situation but nothing ever changed. Family Member #12 stated that she asked weeks later and was still told that it was being investigated and still nothing changed. Family Member #12 stated that she got so frustrated because the facility is supposed to protect the resident's and did nothing to protect. Family Member #12 stated that about the second week of November 2022 she was approached by the DON and stated that the DON told her that there was an incident that the CNA D had Resident #2 up in the Hoyer and CNA D told Resident #2 that if he didn't stop, bitching, and pushing the call light that he (CNA D) would leave him up there. Family Member #12 stated that she was told by DON at the time that CNA D had left Resident #2 in midair in his brief that was soiled and wet for a good period of time. Family member #12 stated that she was told that the situation is being investigated, and again nothing happened. Family Member #12 stated that she went to the DON after days of hearing nothing and asked what was going to be done and DON stated that other residents had to be questioned. Family Member #12 stated that she asked at this time for CNA D not to be allowed to go into the room or care for Resident #2. Family Member #12 stated that she was told by the administrator that the facility could not do that and that is when she knew that there was going to be a problem with this place. Family Member #12 stated that it got to a point that family members would try to go as much as possible in hopes that the situation would stop. Family Member #12 stated that most times she was there that Resident #2 would show anxiety anytime CNA D would work. Family Member #12 stated that another incident happened in December 2022 with CNA D and Resident #2. Family Member #12 stated she was there at the facility with Resident #2, and she pushed the call light because Resident #2 was soaking wet and had, poop in his brief. Family Member #12 stated that Resident #2 started getting really anxious and scared. Family Member #12 stated that CNA D came in the room and told Family Member #12 that she had to leave the room for the privacy of Resident #2. Family Member #12 told CNA D that she would not leave the room. Family Member #12 stated that CNA D then told her that he would not change Resident #2 then. Family Member #12 stated that she told CNA D that she was going to report him to the administrator. Family Member #12 stated when she threatened to report CNA D, he then changed Resident #2, but CNA D was very rough and when he pushed Resident #2 to the side CNA D pushed him so hard that Resident #2 hit his head on the side pull bars. Family Member #12 stated that Resident #2 would cry sometimes and say that he was scared to go to sleep because of CNA D. Family member #12 stated that she did report this to the administrator and again, nothing, just investigating. Family Member #12 stated that she finally got to the point with the administrator that she said, What is it going to take, CNA D seriously hurting someone or killing them? Family Member #12 stated that she was scared daily, and this stressed her out because she was constantly worried about Resident #2. Family member #12 stated that things got worse with CNA D and Resident #2 began telling her that CNA D would twist his arm really hard and yell at him. Family Member #12 stated that she had went to the facility on [DATE]th, 2023, and already had Resident #2 up and in the wheelchair. Family Member #12 stated that Resident #2 was crying and very scared with his fists clenched. Family Member #12 stated, What's wrong, what happened, to Resident #2. Family Member #12 stated that Resident #2 had told her that CNA D was pulling and hitting him in his bad arm and leg. Family Member #12 stated that she had never been so scared before for Resident #2 because it was getting worse. Family Member #12 stated that she would have to go out of town that day due to her daughter having cancer. Family Member #12 stated that she told the current Administrator and was told by the Administrator that she would have to report this to Human Services, and she would question CNA D to see what happened. Family member #12 stated that when she came back from out of town that the Administrator told her that CNA D was on a 30-probation and was suspended. Family Member #12 stated that she told the Administrator not put CNA D to care for Resident #2 and she was told that this could not happen due to lack of staff that the facility had. Resident #3: Record Review of Resident #3's face sheet documented she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 was admitted with diagnoses which included: stroke, anorexia, muscle wasting and atrophy (decrease in size of a body part), dementia, lack of coordination, atherosclerotic heart disease (buildup of fats, cholesterol, and other substances on the artery walls), unsteadiness on feet, schizoaffective disorder, depression, anxiety, seizures, insomnia, high blood pressure, abnormalities of gait and mobility. Record review of Resident #3 admission MDS dated [DATE] documented that Resident #2's BIMS was listed as 12 meaning cognitively moderately impaired. Under B0200-Hearing: Resident #3 was listed as 0 meaning: Adequate- no difficulty in normal conversation, social interaction, listening to tv. Under B0600-Speech Clarity: Resident #3 was listed as 0 meaning: distinct intelligible words. Under B0700-Makes Self Understood: Resident #3 was listed as 1 meaning: Usually Understood-difficulty communicating some words or finishing thoughts but is able if prompted or given time. Under B0800-Understands Verbal Content however able: Resident #3 is listed as a 1 meaning: Usually understands-misses some part/intent of message but comprehends most conversation. Under C1310-Delirium- Resident #3 was listed as a 0 meaning there is no delirium. Under G0110-Functional Status: Bed mobility-Resident #3 was listed as extensive assistance with 2 person assist, Transfer-Resident #3 is listed as total dependence with 2 person assist, walk in room- Resident #3 was listed as activity did not occur, Walk in corridor- Resident #3 was listed as activity occurred only once or twice with 1 person assist, Locomotion on Unit- Resident #3 was listed as extensive assistance with one person assist, Locomotion off Unit- Resident #3 was listed as extensive assistance with one person assist, Dressing- Resident #3 is listed as extensive assistance with 2 person assist, Eating- Resident #3 was listed as supervision with one person assist, Toilet use- Resident #3 was listed as total dependent with 2 person assist, Personal hygiene- Resident #3 is listed as extensive assistance with one person assist. Under G0120-Bathing: Resident #3 was listed as total dependent. Record review of Resident #3s Care Plan dated on 12/11/2018 revealed: Resident #3 had an ADL self-care deficit due with dementia with interventions of: Bed mobility-extensive assistance with 2-person physical assist, Transfer-self-performance extensive assistance with 2 persons physical assist, walk in room-self-performance activity did not occur, Walk in corridor-self-performance activity did not occur, locomotion on unit- self-performance extensive assistance with one person physical assistance, locomotion off unit: self-performance extensive assistance with one person physical assist, dressing- self-performance extensive assistance with 2 person physical assist, eating: self-performance supervision with support provided setup help only, toilet use: self-performance total dependence with 2 person physical assist, personal hygiene: self-performance extensive assistance with 2 persons physical assistance, Refer to Physical therapy/occupational therapy/ speech therapy or restorative in ADL self-performance, Nurse aides to document her most dependent self-performance per shift. Monitor for signs and symptoms ADL decline and notify family, and MD, identifying causes and solutions. Monitor/ document/ report to MD as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Allow her sufficient [NAME] [TRUNCATED]

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent resident to resident altercations for 2 of 2 residents reviewed for supervision. (Resident #1 and #2) The facility did not develop and implement consistent or effective supervision to prevent Resident #1, a resident who had a history of being physically aggressive from continuing to physically attack and target other residents in the facility. The facility did not develop and implement consistent or effective supervision to prevent Resident #2, a resident who had a history of being physically aggressive from continuing to physically attack and target other residents in the facility. This failure could placed all residents at risk of being harmed, injured or possible death. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 09/30/22. While the IJ was removed on 10/03/22, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The findings include: Record review of Resident #1's face sheet dated 09/30/22 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including the following: [CONDITION(S)] (disturbance in brain function), [CONDITION(S)] and [CONDITION(S)] following cerebral infarction ([CONDITION(S)] following stroke), muscle weakness, malnutrition, difficulty walking, Alzheimer's, [CONDITION(S)] with delusions (severe mental illness including distorted beliefs), and anxiety disorder. Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 99, indicating the resident could not complete the assessment. Record Review of Resident #1's progress note dated 9/18/22 at 1:00 PM, entered by DON revealed; 1:1 for resident #1; administrator confirmed 1:1 at 3:33 pm Record review of Resident #2's face sheet dated 09/30/22 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including the following: unspecified dementia with behavioral disturbance (breakdown of thought process causing disruptive behavior), intermittent explosive disorder (repeated sudden outbursts of anger), epileptic seizures related to external causes (sudden uncontrolled electrical disturbance in the brain), unspecified lack of coordination, history of falling, [CONDITION(S)] disorder [CONDITION(S)] type (mental health disorder with symptoms of distorted reality and mood fluctuation), anxiety disorder, [CONDITION(S)] (disturbance in brain function), muscle weakness, abnormalities of gait and mobility, unspecified convulsions, and history of traumatic brain injury (injury that changes how the brain works). Record review of Resident #2' MDS dated [DATE] revealed a BIMS score of 05, indicating severe cognitive impairment. The facility has failed to provide adequate supervision and maintain an environment free from accident hazards when the risk of resident-to-resident altercations had been identified. Resident #1 Record review of facility incident reports reflected Resident #1 initiated 10 residentresidents to resident altercations between 09/12/22 and 09/24/22: 9/12/22 - at 9:48 pm Resident 1 attacked Resident 4. Resident 1 wandered into Resident 4's room, Resident 1 grabbed hit t-shirt sleeve and tried to hit Resident 4, but Resident 4 took down Resident 1 by sweeping his legs out from under him with his good arm (Resident 4 has [CONDITION(S)]). Resident 4 had torn shirt. Resident 1 had a skin tear to left distal forearm, scratch on top of left forearm, busted blood vessel to right eye, blood coming from left nostril and multiple small scratches to right side of face. Neither Resident 1's nor Resident 4's family were notified per incident report and progress notes. 9/16/22 - at 9:08 pm, Resident 1 swung at Resident 2 and hit him on his shoulder in the hallway, then Resident 1 wandered into Resident 10's room. Resident 10 was heard yelling for help and stated, he just came in here and hit me!. Family members of Residents 1, 2 and 10 were not notified according to documentation in the incident reports and progress notes for each resident. 9/17/22 - at 4:00 pm, Resident 1 was in the hall with an aide at his side and he struck out and hit Resident 2, he was then escorted to his room and was in an altercation with his roommate, Resident 1 then walked up to Resident 3 in the hallway and grabbed her face and started shaking her head back and forth. No injuries were documented for any residents in these incidents. No family members were notified based on progress notes and incident reports. 9/18/22 - at 11:00 am, Resident 1 attacked Resident 11; Resident 1 grabbed Resident 11 by her arm and was pulling her, she yelled for help. Resident 11 was noted to have 3 small bruises on her right inner arm. Her husband was notified, no documentation of Resident 1's family being notified. 9/18/22 - at 12:50 pm Resident 1 told Resident 3 shut the [OBSCENITY] up [OBSCENITY] , Resident #3 began yelling for help, Resident 1 got in her face and continued yelling, Resident 3 threw water in his face, and Resident 1 turned around and pushed Resident 3 causing her to fall on the scale in the dining room, and he tried to attack her again, staff intervened and he attacked staff, chasing them down the hall. Resident 3 stated she was scared; her husband was notified. No documentation of Resident 1's family being notified was found. 9/18/22- at 7:20 pm Resident 10 was yelling for help; Resident 1 was in Resident 10's room with Resident 10 in a headlock with her arm extended back while Resident 1 said I am going to kill this [OBSCENITY] . Resident 10 stated, He just came into my room and hit me, he hurt my shoulder. Her family was notified, but there was no documentation of Resident 1's family being notified of the incident in either the report or the progress notes. 9/19/22 - at 10:44 pm, Resident 1 was in Resident 8's room swinging on Resident 8. Resident 8 was kicking and swinging to protect himself from Resident 1. No injuries were documented in the incident report, but no incident report was found for Resident 8 and no progress note was found in Resident 8's chart. No documentation of either family being notified of the incident. 9/20/22 - at 4:50 am, Resident 1 was found in Resident 8's room swinging at him. Resident 8 was swinging and trying to defend himself. Resident 8 was noted to have a skin tear to his left hand; no injuries were noted on Resident 1. No incident report for Resident 8 or progress note for Resident 8 was found related to this incident, no documentation of notification of family was found for either resident. 9/20/22 - at 8:00 am, Resident 1 and Resident 2 had an altercation, and after they were separated, Resident 1 attacked Resident 5, hitting him in head. No injuries were noted, family of Resident 2 and Resident 5 were notified; no documentation of Resident 1's family being notified. Resident 2 required [MEDICATION(S)] after this incident. 9/24/22 - at 3:00 pm, Resident 1 was wandering in the hall and attacked Resident 2 (who was sitting in his wheelchair); then attacked Resident 4 by hitting him in the back. No injuries were noted, and no family members were notified per review of incident reports and progress notes. Resident #2 Record review of incident reports reflected Resident #2 has initiated 6 residents to resident altercations between 9/17/22 and 9/25/22: 9/17/22 - at 10:53 am, Resident 2 tipped over Resident 8's wheelchair causing a skin tear to his left hand. No injuries were noted on Resident 2. 9/17/22 - at 6:00 pm, Resident 2, having just been hit by Resident 1, hit Resident 6 as he walked past, which knocked Resident 6 to the ground. No injuries were noted, and no family members were notified according to progress notes and incident reports. 9/20/22 - at 5:07 pm, Resident 1 walked in the dining room and Resident 2 said, back up [OBSCENITY] and both residents hit each other. Resident 1 had scratches on his face, a skin tear to his right arm, and his left wrist was scratched. Resident 1's family was notified, but no documentation of Resident 2's family being notified was found in progress notes or incident reports. 9/23/22 - at 1:35 p.m., Resident 2 attacked Resident 1 causing scratches to Resident 1's face, a deep skin tear to his right forearm from nails, and a shallow bit on Resident 1's right top ear, causing bleeding. Staff intervened. Resident 2 was moved to different area, and Resident 1 was given a sedative. 9/24/22 - at 4:30 pm, Resident 2 attacked Resident 7 hitting him, then biting him on the right upper back and refusing to release his mouth from Resident 7's back. Resident 2 has a diagnosis of [CONDITION(S)], which is transmissible via bodily fluids. No documentation of either family being notified of this incident and no incident report with Resident 7's information. 9/25/22 - at 8:41 pm, Resident 2 pulled Resident 6 to the ground and hit him. Resident 11 walked into the area and Resident 2 slapped her 4 times in the face. No injuries were noted for any of the 3 residents involved. During an interview on 9/21/22 at 10:05 a.m. with the facility Administrator (ADM) and Director of Nurses(DON); ADM stated that Resident #1 has had several physical aggression incidents in the last 9 days since admission on 9/12/22 with several residents and several staff. ADM Stated that Resident #1 came from another facility, but the transfer paper did not document this type of behaviors. ADM stated that when he is awake, they have him on a 1:1 level of supervision and when he is asleep, he is on every 15-minute checks. DON stated that Resident #1 has been moved to a room , next to her and the ADON office so he can be monitored closely. DON stated that Resident #1 is NPO Nothing by mouth and when he sees people with food he will go and grab it from them. DON state d that Resident #1 hit resident #5 on 9/20/22. Stated that Resident #1 has attacked the following residents: Resident #10, Resident #3 by knocking her down and she wears a helmet to protect her head from seizures; Resident #2, Resident #4, Resident #5 who punched Resident #1 in the face but left no marks; and Resident #11 by scratching her arm. DON stated that Resident #1 has been physically aggressive with several staff including, DON, ADM, Housekeeping, Aide, Assistant Director of Nursing (ADON). DON stated that he put the housekeeping staff into a choke hold. DON stated that Investigator (INV) should not enter Resident #1's room alone or approach him without a staff member with the INV. DON stated that INV should be aware of surroundings if Resident #1 is out of his room. Facility became aware of Resident #1's physically aggressive behavior on 9/12/22 and from 9/12/22 to 9/24/22 Resident #1 has initiated 9 separate physically aggressive incidents with other residents including resident #2. -Resident #1 has initiated 10 residents to resident altercations. 9/12/22 In a record review of incident reports 799 and 800 dated 9/12/22 at 9:48 pm Resident 1 attacked Resident 4. Resident 1 wandered into Resident 4's room, Resident 1 grabbed hit t-shirt sleeve and tried to hit Resident 4, but Resident 4 took down Resident 1 by sweeping his legs out from under him with his good arm (Resident 4 has [CONDITION(S)]). Resident 4 had torn shirt. Resident 1 had a skin tear to left distal forearm, scratch on top of left forearm, busted blood vessel to right eye, blood coming from left nostril and multiple small scratches to right side of face. Neither Resident 1's nor Resident 4's family were notified per incident report and progress notes. 9/16/22 In a record review of incident reports 802, 803, and 804 dated 9/16/22 at 9:08 pm, Resident 1 swung at Resident 2 and hit him on his shoulder in the hallway, then Resident 1 wandered into Resident 10's room. Resident 10 was heard yelling for help and stated, he just came in here and hit me!. Family members of Residents 1, 2 and 10 were not notified according to documentation in the incident reports and progress notes for each resident. 9/17/22 In a record review of incident reports 808, 809, and 810, dated 9/17/22 at 4:00 pm, Resident 1 was in the hall with an aide at his side and he struck out and hit Resident 2, he was then escorted to his room and was in an altercation with his roommate, Resident 1 then walked up to Resident 3 in the hallway and grabbed her face and started shaking her head back and forth. No injuries were documented for any residents in these incidents. No family members were notified based on progress notes and incident reports. 9/18/22 In a record review of incident 814 dated 9/18/22 at 11:00 am, Resident 1 attacked Resident 11; Resident 1 grabbed Resident 11 by her arm and was pulling her, she yelled for help. Resident 11 was noted to have 3 small bruises on her right inner arm. Her husband was notified, no documentation of Resident 1's family being notified. 9/18/22 In a record review of incident 813 and 816 dated 9/18/22 at 12:50 pm Resident 1 told Resident 3 shut the [OBSCENITY] up [OBSCENITY] , she was yelling for help, Resident 1 got in her face and continued yelling, Resident 3 threw water in his face, and Resident 1 turned around and pushed Resident 3 causing her to fall on the scale in the dining room, and he tried to attack her again, staff intervened and he attacked staff, chasing them down the hall. Resident 3 stated she was scared; her husband was notified. No documentation of Resident 1's family being notified was found. 09/18/22 In a record review of incident 815 dated 9/18/22 7:20 pm Resident 10 was yelling for help; Resident 1 was in Resident 10's room with Resident 10 in a headlock with her arm extended back while Resident 1 said I am going to kill this [OBSCENITY] . Resident 10 stated, He just came into my room and hit me, he hurt my shoulder. Her family was notified, but there was no documentation of Resident 1's family being notified of the incident in either the report or the progress notes. 9/19/22 In a record review of incident 818 dated 9/19/22 at 10:44 pm, Resident 1 was in Resident 8's room swinging on Resident 8. Resident 8 was kicking and swinging to protect himself from Resident 1. No injuries were documented in the incident report, but no incident report was found for Resident 8 and no progress note was found in Resident 8's chart. No documentation of either family being notified of the incident. 9/20/22 In a record review of incident 819 dated 9/20/22 at 4:50 am, Resident 1 was again found in Resident 8's room swinging at him. Resident 8 was swinging and trying to defend himself. Resident 8 was noted to have a skin tear to his left hand; no injuries were noted on Resident 1. No incident report for Resident 8 or progress note for Resident 8 was found related to this incident, no documentation of notification of family was found for either resident. 9/20/22 In a record review of incidents 820, 821, and 822 dated 9/20/22 at 8:00 am, Resident 1 and Resident 2 had an altercation, and after they were separated, Resident 1 attacked Resident 5, hitting him in head. No injuries were noted, family of Resident 2 and Resident 5 were notified; no documentation of Resident 1's family being notified. Resident 2 required [MEDICATION(S)] after this incident. 9/24/22 In a record review of incidents 832, 834, and 835 dated 9/24/22 at 3:00 pm, Resident 1 was wandering in the hall and attacked Resident 2 (who was sitting in his wheelchair); then attacked Resident 4 by hitting him in the back. No injuries were noted, and no family members were notified per review of incident reports and progress notes. Resident #2 -Resident #2 has initiated 6 residents to resident altercations. 9/17/22 In a record review of incident reports 805 and 807 dated 9/17/22 at 10:53 am, Resident 2 tipped over Resident 8's wheelchair causing a skin tear to his left hand. No injuries were noted on Resident 2. 9/17/22 In a record review of incident reports 811 and 812 dated 9/17/22 at 6:00 pm, Resident 2, having just been hit by Resident 1, hit Resident 6 as he walked past, which knocked Resident 6 to the ground. No injuries were noted, and no family members were notified according to progress notes and incident reports. 9/20/22 In a record review of incident reports 823 and 824 dated 9/20/22 at 5:07 pm, Resident 1 walked in the dining room and Resident 2 said, back up [OBSCENITY] and both residents hit each other. Resident 1 had scratches on his face, a skin tear to his right arm, and his left wrist was scratched. Resident 1's family was notified, but no documentation of Resident 2's family being notified was found in progress notes or incident reports. 9/23/22 In a record review of incident reports 826 and 827, Resident 2 attacked Resident 1 causing scratches to Resident 1's face, a deep skin tear to his right forearm from nails, and a shallow bit on Resident 1's right top ear, causing bleeding. Staff intervened. Resident 2 was moved to different area, and Resident 1 was given a sedative. 9/24/22 In a record review of incident report 833 dated 9/24/22 at 4:30 pm, Resident 2 attacked Resident 7 hitting him, then biting him on the right upper back and refusing to release his mouth from Resident 7's back. Resident 2 has a diagnosis of [CONDITION(S)], which is transmissible via bodily fluids. No documentation of either family being notified of this incident and no incident report with Resident 7's information. 9/25/22 In a record review of incident reports 828, 829, and 830 dated 9/25/22 starting at 8:41 pm, Resident 2 pulled Resident 6 to the ground and hit him. Resident 11 walked into the area and Resident 2 slapped her 4 times in the face. No injuries were noted for any of the 3 residents involved. Record review of Resident #1's face sheet dated 09/30/22 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including the following: [CONDITION(S)] (disturbance in brain function), [CONDITION(S)] and [CONDITION(S)] following cerebral infarction ([CONDITION(S)] following stroke), muscle weakness, malnutrition, difficulty walking, Alzheimer's, [CONDITION(S)] with delusions (severe mental illness including distorted beliefs), and anxiety disorder. Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 99, indicating the resident could not complete the assessment. Record Review of Resident #1's progress note dated 9/18/22 at 1:00 PM, entered by DON revealed; 1:1 for resident #1; administrator confirmed 1:1 at 3:33 pm Record review of Resident #2's face sheet dated 09/30/22 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including the following: unspecified dementia with behavioral disturbance (breakdown of thought process causing disruptive behavior), intermittent explosive disorder (repeated sudden outbursts of anger), epileptic seizures related to external causes (sudden uncontrolled electrical disturbance in the brain), unspecified lack of coordination, history of falling, [CONDITION(S)] disorder [CONDITION(S)] type (mental health disorder with symptoms of distorted reality and mood fluctuation), anxiety disorder, [CONDITION(S)] (disturbance in brain function), muscle weakness, abnormalities of gait and mobility, unspecified convulsions, and history of traumatic brain injury (injury that changes how the brain works). Record review of Resident #2' MDS dated [DATE] revealed a BIMS score of 05, indicating severe cognitive impairment. Record review of Resident #3's face sheet dated 09/30/22 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including the following: Alzheimer's disease, paranoid [CONDITION(S)] (serious mental health disease causing misinterpretation of reality), malnutrition, seizures (uncontrolled electrical disturbance in the brain), muscle weakness, difficulty in walking, conversion disorder with seizures or convulsions (condition where a mental health issue disrupts how the brain works), generalized anxiety disorder, [CONDITION(S)] disorder [CONDITION(S)] type (mental health disorder with symptoms of distorted reality and mood fluctuation), major depressive disorder (mental illness causing sadness due to lack of chemicals in the brain that cause happiness), and lack of coordination. Record review of Resident #3s MDS dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment. Record review of Resident #4's face sheet dated 09/30/22 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including the following: [CONDITION(S)] and [CONDITION(S)] following cerebral infarction ([CONDITION(S)] following stroke), intermittent explosive disorder (repeated sudden outbursts of anger), muscle weakness, lack of coordination, muscle wasting and atrophy (breakdown of muscles), [CONDITION(S)] disorder (mental health disorder with symptoms of distorted reality), major depressive disorder (mental illness causing sadness due to lack of chemicals in the brain that cause happiness), anxiety disorder, and [CONDITION(S)] (disorder that causes abnormal brain function like seizures). Record review of Resident #4's MDS dated [DATE] revealed a BIMS score of 13, indicating intact cognitive function. Record review of Resident #5's face sheet dated 09/30/22 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including the following: history of traumatic brain injury (injury that changes how the brain works), muscle wasting and atrophy (breakdown of muscles), other recurrent depressive disorders (mental health illness causing prolonged sadness), and difficulty in walking. Record review of Resident #5's MDS dated [DATE] revealed a BIMS score of 15, indicating intact cognitive function. Record Review of Resident #6's face sheet dated 09/30/22 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including the following: Unspecified dementia with behavioral disturbance (breakdown of thought process causing disruptive behavior), adjustment disorder with mixed anxiety and depressed mood (mental health issues caused by a sudden change), other seizures, restlessness and agitation, and metabolic [CONDITION(S)] (problems in the brain from chemicals in the blood), and [CONDITION(S)]. Record Review of Resident #6's MDS dated [DATE] revealed a BIMS score of 00, indicating severe cognitive impairment. Record review of Resident #7's face sheet dated 09/30/22 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including the following: altered mental status (change in brain function), unspecified lack of coordination, cognitive communication deficit (impaired thought processes), difficulty in walking, [CONDITION(S)] ([CONDITION(S)] inflammation of the joints), paranoid [CONDITION(S)] (serious mental health disease causing misinterpretation of reality), Alzheimer's disease, [CONDITION(S)] disorder (mental health disease causing severe mood swings), major depressive disorder (mental illness caused by lack of chemicals in the brain that cause happiness), and anxiety disorder. Record review of Resident #7's MDS dated [DATE] revealed a BIMS score of 10, indicating moderate cognitive impairment. Record review of Resident #8's face sheet dated 09/30/22 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including the following: Alzheimer's disease, paranoid [CONDITION(S)] (serious mental health disease causing misinterpretation of reality), intermittent explosive disorder (repeated sudden outbursts of anger), history of transient ischemic attack (stroke), neuroleptic induced parkinsonism (irregular movements caused by use of antipsychotics), muscle weakness, difficulty in walking, and unsteadiness on feet. Record review of Resident #8's MDS dated [DATE] revealed a BIMS score of 00, indicating severe cognitive impairment. Record review of Resident #10's's face sheet dated 09/30/22 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including the following: cerebral infarction (stroke), malnutrition, anorexia (not eating), lack of coordination, muscle weakness, unsteadiness on feet, [CONDITION(S)] disorder (mental health disorder with symptoms of distorted reality), major depressive disorder (mental illness causing sadness due to lack of chemicals in the brain that cause happiness), anxiety disorder, seizures (uncontrolled electrical disturbance in the brain), and abnormalities of gait and mobility. Record review of Resident #10's MDS dated [DATE] revealed a BIMS score of 7, indicating severe cognitive impairment. Record review of Resident #11's face sheet dated 09/30/22 revealed an [AGE] year-old female admitted on [DATE] with diagnoses including the following: unspecified dementia, [CONDITION(S)] with hallucinations (severe mental illness including seeing things that are not there), [CONDITION(S)], impulse disorder (lack of ability to control self), major depressive disorder (mental illness caused by lack of chemicals that cause happiness in the brain), and anxiety disorder. Record review of Resident #11's MDS dated [DATE] revealed a BIMS score of 00, indicating severe cognitive impairment. During an interview on 9/21/22 at 10:05 a.m. with the facility Administrator (ADM) and Director of Nurses(DON); ADM stated that Resident #1 has had several physical aggression incidents in the last 9 days since admission on 9/12/22 with several residents and several staff. Stated that it is a dangerous situation, and the facility is trying to find another facility for him but due to Resident #1 having a peg tube for feeding they are not having any success in transferring him. Stated that Resident #1 came from another facility, but the transfer paper did not document this type of behaviors. Stated that when he is awake, they have him on a 1:1 level of supervision and when he is asleep, he is on every 15-minute checks. Stated resident has BIMS of 0 and history of dementia. During the same interview, DON stated that Resident #1 has been moved to a room 11, next to her and the ADON office so he can be monitored closely. Stated that when he is awake, they have him on a 1:1 level of supervision and when he is asleep, he is on every 15-minute checks. DON confirmed resident #1 has a BIMS of 0 and history of dementia. DON stated that Resident #1 is NPO Nothing by mouth and when he sees people with food he will go and grab it from them. Stated that his Resident #1's wife signed the senior psych referral. Stated that Resident #1 hit resident #5 on 9/20/22. Stated that Resident #1 has attacked the following residents: Resident #10, Resident #3 by knocking her down and she wears a helmet to protect her head from seizures; Resident #2, Resident #4, Resident #5 who punched Resident #1 in the face but left no marks; and Resident #11 by scratching her arm. Stated that Resident #1 has been physically aggressive with several staff including, DON, ADM, Housekeeping, Aide, Assistant Director of Nursing (ADON). Stated that he put the housekeeping staff into a choke hold. Stated that their priority is to find placement by end of business today but so far, no luck and have contacted several facilities in the area. DON stated that Investigator (INV) should not enter Resident #1's room alone or approach him without a staff member with the INV. DON stated that INV should be aware of surroundings if Resident #1 is out of his room. During an interview and observation on 9/21/22 at 10:35 a.m. with Resident #4, stated he punched another male resident [Resident #1] in the face when the resident came up and grabbed him in his room. Stated he gave him a black eye and he will fight back if needed. During an interview and observation on 9/21/22 at 10:38 a.m. with Resident #11, stated that the man grabbed her wrists and scratched her and pointed to bruising on her right wrist. DON stated the bruises were a result from Resident #1 grabbing Resident #11. During an interview on 9/21/22 at 10:44 a.m. with the Director of Nurses (DON), stated that this is a dangerous situation because Resident #1 becomes aggressive with no warning. Stated I cannot ensure safety of the residents or staff due to the aggressive behavior of Resident #1. Stated that they are using the maintenance director in assisting with Resident #1 and having the maintenance director use bear hug physical restraints on Resident #1. Stated a bear hug restraint is coming from behind the resident and holding him from behind with his arms held in front of the resident to prevent him from hitting others. Stated that they are also using [MEDICATION(S)] every 12 hours as needed (PRN) to calm Resident #1 down but the medication wears out about 8 hours after given. Stated that the facility is continuing to find another facility to take Resident #1 but is not having any luck. Observation on 9/21/22 at 11:55 a.m. of Resident #1 laying in bed awake and had no 1:1 supervision. DON notified and 1:1 was assigned. During an observation and interview on 9/21/22 at 1:15 p.m. with Nurses Assistant A(NA), sitting in chair in Resident #1's room. Resident #1 was observed sleeping in his bed. NA A stated she has only worked here for 3 days and started at 6 a.m. today. Stated that she is Resident #1's 1:1 level of supervision right now and that she is aware of his physical aggression behaviors but is not afraid to work with him. During an interview on 9/21/22 at 1:50 p.m. with CNA A, stated she did not observe the incident with Resident #1 and Resident #3. Stated she was here for the incident with Resident #1 and Resident #11, and it was unprovoked, and Resident #1 started hitting and punching. CNA Sstated that she and LVN C intervened by trying to redirect Resident #1 and removing the residents he was targeting. CNA A Sstated that Resident #1 chases staff, and they try to redirect with snacks. Stated that Resident #1 is okay as long as he is in his bed but once he gets out of bed, they have issues. Stated that they check him every 2 hours if he is awake or not. Stated that if he is asleep, he is left alone in his room and checked on. CNA stated if he is awake, he is 1:1 level of supervision. During an interview on 9/21/22 at 2:13 p.m. with LVN C, stated that Resident #1 is being aggressive and attacking other residents or staff, they intervene by taking the other resident out of the situation. Stated that it's hard to redirect Resident #1 because it seems like he is focused on the behavior, so if he is moved away from a resident and sees someone in front of him, he will attack them. Stated she feels bad for Resident #1 because he is not aware of what he is doing. Stated there was an in-service on how to redirect him the other day. Stated that Resident #3 is scared of Resident #1 and stated the incident between them started when Resident #1 was reaching for something from the table where Resident #3 was. Stated Resident #3 started screaming and Resident #1 said, shut up [OBSCENITY] and pushed her. Stated she assessed Resident #3 and she had no injuries and was wearing her helmet at the time. LVN C stated Resident #1 swung at her as she was trying to call him away from Resident #3. Stated Resident #1 started chasing her and another CNA down the hall and she told the CNA to lock herself in a room until he forgot. Stated if Resident #1 is angered, it can take a few minutes before he calms down. Stated Resident #1 put Resident #10 in a headlock, and we had to get x-rays on her right arm, but she had no injuries. Stated families are being notified when these incidents happened. Stated she has personally done the notifications to family members via phone. Stated she is documenting the notifications in the progress notes in Point Click Care on the computer. During an observation on 9/21/22 at 2:15 p.m., Nurses assistant (NA) observed sitting in chair in Resident #1's room. NA had face resting on hand and asleep while Resident #1 was awake in bed. Nurse assistant did not acknowledge INV was in room and continued to sleep. DON notified. Interview and obse [TRUNCATED]

Based on interview and record review, the facility failed to provide a safe environment free from abuse for 10 of 10 residents (Resident #1, #2, #3, 4, #5, #6, #7, #8, #9, #10) reviewed for abuse. The facility failed to implement and provide immediate interventions to assure the safety of residents to protect from resident-to-resident abuse from Resident #1, a resident who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to implement and provide immediate interventions to assure the safety of residents to protect from resident-to-resident abuse from Resident #2, a resident who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures placed residents at risk of abuse, mental anguish, injury, fear, and hopelessness. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 09/30/22. While the IJ was removed on 10/03/22, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective syst The findings include: Record review of Resident #1's face sheet dated 09/30/22 revealed a [AGE] year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's MDS dated [DATE] revealed a BIMS score of 99, indicating the resident could not complete the assessment. Record Review of Resident #1's progress note dated 9/18/22 at 1:00 PM, entered by DON revealed; 1:1 for resident #1; administrator confirmed 1:1 at 3:33 pm Record review of Resident #2's face sheet dated 09/30/22 revealed a [AGE] year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2' MDS dated [DATE] revealed a BIMS score of 05, indicating severe cognitive impairment. Record review of Resident #3's face sheet dated 09/30/22 revealed a [AGE] year-old female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3s MDS dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment. Record review of Resident #4's face sheet dated 09/30/22 revealed a [AGE] year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's MDS dated [DATE] revealed a BIMS score of 13, indicating intact cognitive function. Record review of Resident #5's face sheet dated 09/30/22 revealed a [AGE] year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's MDS dated [DATE] revealed a BIMS score of 15, indicating intact cognitive function. Record Review of Resident #6's face sheet dated 09/30/22 revealed a [AGE] year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #6's MDS dated [DATE] revealed a BIMS score of 00, indicating severe cognitive impairment. Record review of Resident #7's face sheet dated 09/30/22 revealed a [AGE] year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #7's MDS dated [DATE] revealed a BIMS score of 10, indicating moderate cognitive impairment. Record review of Resident #8's face sheet dated 09/30/22 revealed a [AGE] year-old male admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #8's MDS dated [DATE] revealed a BIMS score of 00, indicating severe cognitive impairment. Record review of Resident #10's's face sheet dated 09/30/22 revealed a [AGE] year-old female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #10's MDS dated [DATE] revealed a BIMS score of 7, indicating severe cognitive impairment. Record review of Resident #11's face sheet dated 09/30/22 revealed an [AGE] year-old female admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #11's MDS dated [DATE] revealed a BIMS score of 00, indicating severe cognitive impairment. Resident #1 Record review of facility incident reports reflected Resident #1 initiated 10 residents to resident altercations between 09/12/22 and 09/24/22: 9/12/22 - at 9:48 pm Resident 1 attacked Resident 4. Resident 1 wandered into Resident 4's room, Resident 1 grabbed hit t-shirt sleeve and tried to hit Resident 4, but Resident 4 took down Resident 1 by sweeping his legs out from under him with his good arm (Resident 4 has [CONDITION(S)]). Resident 4 had torn shirt. Resident 1 had a skin tear to left distal forearm, scratch on top of left forearm, busted blood vessel to right eye, blood coming from left nostril and multiple small scratches to right side of face. Neither Resident 1's nor Resident 4's family were notified per incident report and progress notes. 9/16/22 - at 9:08 pm, Resident 1 swung at Resident 2 and hit him on his shoulder in the hallway, then Resident 1 wandered into Resident 10's room. Resident 10 was heard yelling for help and stated, he just came in here and hit me!. Family members of Residents 1, 2 and 10 were not notified according to documentation in the incident reports and progress notes for each resident. 9/17/22 - at 4:00 pm, Resident 1 was in the hall with an aide at his side and he struck out and hit Resident 2, he was then escorted to his room and was in an altercation with his roommate, Resident 1 then walked up to Resident 3 in the hallway and grabbed her face and started shaking her head back and forth. No injuries were documented for any residents in these incidents. No family members were notified based on progress notes and incident reports. 9/18/22 - at 11:00 am, Resident 1 attacked Resident 11; Resident 1 grabbed Resident 11 by her arm and was pulling her, she yelled for help. Resident 11 was noted to have 3 small bruises on her right inner arm. Her husband was notified, no documentation of Resident 1's family being notified. 9/18/22 - at 12:50 pm Resident 1 told Resident 3 shut the [OBSCENITY] up [OBSCENITY] , Resident #3 began yelling for help, Resident 1 got in her face and continued yelling, Resident 3 threw water in his face, and Resident 1 turned around and pushed Resident 3 causing her to fall on the scale in the dining room, and he tried to attack her again, staff intervened and he attacked staff, chasing them down the hall. Resident 3 stated she was scared; her husband was notified. No documentation of Resident 1's family being notified was found. 9/18/22- at 7:20 pm Resident 10 was yelling for help; Resident 1 was in Resident 10's room with Resident 10 in a headlock with her arm extended back while Resident 1 said I am going to kill this [OBSCENITY] . Resident 10 stated, He just came into my room and hit me, he hurt my shoulder. Her family was notified, but there was no documentation of Resident 1's family being notified of the incident in either the report or the progress notes. 9/19/22 - at 10:44 pm, Resident 1 was in Resident 8's room swinging on Resident 8. Resident 8 was kicking and swinging to protect himself from Resident 1. No injuries were documented in the incident report, but no incident report was found for Resident 8 and no progress note was found in Resident 8's chart. No documentation of either family being notified of the incident. 9/20/22 - at 4:50 am, Resident 1 was found in Resident 8's room swinging at him. Resident 8 was swinging and trying to defend himself. Resident 8 was noted to have a skin tear to his left hand; no injuries were noted on Resident 1. No incident report for Resident 8 or progress note for Resident 8 was found related to this incident, no documentation of notification of family was found for either resident. 9/20/22 - at 8:00 am, Resident 1 and Resident 2 had an altercation, and after they were separated, Resident 1 attacked Resident 5, hitting him in head. No injuries were noted, family of Resident 2 and Resident 5 were notified; no documentation of Resident 1's family being notified. Resident 2 required [MEDICATION(S)] after this incident. 9/24/22 - at 3:00 pm, Resident 1 was wandering in the hall and attacked Resident 2 (who was sitting in his wheelchair); then attacked Resident 4 by hitting him in the back. No injuries were noted, and no family members were notified per review of incident reports and progress notes. Resident #2 Record review of incident reports reflected Resident #2 has initiated 6 residents to resident altercations between 9/17/22 and 9/25/22: 9/17/22 - at 10:53 am, Resident 2 tipped over Resident 8's wheelchair causing a skin tear to his left hand. No injuries were noted on Resident 2. 9/17/22 - at 6:00 pm, Resident 2, having just been hit by Resident 1, hit Resident 6 as he walked past, which knocked Resident 6 to the ground. No injuries were noted, and no family members were notified according to progress notes and incident reports. 9/20/22 - at 5:07 pm, Resident 1 walked in the dining room and Resident 2 said, back up [OBSCENITY] and both residents hit each other. Resident 1 had scratches on his face, a skin tear to his right arm, and his left wrist was scratched. Resident 1's family was notified, but no documentation of Resident 2's family being notified was found in progress notes or incident reports. 9/23/22- at 1:35 p.m., Resident 2 attacked Resident 1 causing scratches to Resident 1's face, a deep skin tear to his right forearm from nails, and a shallow bit on Resident 1's right top ear, causing bleeding. Staff intervened. Resident 2 was moved to different area, and Resident 1 was given a sedative. 9/24/22 - at 4:30 pm, Resident 2 attacked Resident 7 hitting him, then biting him on the right upper back and refusing to release his mouth from Resident 7's back. Resident 2 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . No documentation of either family being notified of this incident and no incident report with Resident 7's information. 9/25/22 - at 8:41 pm, Resident 2 pulled Resident 6 to the ground and hit him. Resident 11 walked into the area and Resident 2 slapped her 4 times in the face. No injuries were noted for any of the 3 residents involved. During an interview on 9/21/22 at 10:05 a.m. with the facility Administrator (ADM) and Director of Nurses(DON); ADM stated that Resident #1 has had several physical aggression incidents in the last 9 days since admission on 9/12/22 with several residents and several staff. ADM stated that Resident #1 came from another facility, but the transfer paper did not document this type of behaviors. ADM stated that when he is awake, they have him on a 1:1 level of supervision and when he is asleep, he is on every 15-minute checks. DON stated that Resident #1 has been moved to a room, next to her and the ADON office so he can be monitored closely. DON stated that Resident #1 is NPO Nothing by mouth and when he sees people with food he will go and grab it from them. DON stated that Resident #1 hit resident #5 on 9/20/22. Stated that Resident #1 has attacked the following residents: Resident #10, Resident #3 by knocking her down and she wears a helmet to protect her head from seizures; Resident #2, Resident #4, Resident #5 who punched Resident #1 in the face but left no marks; and Resident #11 by scratching her arm. DON stated that Resident #1 has been physically aggressive with several staff including, DON, ADM, Housekeeping, Aide, Assistant Director of Nursing (ADON). DON stated that he put the housekeeping staff into a choke hold. DON stated that Investigator (INV) should not enter Resident #1's room alone or approach him without a staff member with the INV. DON stated that INV should be aware of surroundings if Resident #1 is out of his room. During an interview and observation on 9/21/22 at 10:35 a.m. with Resident #4, stated he punched another male resident [Resident #1] in the face when the resident came up and grabbed him in his room. Stated he gave him a black eye and he will fight back if needed. During an interview and observation on 9/21/22 at 10:38 a.m. with Resident #11, stated that the man (Resident #1) grabbed her wrists and scratched her and pointed to bruising on her right wrist. DON stated the bruises were a result from Resident #1 grabbing Resident #11. During an interview on 9/21/22 at 10:44 a.m. with the Director of Nurses (DON), stated that this is a dangerous situation because Resident #1 becomes aggressive with no warning. DON stated I cannot ensure safety of the residents or staff due to the aggressive behavior of Resident #1. Observation on 9/21/22 at 11:55 a.m. of Resident #1 laying in bed awake and had no 1:1 supervision. DON notified and 1:1 was assigned. During an observation and interview on 9/21/22 at 1:15 p.m. with Nurses Assistant A(NA), sitting in chair in Resident #1's room. Resident #1 was observed sleeping in his bed. NA stated she has only worked here for 3 days and started at 6 a.m. today. Stated that she is Resident #1's 1:1 level of supervision right now and that she is aware of his physical aggression behaviors but is not afraid to work with him. During an interview on 9/21/22 at 1:50 p.m. with CNA A, stated she did not observe the incident with Resident #1 and Resident #3. CNA A stated she was here for the incident with Resident #1 and Resident #11, and it was unprovoked, and Resident #1 started hitting and punching. Stated that she and LVN C intervened by trying to redirect Resident #1 and removing the residents he was targeting. Stated that Resident #1 chases staff, and they try to redirect with snacks. CNA A stated that Resident #1 is okay as long as he is in his bed but once he gets out of bed, they have issues. Stated that they check him every 2 hours if he is awake or not. Stated that if he is asleep, he is left alone in his room and checked on. CNA A stated if he is awake, he is 1:1 level of supervision. During an interview on 9/21/22 at 2:13 p.m. with LVN C, stated that Resident #1 is being aggressive and attacking other residents or staff, they intervene by taking the other resident out of the situation. Stated that it's hard to redirect Resident #1 because it seems like he is focused on the behavior, so if he is moved away from a resident and sees someone in front of him, he will attack them. During an observation on 9/21/22 at 2:15 p.m., Nurses assistant(NA) observed sitting in chair in Resident #1's room. NA had face resting on hand and asleep while Resident #1 was awake in bed. Nurse assistant did not acknowledge INV was in room and continued to sleep. DON notified. Interview and observation of Resident #1 in room [ROOM NUMBER] on 9/21/22 at 2:49 p.m.; DON with INV and Nurse Assistant (NA) in room. Resident #1 was awake lying in bed. Nurse assistant observed eating skittles from her pocket, mask lowered and using personal cell phone. Resident #1 stated he was doing okay. When asked where he lives, Resident #1 pointed to the door and stated, I live in the door. INV asked if he remembers getting into a physical altercation with another resident and resident stated no. Resident #1 observed with bruising to face and eye area, numerous scratches, and abrasions to face and arms. Interview on 9/21/22 at 3:12 p.m. with Nurse Assistant (NA), stated she was not sleeping but stated she did not see INV stand in front of her. Nurse assistant stated she knows Resident #1 is food aggressive and that it could have become a dangerous situation with her eating in front of him. During an observation and interview on 9/21/22 at 3:20 p.m. with Resident #3, observed sitting in dining room with activity director, in her wheelchair, wearing helmet. Resident #3 stated he hit me and grabbed me, he pushed me to the ground. Look at my arm. Resident #3 pointed to right arm where a red abrasion and bruising were observed near her elbow. Resident #3 stated she is not scared anymore because they are going to send him away. During an interview on 9/21/22 at 3:38 p.m. with Housekeeping Supervisor, stated she has observed Resident #1 having behaviors and he has hit her, grabbed her from the neck and started slapping her. Stated that he has also gotten her arm, showed right forearm with red scrape/abrasion. Stated he will attack out of nowhere and some residents are scared. Stated when he gets physically aggressive staff immediately intervene by trying to separate him from the other person, but he can turn on that staff member. During an interview on 9/21/22 at 4:57 p.m. with Resident #5, stated he was doing okay and likes it here. Stated that he tried to hit me, he hit me on my shoulder. And pointed to room [ROOM NUMBER] where Resident #1 was. Stated he hit Resident #1 back and would do it again if he had to. During a phone interview on 9/28/22 at 12:22 p.m. with the Administrator; stated last incident with Resident #1 was on 9/23/22 with Resident #2. Stated the incident started verbal with Resident #2 yelling at Resident #1. Stated that Resident #1 started swinging at Resident #2 and Resident #2 ended up biting Resident #1 on the ear near the nurses' station. Stated that all residents were cleared from the area . Stated Resident #1 and #2 were separated by staff to different areas. Stated Resident #1 became physically violent towards staff who were attempting to intervene, and the nurse administered [MEDICATION(S)] and he calmed down and was assessed for injury to ear. Stated Resident #1 was bleeding from ear and no sutures were needed. Stated that Resident #2 has [CONDITION(S)] and Resident #1 was treated with medications, [CONDITION(S)] shot, and a Hep panel was run. Stated Resident #2 has scratches and redness to eye. ADM stated she cannot verify if Resident #1 was on a 1:1 at that time. Stated that he is/was supposed to be but could not confirm. Stated that Resident #1 has had no other incidents since INV left on 9/21/22 besides above incident with Resident #2 on 9/23/22. ADM stated that now that Resident #1 has calmed down, they are having issues with Resident #2 having physical aggression on 9/23/22 with Resident #1, and with two separate incidents on 9/25/22 with 2 different residents. ADM stated she reported to the State Survey Agency. During an interview on 9/29/22 at 1:18 p.m. with Administrator (ADM) and RN Nursing consultant; ADM stated that Resident #2 is being transferred to another facility. ADM stated that Resident #1 is being admitted to Hospice. ADM stated that Resident #1 was a trigger for Resident #2 and if Resident #2 saw Resident #1 he would start attacking. ADM stated that there was an incident between Resident #2 and Resident #7 where Resident #2 bit Resident #7's back but did not break skin. ADM stated that there was also an incident involving Resident #2 and Resident #6, where Resident #2 pushed Resident #6 and then Resident #2 went after Resident #11 and slapped her several times in the face. RN Consultant stated that Resident #1 is not on a level of supervision but is eyes on because he is no longer getting out of bed. Stated that Resident #1 was on Q15 minute checks when he had the incident where Resident #2 bit him on the back. RN Consultant stated that Resident #1 was put on Hospice referral on 9/21/22 and was on 1:1. RN Consultant stated Resident #2 was placed on eyes on as he wanders. Interview on 9/29/22 at 1:45 p.m. with ADON/LVN; stated she has close monitoring sheets for Resident #1 from 9/18/22 to 9/21/22 and then 9/26/22 but does not have the dates in-between. Stated there should have been monitoring sheets from 9/22/22 to 9/25/22. Stated she was having 3 CNAs on shift and would designate verbally which CNA was assigned to 1:1 on Resident #1 but has no actual sign on sheets for him. Stated that the CNA could leave the room if Resident #1 was sleeping, and they should have checked Q 15 min but there are no close monitoring sheets for those days to confirm. Stated on 9/23/22 Resident #1 was on 1:1 and there were 2 CNA's who were supposed to alternate but there is no sign on sheets to prove it. Stated that she cannot say who was watching him when the incident happened. Stated the Activity director witnessed incident. Stated Resident #1 was put on 1:1 to prevent these incidents of aggression from occurring and to prevent injuries. Stated he is still assigned 1:1. Stated Resident #1 should be 1:1 at all times, but they have not been with him at all times. Stated when he is asleep staff come out of the room. Stated when he is awake, they are supposed to be in there. Stated there is no system in place right now to make sure that there is 1:1 coverage on Resident #1 when he awakes from sleeping. Stated there is no method of documentation or checking to verify what he is doing. And No Q 15 checks. Stated on 9/23/22 she did not have someone designated to be Resident #1 1:1 because she did not have enough staff. Stated that Resident #2 is all over the place, we always knew where he was and kept him separated from Resident #1. Stated Resident #1 is a trigger for him, so if he sees him, Resident #2 flips out and it's a trigger. Stated when Resident #1 is not around, Resident #2 is fine. Stated Resident #2 was not put on a 1:1 or Close monitoring. During an interview on 9/29/22 3:28 p.m. with CNA B, stated on 9/23/22 she was working 6 a to 6 p. Stated she was not assigned to Resident #1's level of supervision and does not believe anyone else was either. Stated 9/23/22 they would check on him, but they didn't start doing the close monitoring form for 15 Q checks. Stated that she has had no training on what to do when Resident #1 attacks a resident or when he is attacking staff. Stated she doesn't know how she is to protect him or others. Stated Resident #1 will attack everyone in the building. Stated today is the first time she has seen a 1:1 Level of supervision (LOS) on Resident #1, and only because the Investigator (INV) is in the building. Stated that there are only 2 aides during the day shift, and they cannot do 1:1 and perform their duties. During an interview on 9/29/22 at 4:45 p.m. with the activity director; Stated on 9/23/22 Resident #2 was sitting in his wheelchair and Resident #1 came out of his room alone and put his hand out to Resident #2, like he wanted to shake his hand. Stated she immediately tried to get between them, but it happened so quickly. Stated Resident #2 pulled Resident #1 to the floor. Stated she started yelling for help and Resident #2 was biting Resident #1. , Stated a male nurse came and separated them. Stated there was an in-service after 9/12/22 when the first incident occurred with Resident #1. We have not received any in-service regarding Resident #1 and #2 having physical incidents or how Resident #2 is set off by Resident #1. Stated that before today, there were not enough staff to assist, and she was afraid of what could happen. Stated that they had a hard time trying to keep Resident #1 from attacking other residents. Stated that Resident #2 will attack residents if he feels that a resident is in his way or in his space. Stated that once Resident #2 is in an aggressive state he stays in that state. IJ called at 9/30/22 at 1:13 p.m. with Administrator and RN Consultant. Investigator provided 3 strikes letter, IJ Template, Plan of Removal form. No questions asked at this time. During an interview on 9/30/22 at 2:08 p.m. with the Director of Nurses, stated that the Administrator and Business Manager are admitting residents without having me review their needs to see if we can meet their medical needs. Stated she was never asked to review the admission packet for Resident #1. Stated she did not know he was being admitted until he was already approved. Stated no eyes were laid on him before he got here. Stated we are not equipped to take some of these residents if they are physically aggressive or a wanderer. Stated she did not find out about incident's until 9/26/22 of anything that occurred over the weekend. Stated no one is notifying her of anything. Stated she has presented in-services on patient aggression, remaining calm and has sign in sheets for some of them. Stated Resident #1 was on close monitoring, but no one had been filling out the sheet and we can't prove that. Stated no one from the facility laid eyes on him before he got here. Stated We are not equipped to take some of these residents if they are physically aggressive or a wanderer. During an interview on 9/30/22 at 3:30 p.m. with the Administrator, Stated Resident #1 came from New Mexico at a hospital, and they sent the referral. He had been at another nursing facility previously before coming here. Stated that she reviewed the admit records along with the Business Manager, Corporate Manager, DON and ADON. Stated she did not see anything, and they didn't talk about there being any concerns. Stated she didn't see anything on the referral about behaviors and she would be happy to get what was sent in the referral so we can go over it. ADM returned and stated that the hospital was ready to discharge him, and the NH refused to take him back. When asked why they refused to take Resident #1 back, ADM stated because of his behaviors. Like Resident #2 he was here for months no problems then I don't know I don't know what set him off. When asked the referral documentation does have behaviors and aggression documents she stated, it does mention he was becoming aggressive with residents and staff. She stated first physical altercation was on 9/12/22 the day he admitted to the facility. ADM stated she told staff to not let Resident #2 and Resident #1 and near each other. When asked was staff keeping them separated, she stated I did not witness if they did or not. When asked if you told staff to monitor and keep Resident #1 and Resident #2 separated how did they continue to have altercations? ADM stated, I am not sure that is a good question. ADM stated it could have been a pretty serious outcome. INV asked how staff were notified of 1:1 or Q15 minute check, ADM stated Resident #1 was never on 1:1 and when he was out in the hall, we had staff with him. During an interview on 10/1/22 at 6:23 a.m. with LVN A, stated that the facility did not have staff or resources to care for Resident #1 because he has too many behaviors. Stated that she complained to the ADON about it and the ADON stated she was doing the best she could. Stated that it was not fair to the rest of the residents. Stated when Resident #1 was admitted it was all downhill from there. Stated Resident #2 is loud and cusses, he is an old biker. Stated she never had any incidents with Resident #2 but when Resident #1 came, it became bad. Stated Resident #2 was our protector and if he saw Resident #1 hit one of the staff or one of the lady residents, Resident #2 would become very upset. Stated the only intervention provided by the administration was to just keep an eye on him meaning Resident #1. Stated at night it is very hard to do because they do not have the staff. Stated there was no way to monitor Resident #1 every 15 minutes during the 6 p to 10 p timeframe. Stated they would try but they could not do it. 10/1/22 7:24 p.m. Plan of Removal received via email from ADM; Investigator forwarded it to region 1 for review. During an interview on 10/1/22 at 8:13 a.m. with Resident #4; stated Resident #1 tried to pull me out of my wheelchair and the chair ended up on top of him. Stated that he kicked at Resident #1 and made him fall. Stated that he feels reasonably safe here. Stated that Resident #1 has the right to live here too but [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving mistreatment, neglect or abuse were reported immediately to the administrator of the facility, failed to have evidence that all alleged violations were thoroughly investigated and failed to prevent further potential abuse while the investigation was in progress for 5 of 11 residents (#s 1, 2, 11, 5, and 10) reviewed for abuse: 1. Staff failed to immediately report CNA #1's mistreatment of [REDACTED].#2, and #11. CNA #1 worked two full shifts before the ADM became aware of abuse allegations. 2. The ADM's failure to conduct a thorough investigation and inconclusive findings prevented the identification of additional residents (#5, #10) mistreated by or witness to mistreatment by CNA #1. 3. The facility failed to protect the residents from further potential abuse by allowing CNA #1 to resume regular work duties without making a final determination of findings and without restriction after a two day suspension. CNA #1 mistreated Resident #10 since being investigated for abuse. This deficient practice resulted in an identification of an Immediate Jeopardy (IJ) on 2/3/16. While the IJ was removed on 2/4/16, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as widespread. The facility was continuing to in-service staff on abuse prevention/identification/reporting and providing residents with mental health care. The facility's failure to ensure implementation of its policies and procedures regarding identifying/reporting/investigating abuse and protection of residents during investigation caused mental and psychosocial harm to 5 residents (#s 1, 2, 11, 5 and 10) with the potential to harm the psychosocial well-being of the other 31 residents dependent upon staff assistance for care, by placing at risk for mistreatment and degradation through continued contact with CNA #1. Findings include: Resident #1 Record review of Resident #1's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old female admitted to the facility on [DATE] from a behavioral health facility and had [DIAGNOSES REDACTED]. Record review of Resident #1's admission comprehensive MDS dated [DATE] reflected a BIMS score of 15 indicating the resident was cognitively intact. Review of Resident #1's functional status reflected she was dependent upon staff assistance with all ADLs except for eating and was continent of bowel and bladder. The resident had range of motion impairment to both extremities of one side of the body and used a wheelchair for mobility. Observation of Resident #1 conducted on 2/2/16 at 12:36pm revealed the resident had functional limitations to the left side of the body and used a wheelchair for mobility. In an interview with the AD on 2/2/16 at 1:43pm, she stated on Saturday the 16th at 6:15pm, Resident #1 approached the nurses' station in her motorized wheelchair and asked for assistance with opening her snack. CNA #1 approached the nurses' station while yelling and cursing at Resident #1 for blocking the hallway by the nurses' station with her motorized wheelchair and directed her to move. CNA #1 used the control on the back of the chair to move the resident. The resident became very upset and shouted at CNA #1 to not touch her wheelchair voicing fear he would damage the chair. He responded by telling the resident that he would throw the chair out the door and the resident could leave with it. The AD reported the incident to the ADM the following Monday. She stated she should have reported the incidents when they occurred. Confidential Interview A stated that CNA #1 caused the resident anxiety; Resident #1 would rather risk incontinence and hold her bladder and bowels than to ask CNA #1 for assistance with toileting. Confidential Interview A stated Resident #1 could self-toilet and only required assistance with pulling down/pulling up the pants; the resident had use of only one hand. Confidential Interview A stated that CNA #1 called Resident #1 the expletive f***ing b**ch. It was stated, with head lowered and eyes filled with tears, that CNA #1's treatment of [REDACTED]. Confidential Interview A stated Resident #1 avoided asking CNA #1 for assistance because of the demeaning manner in which he spoke to Resident #1. It was stated Resident #1 did not feel comfortable voicing grievances about CNA #1; the process did not provide resolution Resident #2 Record review of Resident #2's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old male admitted to the facility 9/20/13 from home and had [DIAGNOSES REDACTED]. Record review of Resident #2's comprehensive MDS dated [DATE] reflected the resident had a BIMS of 6 indicating severe cognitive impairment. Review reflected the resident was totally dependent upon staff for all ADLs except for eating and was incontinent of bowel and bladder. He had functional limitations in range of motion to the upper and lower extremities. Observation of Resident #2 conducted during the initial tour on 2/2/16 at 9:47am revealed the resident was dependent upon a Geri-chair for mobility and had no functional use of the lower extremities. During Confidential Interview B it was stated that CNA #1 had taken Resident #2's call light and placed it out of his reach and cursed him. It was stated the call light was taken from the resident for asking for coffee. It was stated CNA #1 told the resident his light would be taken away and the resident could not do anything about it. Confidential Interview B stated Resident #2 felt awful and belittled and it was obvious CNA #1 did not care about the residents. Confidential Interview B revealed Resident #2 was distressed and angered by CNA #1. In an interview with RN #1 on 2/3/16 at 3:28pm, he stated he did observe Resident #2's call light not within his reach and when he asked why, the resident stated CNA #1 took it away the night before for being on it too much. When asked if he had observed CNA #1 curse at residents, RN#1 paused, then stated CNA #1 has the language, (curses) but he had not observed it directed at residents. He stated it would not surprise him if CNA #1 cursed at residents. Resident #11 Review of Resident #11's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old male re-admitted to the facility on [DATE] from the hospital and had [DIAGNOSES REDACTED]. Record review of Resident #11's annual comprehensive MDS dated [DATE] reflected the resident's vision was severely impaired; his hearing was adequate. The resident had a BIMS of 5 indicating severe cognitive impairment and was not oriented to time and had difficulty with recall. Review of functional status reflected the resident was totally dependent upon staff for all ADLs except eating. He had functional limitations in range of motion of both upper and lower extremities and required a wheelchair for mobility. The resident was incontinent of bowel and bladder. Observation of Resident #11 conducted on 2/2/16 at 7:02pm revealed the resident was dependent upon a wheelchair for mobility and required extensive assistance with transfers. Observation revealed staff did not have to raise their voice when speaking to the resident; he had adequate hearing. In an interview with the AD on 2/2/16 at 1:43pm, she stated on Saturday 1/16/16, shortly after shift change, she was about to leave the facility after checking on her grandmother, a resident. She observed Resident #11 seated in his wheelchair in the hall across from the nurses' station. Resident #11 asked CNA #1 if it was his shower night, a question the resident asked each day, to which CNA #1 leaned down to place his face close to the resident's face and exclaimed no in a prolonged verbalization and raised voice. The resident responded by saying okay. Confidential Interview H stated Resident #11 was unable to remember any incidents involving CNA #1. Confidential Interview H stated Resident #11 was unable to recall what the resident had eaten for breakfast that day. --Record review of Form 3613-A Provider Investigation Report signed and dated by the ADM on 1/24/16 reflected: 1. The AD reported CNA #1's mistreatment of [REDACTED]. 2. On Saturday 1/16/16 at 6:15p, the AD was providing assistance to Resident #1 with opening a snack package at the facility's only nurses' station. Resident #1 was seated in her motorized wheelchair. CNA #1 approached the nurses' station while yelling and cursing at Resident #1 for blocking the hallway by the nurses' station with her motorized wheelchair and directed her to move. CNA #1 used the control located behind the resident's chair to propel the wheelchair without her approval. The resident shouted at CNA #1 to not touch her wheelchair voicing fear he would damage the chair. He responded by threatening to throw out the chair, if damaged, and told her she could leave the facility as well. The AD reported the incident to the ADM. The ADM's interview with Resident #1 corroborated the AD's incident report. The ADM reported this incident to the appropriate investigating authority. 3. CNA #1's written statement included with the Provider Investigation Report, dated 1/22/16 at 3:01pm reflected he told Resident #1 to stop blocking the area by the nurses' station, to go to her room, and propelled her wheelchair for her. CNA #1 documented Resident #1 had already been told not to crowd the nurses' station. CNA #1 wrote he did not curse at the resident and spoke to her kindly and respectfully. 4. Before the incident with Resident #1, the AD witnessed Resident #11 ask CNA #1 if it was his shower night and CNA #1 yell No directly into Resident #11's face. The resident asked that question daily. This incident was not reported to the appropriate authority and was revealed in the facility investigation. 5. On 1/17/16, RN #1 observed Resident #2 lying in bed with his call light not within his reach. Resident #2 reported CNA #1 placed the call light out of his reach the prior evening because the resident kept calling for assistance; the resident wanted coffee. Interview with the resident corroborated RN #1's statement. This incident was not reported to the appropriate authority and was revealed in the facility investigation. 6. CNA #1's written statement included in the facility investigation dated 1/21/16 at 10:38am documented he placed Resident #2's call light out of his reach. The statement reflected each time Resident #2 called for assistance he would state to CNA #1 nothing from you when CNA #1 asked what the resident needed. 7. CNA #1 was suspended pending the outcome of the investigation. 8. The facility's findings were inconclusive; the ADM documented she needed the agency nurse on duty when the incidents occurred to provide a statement before she could make a determination. The ADM documented she could not make a decision because the statements obtained were he-said, she-said.-- 9. The facility's documented immediate plan: a) Have an impartial person talk to each interviewable resident to ascertain whether the residents had witnessed the incidents or had similar incidents with CNA #1. b) Conduct in-services, one-on-one and in groups with all staff on abuse and reporting for 2 months or longer if needed.-- Record review of the facility's Nursing Schedule dated January 2016 reflected CNA #1 was assigned the 6p-6a shift with CNA #6. Review reflected CNA #1's schedule for the days of 1/18/16 to 1/25/16: off 1/18/16 and 1/19/16, on 1/20/16 and 1/21/16, off 1/22/16, 1/23/16 and 1/24/16, and back on duty 1/25/16. Review reflected 1/18/16-1/19/16 and 1/22/16-1/24/16 were scheduled off days per the rotation. Review reflected CNA #1's suspension pertained only to 1/20/16 and 1/21/16. Review reflected CNA #1 was scheduled to work 1/25/16-1/26/16 and 1/29/16-1/31/16. Review reflected the document did not reflect CNA #1's suspension. In an interview with the ADON on 2/2/16 at 6:15pm, she stated CNA #1 was suspended for 2 days, 1/20/16 and 1/21/16. On 2/3/16 at 11:41am, the surveyor requested the facility's assistance with obtaining an interview with CNA #1; surveyor attempts to contact CNA #1 by phone were unsuccessful. In an interview conducted with the ADM on 2/3/16 at 12:06pm the ADM stated she took immediate action in response to the allegations reported by staff by suspending CNA #1 from 1/18/16 to 1/25/16 without pay rather than opting to assign him to no-resident contact duties. Suspension meant CNA #1 was not allowed in the building. In review of the January 2016 staffing schedule, she acknowledged 5 of the 8 days of suspension were his scheduled off days. She stated CNA #1 resumed his normal work duties on 1/25/16. When asked why she needed a statement from Agency LVN #1, the nurse on duty when the incidents occurred, to determine the findings when she had witness statements from staff and corroborating resident statements,, she stated so far the allegation was he said-she said. She stated only Residents #1 and #2 were interviewed. She could not find an impartial person to interview the rest of the residents. The ADM stated no in-services had been conducted as a result of the investigation. --Review of the facility's Payroll Summary reports for the dates of 1/16/16 through 1/27/16 reflected CNA #1's time clock punch detail: 1. 1/16/16: in at 6:03p, out at 6:06a 2. 1/17/16: in at 6:15p, out at 5:58a 3. 1/25/16: in at 6:32p, out at 6:16a 4. 1/27/16: time in not documented, out at 1:19a, in at 2:14a, then out 6:05a.-- Resident #5 Record review of Resident #5's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old female readmitted to the facility from the hospital on [DATE] and had [DIAGNOSES REDACTED]. Record review of Resident #5's MDS dated [DATE] reflected the resident was continent of bowel and bladder. Review reflected the resident was dependent upon staff for mobility and transfers. Review reflected a BIMS of 15 indicating intact cognition. Observation of Resident #5 conducted on 2/2/16 at 12:10pm reflected the resident was dependent upon a wheelchair for mobility. Confidential Interview E stated CNA #1 did not want to provide care to Resident #5. It was stated Resident #5 would push the call button to request assistance to the toilet. CNA #1 would turn off the call light without providing care and walk out of the room saying yeah, uh huh. It was stated Resident #5 had more than 1 episode of urinary incontinence due to CNA #1's refusal to provide care. It was stated Resident #5 had to receive incontinent care from CNA #6 during CNA #1's shift. It was stated CNA #1 had yelled at Resident #5 and had placed the resident's call light out of reach. Confidential Interview E stated CNA #1 had treated the resident in such a manner for weeks; the resident was intimidated by CNA #1 and reluctant to report mistreatment. Confidential Family Interview A was aware that Confidential Interview E did not report CNA #1's mistreatment for [REDACTED].#1 against the resident or loved ones and tearfully begged that Confidential Family A also not report. Interviews conducted with witnesses of CNA #1's mistreatment of [REDACTED].>a. Confidential Interview C stated Resident #4 had witnessed CNA #1 verbally abuse other residents. It was stated All I witnessed is verbal. Things you would not want said to you or ones you cared about. It was stated incidents went unreported for fear of retaliation because CNA #1 was a current employee. b. Confidential Interview G frowned, shook head, made a sign of the cross, then made a zipping motion across closed mouth when asked to describe CNA #1 and repeated the motion when assured statements would be kept confidential. Confidential Interview G had no issues with other staff. Record review of CNA #1's Employee Corrective Action Form dated 1/25/16, signed by the ADM and CNA #1 reflected CNA #1 received a written warning for verbal abuse and neglect. The Reason for Action was Employee was heard talking loud & harsh using curse words. Taking a resident's call light out of his reach. The document reflected Action Required: Take 2 extra courses on (electronic training program) & will be on probation for 1 month. He was suspended from 1-18-2016 till 1-25-16. Review of the facility's Education Completion Report for the dates of 1/1/16 through 2/3/16 reflected CNA #1 completed 2 courses on 1/21/16: Preventing, Recognizing, and Reporting Resident Abuse and Residents' Rights. The date due for both courses was 1/31/16. CNA #1 received 1 credit hour for each course. In an interview conducted with the ADM on 2/3/16 at 2:37pm, when asked what her findings were regarding the allegations of abuse made against CNA #1, she stated she had not made a determination. In review of the provider investigation report she submitted on 1/24/16 documenting CNA #1 was suspended pending the outcome of investigation, when asked why CNA #1 was allowed to resume normal work duties on 1/25/16 she stated she did not think his actions were abuse and that he was being monitored. When asked what monitoring was performed and by whom, she stated CNA #1 was not being monitored. When asked why CNA #1 was physically present in the facility on 1/21/16, a suspension day, to take 2 hours of his mandatory annual training, she stated she told him to leave the building when she saw him that day. In review of CNA #1's Employee Corrective Action Form dated 1/25/16, she stated the 2 modules CNA #1 completed was not part of the disciplinary action; they were mandatory annual training. CNA #1 did not complete the extra 2 training modules as disciplinary action. When asked what she considered placing call lights out of reach of residents, she stated abuse. When asked why she did not put protections in place when CNA #1 admitted to the incidents with Residents #1and #2, and only denied cursing and raising his voice during the incident with Resident #1, she stated she maybe should have terminated CNA #1. The ADM's inflection made the statement a question. She stated CNA #1 needed more training and monitoring. When asked why the facility investigation did not address the allegation regarding Resident #11, the ADM stated she spoke with Resident #11 and was told nothing happened. When asked if Resident #11's cognitive status allowed recall, she stated no. Resident #10 Review of Resident #10's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old male admitted to the facility from the hospital on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident #10's annual comprehensive MDS dated [DATE] reflected a BIMS of 6 indicating severe cognitive impairment. The resident had unclear speech (slurred or mumbled), could usually make self understood, could usually understand others and had minimal difficulty hearing. Review of ADLs reflected the resident required staff assistance with all ADLs except for eating; had functional limitations in range of motion to the upper and lower extremities and required a wheelchair for mobility. The resident was frequently incontinent of bowel and bladder. The MDS reflected hospice status. Observation of Resident #10 conducted during initial tour on 2/3/16 at 9:20am reflected the Resident was dependent upon a wheelchair for mobility. Confidential Interview B stated CNA #1's treatment of [REDACTED]. It was stated that Resident #2 pushed the call button at 9pm for urinary incontinent care during CNA #1's last shift. CNA #6 answered the call light and left the room without providing care. At 10:25pm, Resident #10 pushed the call button and CNA #1 responded. Resident #10 requested incontinent care when CNA #1 asked what he needed. Confidential Interview B stated Resident #10 told CNA #1 that he was wet with urine since 9pm. CNA #1 stated that rounds were not until 3am, took the resident's clock from the wall and left the room without providing care. It was stated this was not the only incident with CNA #1; it was the most recent. It was stated CNA #1 made Resident #10 feel insignificant and worthless. Review of the facility's Operational Policy and Procedure Manual for Long -Term Care, Resident Behavior and Facility Practices revised April 2015 showed the following procedures under the section titled Abuse Prevention: -Reporting Abuse to Facility Management: 4. Employees, facility consultants and/or attending physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the DON such reports may be made to the nurse supervisor on duty. 5. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator, DON, or charge nurse. 9. When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of time lapse since the incident occurred. -- -Reporting Abuse to State Agencies and Other Entities/Individuals: 2. Verbal/written notices to agencies will be made within 24 hours of the occurrence of such incident. Notices will include as appropriate: e. The names of all persons involved in the alleged incident. f. What immediate action was taken by the facility. 5. Should the allegations be true, the employee(s) will be terminated from employment.-- -Abuse investigations: 3. Investigations must include at a minimum 10 components including: interview any witnesses to the incident, interview staff members who have had contact with the resident during the period of the alleged incident; interview the resident's roommate, family members, and visitors; interview other residents to whom the accused employee provides care or services; and review all events leading up to the alleged incident. 8. Employees of the facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation. 14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, and other officials, within 5 working days of the reported incident.-- -Protection of Residents During Abuse Investigations: 1. During abuse investigations, residents will be protected from harm by: a. Employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended until the findings of the investigation have been reviewed by the Administrator. b. Should the employee(s) be reassigned to non-resident care duties, such assignment will not be in any part of the building which the resident frequents.-- -Preventing Resident Abuse: 2.i. Monitoring staff on all shifts to identify inappropriate behaviors toward residents (e.g., using derogatory language, rough handling of residents, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their clothing/beds, etc.)-- -Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures: 1. The Administrator has the overall responsibility for the coordination and implementation of our facility's abuse prevention program policies and procedures.-- Review of the operational manual, policy Recognizing Signs and Symptoms of Abuse/Neglect revised 1/2011 reflected the facility defined abuse as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish; defined neglect as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. Record review of the facility's Nursing Schedule dated February 2016 reflected CNA #1 was off 2/1/16-2/2/16 and was scheduled to work the 6p to 6a shift, 2/3/16-2/4/16. In an interview conducted with the ADM on 2/3/16 at 6:15pm, when asked what staff was on duty for the 6p-6a shift, she stated 2 CNA's from the day shift would be on duty and she called in a CNA who worked nights to come in on her scheduled day off. She stated CNA #1 and CNA #6 were scheduled but were no call, no shows. The facility was unable to assist the surveyor with obtaining an interview with CNA #1; he could not be reached by phone call or by text message. She stated the facility had made the decision to terminate CNA #1 because of something unrelated to the allegations under investigation pertaining to Residents #1, #2 and #11. When asked to clarify, the ADM stated Resident #10 made an allegation against CNA #1. The incident occurred on the last shift worked by CNA #1. CNA #1 answered Resident #10's call light twice, did not provide incontinent care either time, and removed his clock from his room so that the resident could not track how long he had been wet with urine. The first request for assistance was at 9pm; the second request at 10:25pm. The clock was removed from the room at 10:25pm. CNA #1 told the resident he could not provide care to the resident because rounds were not until 3. The facility's administrator ADON, BOM, and Regional Director of Operations were notified on 2/3/16 at 6:30pm that an Immediate Jeopardy situation had been identified due to the facility's failure to prevent CNA #1's abuse of residents and the failure to protect residents from further abuse by CNA #1 once allegations were made. The Plan of Removal was accepted on 2/4/16 and included the following interventions confirmed by the surveyor: 1. CNA #1 was terminated confirmed by review of the Employee Corrective Action form dated 2/3/16 and by observation that CNA #1 was not on duty during his scheduled shift on 2/3/16-2/4/16. 2. The facility initiated staff in-services on identification of abuse and neglect and reporting procedures. This was confirmed by observation of the staff meeting, review of in-service sign-in sheet and interviews with 4 direct care staff. Interviews with direct care staff confirmed staff knowledge of identifying and reporting abuse. 3. The licensed clinical social worker, also the therapist for several residents, was scheduled to provide staff in-services on abuse and neglect, psychiatric [DIAGNOSES REDACTED]. Interview with the clinical social worker confirmed the in-services would continue indefinitely as necessary. 4. The facility conducted resident satisfaction surveys; results reported to licensed clinical social worker for mental health care and follow-up. Observation of the clinical social worker performing rounds at the facility on 2/4/16, interview with residents affected by the deficient practice, interview with the clinical social worker, and records reviewed dated 2/3/16 documenting the resident satisfaction surveys confirmed the intervention was implemented. The facility was notified on 2/4/16 that at 5:12pm the IJ was removed. However, the facility remained out of compliance at a severity of potential for more than minimal harm with a scope identified as widespread. The facility will continue to provide aftercare to residents victimized by CNA #1; to in-service facility staff and agency staff; to monitor staff completion of computer based courses on abuse and to monitor orientation of new staff on abuse and reporting requirements. Review of the resident roster provided by the facility on 2/2/16 reflected a census of 36.

Based on observation, interview and record review facility administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable physical, mental and psychosocial well-being of each resident for 5 of 11 residents (#s 1, 2, 11, 5 and 10) reviewed for abuse. 1. Staff failed to immediately report CNA #1's mistreatment of [REDACTED].#2, and #11 to the ADM, who was the Abuse Coordinator. CNA #1 worked 2 full shifts before initiation of the facility's incident investigation and his subsequent 2 day suspension. 2. The ADM's failure to thoroughly investigate allegations of CNA #1's mistreatment of [REDACTED].#5, #10) mistreated by CNA #1. The ADM failed to identify CNA #1's behavior towards the residents as abusive. 3. The facility failed to implement its policy and procedure to protect residents from further mistreatment by allowing CNA #1 to resume normal duties without making a final determination of findings and without monitoring his treatment of [REDACTED].#1 mistreated Resident #10 after the facility became aware of the abuse allegations. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 2/3/16. While the IJ was removed on 2/4/16, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as widespread. The facility was continuing to in-service staff on abuse prevention/identification/reporting and providing residents with mental health care. The facility's failure to ensure implementation of its policies and procedures regarding identifying/reporting/investigating abuse and protection of residents during investigation caused mental and psychosocial harm to 5 residents (#s 1, 2, 11, 5 and 10) with the potential to harm the psychosocial well-being of the other 31 residents dependent upon staff assistance for care, by placing at risk for mistreatment and degradation through continued contact with CNA #1. Findings include: Resident #1 Record review of Resident #1's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old female admitted to the facility on [DATE] from a behavioral health facility and had [DIAGNOSES REDACTED]. Record review of Resident #1's admission comprehensive MDS dated [DATE] reflected a BIMS score of 15 indicating the resident was cognitively intact. Review of Resident #1's functional status reflected she was dependent upon staff assistance with all ADLs except for eating and was continent of bowel and bladder. The resident had range of motion impairment to both extremities of one side of the body and used a wheelchair for mobility. Observation of Resident #1 conducted on 2/2/16 at 12:36pm revealed the resident had functional limitations to the left side of the body and used a wheelchair for mobility. In an interview with the AD on 2/2/16 at 1:43pm, she stated on Saturday the 16th at 6:15pm, Resident #1 approached the nurses' station in her motorized wheelchair and asked for assistance with opening her snack. CNA #1 approached the nurses' station while yelling and cursing at Resident #1 for blocking the hallway by the nurses' station with her motorized wheelchair and directed her to move. CNA #1 used the control on the back of the chair to move the resident. The resident became very upset and shouted at CNA #1 to not touch her wheelchair voicing fear he would damage the chair. He responded by telling the resident that he would throw the chair out the door and the resident could leave with it. The AD reported the incident to the ADM the following Monday. She stated she should have reported the incidents when they occurred. Confidential Interview A stated that CNA #1 caused the resident anxiety; Resident #1 would rather risk incontinence and hold her bladder and bowels than to ask CNA #1 for assistance with toileting. Confidential Interview A stated Resident #1 could self-toilet and only required assistance with pulling down/pulling up the pants; the resident had use of only one hand. Confidential Interview A stated that CNA #1 called Resident #1 the expletive f***ing b**ch. It was stated, with head lowered and eyes filled with tears, that CNA #1's treatment of [REDACTED]. Confidential Interview A stated Resident #1 avoided asking CNA #1 for assistance because of the demeaning manner in which he spoke to Resident #1. It was stated Resident #1 did not feel comfortable voicing grievances about CNA #1; the process did not provide resolution. Resident #2 Record review of Resident #2's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old male admitted to the facility 9/20/13 from home and had [DIAGNOSES REDACTED]. Record review of Resident #2's comprehensive MDS dated [DATE] reflected the resident had a BIMS of 6 indicating severe cognitive impairment. Review reflected the resident was totally dependent upon staff for all ADLs except for eating and was incontinent of bowel and bladder. He had functional limitations in range of motion to the upper and lower extremities. Observation of Resident #2 conducted during the initial tour on 2/2/16 at 9:47am revealed the resident was dependent upon a Geri-chair for mobility and had no functional use of the lower extremities. During Confidential Interview B it was stated that CNA #1 had taken Resident #2's call light and placed it out of his reach and cursed him. It was stated the call light was taken from the resident for asking for coffee. It was stated CNA #1 told the resident his light would be taken away and the resident could not do anything about it. Confidential Interview B stated Resident #2 felt awful and belittled and it was obvious CNA #1 did not care about the residents. Confidential Interview B revealed Resident #2 was distressed and angered by CNA #1. In an interview with RN #1 on 2/3/16 at 3:28pm, he stated he did observe Resident #2's call light not within his reach and when he asked why, the resident stated CNA #1 took it away the night before for being on it too much. When asked if he had observed CNA #1 curse at residents, RN#1 paused, then stated CNA #1 has the language, (curses) but he had not observed it directed at residents. He stated it would not surprise him if CNA #1 cursed at residents. Resident #11 Review of Resident #11's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old male re-admitted to the facility on [DATE] from the hospital and had [DIAGNOSES REDACTED]. Record review of Resident #11's annual comprehensive MDS dated [DATE] reflected the resident's vision was severely impaired; his hearing was adequate. The resident had a BIMS of 5 indicating severe cognitive impairment and was not oriented to time and had difficulty with recall. Review of functional status reflected the resident was totally dependent upon staff for all ADLs except eating. He had functional limitations in range of motion of both upper and lower extremities and required a wheelchair for mobility. The resident was incontinent of bowel and bladder. Observation of Resident #11 conducted on 2/2/16 at 7:02pm revealed the resident was dependent upon a wheelchair for mobility and required extensive assistance with transfers. Observation revealed staff did not have to raise their voice when speaking to the resident; he had adequate hearing. In an interview with the AD on 2/2/16 at 1:43pm, she stated on Saturday 1/16/16, shortly after shift change, she was about to leave the facility after checking on her grandmother, a resident. She observed Resident #11 seated in his wheelchair in the hall across from the nurses' station. Resident #11 asked CNA #1 if it was his shower night, a question the resident asked each day, to which CNA #1 leaned down to place his face close to the resident's face and exclaimed no in a prolonged verbalization and raised voice. The resident responded by saying okay. Confidential Interview H stated Resident #11 was unable to remember any incidents involving CNA #1. Confidential Interview H stated Resident #11 was unable to recall what the resident had eaten for breakfast that day. --Record review of Form 3613-A Provider Investigation Report signed and dated by the ADM on 1/24/16 reflected: 1. The AD reported CNA #1's mistreatment of [REDACTED]. 2. On Saturday 1/16/16 at 6:15p, the AD was providing assistance to Resident #1 with opening a snack package at the facility's only nurses' station. Resident #1 was seated in her motorized wheelchair. CNA #1 approached the nurses' station while yelling and cursing at Resident #1 for blocking the hallway by the nurses' station with her motorized wheelchair and directed her to move. CNA #1 used the control located behind the resident's chair to propel the wheelchair without her approval. The resident shouted at CNA #1 to not touch her wheelchair voicing fear he would damage the chair. He responded by threatening to throw out the chair, if damaged, and told her she could leave the facility as well. The AD reported the incident to the ADM. The ADM's interview with Resident #1 corroborated the AD's incident report. The ADM reported this incident to the appropriate investigating authority. 3. CNA #1's written statement included with the Provider Investigation Report, dated 1/22/16 at 3:01pm reflected he told Resident #1 to stop blocking the area by the nurses' station, to go to her room, and propelled her wheelchair for her. CNA #1 documented Resident #1 had already been told not to crowd the nurses' station. CNA #1 wrote he did not curse at the resident and spoke to her kindly and respectfully. 4. Before the incident with Resident #1, the AD witnessed Resident #11 ask CNA #1 if it was his shower night and CNA #1 yell No directly into Resident #11's face. The resident asked that question daily. This incident was not reported to the appropriate authority and was revealed in the facility investigation. 5. On 1/17/16, RN #1 observed Resident #2 lying in bed with his call light not within his reach. Resident #2 reported CNA #1 placed the call light out of his reach the prior evening because the resident kept calling for assistance; the resident wanted coffee. Interview with the resident corroborated RN #1's statement. This incident was not reported to the appropriate authority and was revealed in the facility investigation. 6. CNA #1's written statement included in the facility investigation dated 1/21/16 at 10:38am documented he placed Resident #2's call light out of his reach. The statement reflected each time Resident #2 called for assistance he would state to CNA #1 nothing from you when CNA #1 asked what the resident needed. 7. CNA #1 was suspended pending the outcome of the investigation. 8. The facility's findings were inconclusive; the ADM documented she needed the agency nurse on duty when the incidents occurred to provide a statement before she could make a determination. The ADM documented she could not make a decision because the statements obtained were he-said, she-said. 9. The facility's documented immediate plan: a) Have an impartial person talk to each interviewable resident to ascertain whether the residents had witnessed the incidents or had similar incidents with CNA #1. b) Conduct in-services, one-on-one and in groups with all staff on abuse and reporting for 2 months or longer if needed.-- Record review of the facility's Nursing Schedule dated January 2016 reflected CNA #1 was assigned the 6p-6a shift with CNA #6. Review reflected CNA #1's schedule for the days of 1/18/16 to 1/25/16: off 1/18/16 and 1/19/16, on 1/20/16 and 1/21/16, off 1/22/16, 1/23/16 and 1/24/16, and back on duty 1/25/16. Review reflected 1/18/16-1/19/16 and 1/22/16-1/24/16 were scheduled off days per the rotation. Review reflected CNA #1's suspension pertained only to 1/20/16 and 1/21/16. Review reflected CNA #1 was scheduled to work 1/25/16-1/26/16 and 1/29/16-1/31/16. Review reflected the document did not reflect CNA #1's suspension. In an interview with the ADON on 2/2/16 at 6:15pm, she stated CNA #1 was suspended for 2 days, 1/20/16 and 1/21/16. On 2/3/16 at 11:41am, the surveyor requested the facility's assistance with obtaining an interview with CNA #1; surveyor attempts to contact CNA #1 by phone were unsuccessful. In an interview conducted with the ADM on 2/3/16 at 12:06pm the ADM stated she took immediate action in response to the allegations reported by staff by suspending CNA #1 from 1/18/16 to 1/25/16 without pay rather than opting to assign him to no-resident contact duties. Suspension meant CNA #1 was not allowed in the building. In review of the January 2016 staffing schedule, she acknowledged 5 of the 8 days of suspension were his scheduled off days. She stated CNA #1 resumed his normal work duties on 1/25/16. When asked why she needed a statement from Agency LVN #1, the nurse on duty when the incidents occurred, to determine the findings when she had witness statements from staff and corroborating resident statements,, she stated so far the allegation was he said-she said. She stated only Residents #1 and #2 were interviewed. She could not find an impartial person to interview the rest of the residents. The ADM stated no in-services had been conducted as a result of the investigation. --Review of the facility's Payroll Summary reports for the dates of 1/16/16 through 1/27/16 reflected CNA #1's time clock punch detail: 1. 1/16/16: in at 6:03p, out at 6:06a 2. 1/17/16: in at 6:15p, out at 5:58a 3. 1/25/16: in at 6:32p, out at 6:16a 4. 1/27/16: time in not documented, out at 1:19a, in at 2:14a, then out 6:05a.- Resident #5 Record review of Resident #5's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old female readmitted to the facility from the hospital on [DATE] and had [DIAGNOSES REDACTED]. Record review of Resident #5's MDS dated [DATE] reflected the resident was continent of bowel and bladder. Review reflected the resident was dependent upon staff for mobility and transfers. Review reflected a BIMS of 15 indicating intact cognition. Observation of Resident #5 conducted on 2/2/16 at 12:10pm reflected the resident was dependent upon a wheelchair for mobility. Confidential Interview E stated CNA #1 did not want to provide care to Resident #5. It was stated Resident #5 would push the call button to request assistance to the toilet. CNA #1 would turn off the call light without providing care and walk out of the room saying yeah, uh huh. It was stated Resident #5 had more than 1 episode of urinary incontinence due to CNA #1's refusal to provide care. It was stated Resident #5 had to receive incontinent care from CNA #6 during CNA #1's shift. It was stated CNA #1 had yelled at Resident #5 and had placed the resident's call light out of reach. Confidential Interview E stated CNA #1 had treated the resident in such a manner for weeks; the resident was intimidated by CNA #1 and reluctant to report mistreatment. Confidential Family Interview A was aware that Confidential Interview E did not report CNA #1's mistreatment for [REDACTED].#1 against the resident or loved ones and tearfully begged that Confidential Family A also not report. Interviews conducted with witnesses of CNA #1's mistreatment of [REDACTED].>a. Confidential Interview C stated Resident #4 had witnessed CNA #1 verbally abuse other residents. It was stated All I witnessed is verbal. Things you would not want said to you or ones you cared about. It was stated incidents went unreported for fear of retaliation because CNA #1 was a current employee. b. Confidential Interview G frowned, shook head, made a sign of the cross, then made a zipping motion across closed mouth when asked to describe CNA #1 and repeated the motion when assured statements would be kept confidential. Confidential Interview G had no issues with other staff. Record review of CNA #1's Employee Corrective Action Form dated 1/25/16, signed by the ADM and CNA #1 reflected CNA #1 received a written warning for verbal abuse and neglect. The Reason for Action was Employee was heard talking loud & harsh using curse words. Taking a resident's call light out of his reach. The document reflected Action Required: Take 2 extra courses on (electronic training program) & will be on probation for 1 month. He was suspended from 1-18-2016 till 1-25-16. Review of the facility's Education Completion Report for the dates of 1/1/16 through 2/3/16 reflected CNA #1 completed 2 courses on 1/21/16: Preventing, Recognizing, and Reporting Resident Abuse and Residents' Rights. The date due for both courses was 1/31/16. CNA #1 received 1 credit hour for each course. In an interview conducted with the ADM on 2/3/16 at 2:37pm, when asked what her findings were regarding the allegations of abuse made against CNA #1, she stated she had not made a determination. In review of the provider investigation report she submitted on 1/24/16 documenting CNA #1 was suspended pending the outcome of investigation, when asked why CNA #1 was allowed to resume normal work duties on 1/25/16 she stated she did not think his actions were abuse and that he was being monitored. When asked what monitoring was performed and by whom, she stated CNA #1 was not being monitored. When asked why CNA #1 was physically present in the facility on 1/21/16, a suspension day, to take 2 hours of his mandatory annual training, she stated she told him to leave the building when she saw him that day. In review of CNA #1's Employee Corrective Action Form dated 1/25/16, she stated the 2 modules CNA #1 completed was not part of the disciplinary action; they were mandatory annual training. CNA #1 did not complete the extra 2 training modules as disciplinary action. When asked what she considered placing call lights out of reach of residents, she stated abuse. When asked why she did not put protections in place when CNA #1 admitted to the incidents with Residents #1and #2, and only denied cursing and raising his voice during the incident with Resident #1, she stated she maybe should have terminated CNA #1. The ADM's inflection made the statement a question. She stated CNA #1 needed more training and monitoring. When asked why the facility investigation did not address the allegation regarding Resident #11, the ADM stated she spoke with Resident #11 and was told nothing happened. When asked if Resident #11's cognitive status allowed recall, she stated no. Resident #10 Review of Resident #10's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old male admitted to the facility from the hospital on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident #10's annual comprehensive MDS dated [DATE] reflected a BIMS of 6 indicating severe cognitive impairment. The resident had unclear speech (slurred or mumbled), could usually make self understood, could usually understand others and had minimal difficulty hearing. Review of ADLs reflected the resident required staff assistance with all ADLs except for eating; had functional limitations in range of motion to the upper and lower extremities and required a wheelchair for mobility. The resident was frequently incontinent of bowel and bladder. The MDS reflected hospice status. Observation of Resident #10 conducted during initial tour on 2/3/16 at 9:20am reflected the Resident was dependent upon a wheelchair for mobility. Confidential Interview B stated CNA #1's treatment of [REDACTED]. It was stated that Resident #2 pushed the call button at 9pm for urinary incontinent care during CNA #1's last shift. CNA #6 answered the call light and left the room without providing care. At 10:25pm, Resident #10 pushed the call button and CNA #1 responded. Resident #10 requested incontinent care when CNA #1 asked what he needed. Confidential Interview B stated Resident #10 told CNA #1 that he was wet with urine since 9pm. CNA #1 stated that rounds were not until 3am, took the resident's clock from the wall and left the room without providing care. It was stated this was not the only incident with CNA #1; it was the most recent. It was stated CNA #1 made Resident #10 feel insignificant and worthless. Review of the facility's Operational Policy and Procedure Manual for Long -Term Care, Resident Behavior and Facility Practices revised April 2015 showed the following procedures under the section titled Abuse Prevention: -Reporting Abuse to Facility Management: 4. Employees, facility consultants and/or attending physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the DON such reports may be made to the nurse supervisor on duty. 5. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator, DON, or charge nurse. 9. When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of time lapse since the incident occurred. -- -Reporting Abuse to State Agencies and Other Entities/Individuals: 2. Verbal/written notices to agencies will be made within 24 hours of the occurrence of such incident. Notices will include as appropriate: e. The names of all persons involved in the alleged incident. f. What immediate action was taken by the facility. 5. Should the allegations be true, the employee(s) will be terminated from employment.-- -Abuse investigations: 3. Investigations must include at a minimum 10 components including: interview any witnesses to the incident, interview staff members who have had contact with the resident during the period of the alleged incident; interview the resident's roommate, family members, and visitors; interview other residents to whom the accused employee provides care or services; and review all events leading up to the alleged incident. 8. Employees of the facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation. 14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, and other officials, within 5 working days of the reported incident.-- -Protection of Residents During Abuse Investigations: 1. During abuse investigations, residents will be protected from harm by: a. Employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended until the findings of the investigation have been reviewed by the Administrator. b. Should the employee(s) be reassigned to non-resident care duties, such assignment will not be in any part of the building which the resident frequents.-- -Preventing Resident Abuse: 2.i. Monitoring staff on all shifts to identify inappropriate behaviors toward residents (e.g., using derogatory language, rough handling of residents, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their clothing/beds, etc.)-- -Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures: 1. The Administrator has the overall responsibility for the coordination and implementation of our facility's abuse prevention program policies and procedures.-- Review of the operational manual, policy Recognizing Signs and Symptoms of Abuse/Neglect revised 1/2011 reflected the facility defined abuse as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish; defined neglect as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. Record review of the facility's Nursing Schedule dated February 2016 reflected CNA #1 was off 2/1/16-2/2/16 and was scheduled to work the 6p to 6a shift, 2/3/16-2/4/16. In an interview conducted with the ADM on 2/3/16 at 6:15pm, when asked what staff was on duty for the 6p-6a shift, she stated 2 CNA's from the day shift would be on duty and she called in a CNA who worked nights to come in on her scheduled day off. She stated CNA #1 and CNA #6 were scheduled but were no call, no shows. The facility was unable to assist the surveyor with obtaining an interview with CNA #1; he could not be reached by phone call or by text message. She stated the facility had made the decision to terminate CNA #1 because of something unrelated to the allegations under investigation pertaining to Residents #1, #2 and #11. When asked to clarify, the ADM stated Resident #10 made an allegation against CNA #1. The incident occurred on the last shift worked by CNA #1. CNA #1 answered Resident #10's call light twice, did not provide incontinent care either time, and removed his clock from his room so that the resident could not track how long he had been wet with urine. The first request for assistance was at 9pm; the second request at 10:25pm. The clock was removed from the room at 10:25pm. CNA #1 told the resident he could not provide care to the resident because rounds were not until 3. The facility's administrator ADON, BOM, and Regional Director of Operations were notified on 2/3/16 at 6:30pm that an Immediate Jeopardy situation had been identified due to the facility's failure to prevent CNA #1's abuse of residents and the failure to protect residents from further abuse by CNA #1 once allegations were made. The Plan of Removal was accepted on 2/4/16 and included the following interventions confirmed by the surveyor: 1. CNA #1 was terminated confirmed by review of the Employee Corrective Action form dated 2/3/16 and by observation that CNA #1 was not on duty during his scheduled shift on 2/3/16-2/4/16. 2. The facility initiated staff in-services on identification of abuse and neglect and reporting procedures. This was confirmed by observation of the staff meeting, review of in-service sign-in sheet and interviews with 4 direct care staff. Interviews with direct care staff confirmed staff knowledge of identifying and reporting abuse. 3. The licensed clinical social worker, also the therapist for several residents, was scheduled to provide staff in-services on abuse and neglect, psychiatric [DIAGNOSES REDACTED]. Interview with the clinical social worker confirmed the in-services would continue indefinitely as necessary. 4. The facility conducted resident satisfaction surveys; results reported to licensed clinical social worker for mental health care and follow-up. Observation of the clinical social worker performing rounds at the facility on 2/4/16, interview with residents affected by the deficient practice, interview with the clinical social worker, and records reviewed dated 2/3/16 documenting the resident satisfaction surveys confirmed the intervention was implemented. The facility was notified on 2/4/16 that at 5:12pm the IJ was removed. However, the facility remained out of compliance at a severity of potential for more than minimal harm with a scope identified as widespread. The facility will continue to provide aftercare to residents victimized by CNA #1; to in-service facility staff and agency staff; to monitor staff completion of computer based courses on abuse and to monitor orientation of new staff on abuse and reporting requirements. Review of the resident roster provided by the facility on 2/2/16 reflected a census of 36.

Based on observation, interview and record review the facility failed to operationalize its written policies and procedures for training employees, protection of residents and for the prevention, identification, investigation and reporting of abuse, neglect and mistreatment for 5 of 11 residents (#s 1, 2, 5, 10, and 11) reviewed for abuse. 1. Staff failed to immediately report CNA #1's mistreatment of [REDACTED].#2, and #11 to the ADM, who was the Abuse Coordinator. CNA #1 worked 2 full shifts before initiation of the facility's incident investigation and his subsequent 2 day suspension. 2. The ADM's failure to thoroughly investigate allegations of CNA #1's mistreatment of [REDACTED].#5, #10) mistreated by CNA #1. The ADM failed to identify CNA #1's behavior towards the residents as abusive. 3. The facility failed to implement its policy and procedure to protect residents from further mistreatment by allowing CNA #1 to resume normal duties without making a final determination of findings and without monitoring his treatment of [REDACTED].#1 mistreated Resident #10 after the facility became aware of the abuse allegations. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 2/3/16. While the IJ was removed on 2/4/16, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as widespread. The facility was continuing to in-service staff on abuse prevention/identification/reporting and providing residents with mental health care. The facility's failure to operationalize its policies and procedures regarding identifying/reporting/investigating abuse and protection of residents during investigation caused mental and psychosocial harm to 5 residents (#s 1, 2, 11, 5 and 10) with the potential to harm the psychosocial well-being of the other 31 residents dependent upon staff assistance for care, by placing at risk for mistreatment and degradation through continued contact with CNA #1. Findings include: Resident #1 Record review of Resident #1's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old female admitted to the facility on [DATE] from a behavioral health facility and had [DIAGNOSES REDACTED]. Record review of Resident #1's admission comprehensive MDS dated [DATE] reflected a BIMS score of 15 indicating the resident was cognitively intact. Review of Resident #1's functional status reflected she was dependent upon staff assistance with all ADLs except for eating and was continent of bowel and bladder. The resident had range of motion impairment to both extremities of one side of the body and used a wheelchair for mobility. Observation of Resident #1 conducted on 2/2/16 at 12:36pm revealed the resident had functional limitations to the left side of the body and used a wheelchair for mobility. In an interview with the AD on 2/2/16 at 1:43pm, she stated on Saturday the 16th at 6:15pm, Resident #1 approached the nurses' station in her motorized wheelchair and asked for assistance with opening her snack. CNA #1 approached the nurses' station while yelling and cursing at Resident #1 for blocking the hallway by the nurses' station with her motorized wheelchair and directed her to move. CNA #1 used the control on the back of the chair to move the resident. The resident became very upset and shouted at CNA #1 to not touch her wheelchair voicing fear he would damage the chair. He responded by telling the resident that he would throw the chair out the door and the resident could leave with it. The AD reported the incident to the ADM the following Monday. She stated she should have reported the incidents when they occurred. Confidential Interview A stated that CNA #1 caused the resident anxiety; Resident #1 would rather risk incontinence and hold her bladder and bowels than to ask CNA #1 for assistance with toileting. Confidential Interview A stated Resident #1 could self-toilet and only required assistance with pulling down/pulling up the pants; the resident had use of only one hand. Confidential Interview A stated that CNA #1 called Resident #1 the expletive f***ing b**ch. It was stated, with head lowered and eyes filled with tears, that CNA #1's treatment of [REDACTED]. Confidential Interview A stated Resident #1 avoided asking CNA #1 for assistance because of the demeaning manner in which he spoke to Resident #1. It was stated Resident #1 did not feel comfortable voicing grievances about CNA #1; the process did not provide resolution. Resident #2 Record review of Resident #2's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old male admitted to the facility 9/20/13 from home and had [DIAGNOSES REDACTED]. Record review of Resident #2's comprehensive MDS dated [DATE] reflected the resident had a BIMS of 6 indicating severe cognitive impairment. Review reflected the resident was totally dependent upon staff for all ADLs except for eating and was incontinent of bowel and bladder. He had functional limitations in range of motion to the upper and lower extremities. Observation of Resident #2 conducted during the initial tour on 2/2/16 at 9:47am revealed the resident was dependent upon a Geri-chair for mobility and had no functional use of the lower extremities. During Confidential Interview B it was stated that CNA #1 had taken Resident #2's call light and placed it out of his reach and cursed him. It was stated the call light was taken from the resident for asking for coffee. It was stated CNA #1 told the resident his light would be taken away and the resident could not do anything about it. Confidential Interview B stated Resident #2 felt awful and belittled and it was obvious CNA #1 did not care about the residents. Confidential Interview B revealed Resident #2 was distressed and angered by CNA #1. In an interview with RN #1 on 2/3/16 at 3:28pm, he stated he did observe Resident #2's call light not within his reach and when he asked why, the resident stated CNA #1 took it away the night before for being on it too much. When asked if he had observed CNA #1 curse at residents, RN#1 paused, then stated CNA #1 has the language, (curses) but he had not observed it directed at residents. He stated it would not surprise him if CNA #1 cursed at residents. Resident #11 Review of Resident #11's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old male re-admitted to the facility on [DATE] from the hospital and had [DIAGNOSES REDACTED]. Record review of Resident #11's annual comprehensive MDS dated [DATE] reflected the resident's vision was severely impaired; his hearing was adequate. The resident had a BIMS of 5 indicating severe cognitive impairment and was not oriented to time and had difficulty with recall. Review of functional status reflected the resident was totally dependent upon staff for all ADLs except eating. He had functional limitations in range of motion of both upper and lower extremities and required a wheelchair for mobility. The resident was incontinent of bowel and bladder. Observation of Resident #11 conducted on 2/2/16 at 7:02pm revealed the resident was dependent upon a wheelchair for mobility and required extensive assistance with transfers. Observation revealed staff did not have to raise their voice when speaking to the resident; he had adequate hearing. In an interview with the AD on 2/2/16 at 1:43pm, she stated on Saturday 1/16/16, shortly after shift change, she was about to leave the facility after checking on her grandmother, a resident. She observed Resident #11 seated in his wheelchair in the hall across from the nurses' station. Resident #11 asked CNA #1 if it was his shower night, a question the resident asked each day, to which CNA #1 leaned down to place his face close to the resident's face and exclaimed no in a prolonged verbalization and raised voice. The resident responded by saying okay. Confidential Interview H stated Resident #11 was unable to remember any incidents involving CNA #1. Confidential Interview H stated Resident #11 was unable to recall what the resident had eaten for breakfast that day. --Record review of Form 3613-A Provider Investigation Report signed and dated by the ADM on 1/24/16 reflected: 1. The AD reported CNA #1's mistreatment of [REDACTED]. 2. On Saturday 1/16/16 at 6:15p, the AD was providing assistance to Resident #1 with opening a snack package at the facility's only nurses' station. Resident #1 was seated in her motorized wheelchair. CNA #1 approached the nurses' station while yelling and cursing at Resident #1 for blocking the hallway by the nurses' station with her motorized wheelchair and directed her to move. CNA #1 used the control located behind the resident's chair to propel the wheelchair without her approval. The resident shouted at CNA #1 to not touch her wheelchair voicing fear he would damage the chair. He responded by threatening to throw out the chair, if damaged, and told her she could leave the facility as well. The AD reported the incident to the ADM. The ADM's interview with Resident #1 corroborated the AD's incident report. The ADM reported this incident to the appropriate investigating authority. 3. CNA #1's written statement included with the Provider Investigation Report, dated 1/22/16 at 3:01pm reflected he told Resident #1 to stop blocking the area by the nurses' station, to go to her room, and propelled her wheelchair for her. CNA #1 documented Resident #1 had already been told not to crowd the nurses' station. CNA #1 wrote he did not curse at the resident and spoke to her kindly and respectfully. 4. Before the incident with Resident #1, the AD witnessed Resident #11 ask CNA #1 if it was his shower night and CNA #1 yell No directly into Resident #11's face. The resident asked that question daily. This incident was not reported to the appropriate authority and was revealed in the facility investigation. 5. On 1/17/16, RN #1 observed Resident #2 lying in bed with his call light not within his reach. Resident #2 reported CNA #1 placed the call light out of his reach the prior evening because the resident kept calling for assistance; the resident wanted coffee. Interview with the resident corroborated RN #1's statement. This incident was not reported to the appropriate authority and was revealed in the facility investigation. 6. CNA #1's written statement included in the facility investigation dated 1/21/16 at 10:38am documented he placed Resident #2's call light out of his reach. The statement reflected each time Resident #2 called for assistance he would state to CNA #1 nothing from you when CNA #1 asked what the resident needed. 7. CNA #1 was suspended pending the outcome of the investigation. 8. The facility's findings were inconclusive; the ADM documented she needed the agency nurse on duty when the incidents occurred to provide a statement before she could make a determination. The ADM documented she could not make a decision because the statements obtained were he-said, she-said.- 9. The facility's documented immediate plan: a) Have an impartial person talk to each interviewable resident to ascertain whether the residents had witnessed the incidents or had similar incidents with CNA #1. b) Conduct in-services, one-on-one and in groups with all staff on abuse and reporting for 2 months or longer if needed.-- Record review of the facility's Nursing Schedule dated January 2016 reflected CNA #1 was assigned the 6p-6a shift with CNA #6. Review reflected CNA #1's schedule for the days of 1/18/16 to 1/25/16: off 1/18/16 and 1/19/16, on 1/20/16 and 1/21/16, off 1/22/16, 1/23/16 and 1/24/16, and back on duty 1/25/16. Review reflected 1/18/16-1/19/16 and 1/22/16-1/24/16 were scheduled off days per the rotation. Review reflected CNA #1's suspension pertained only to 1/20/16 and 1/21/16. Review reflected CNA #1 was scheduled to work 1/25/16-1/26/16 and 1/29/16-1/31/16. Review reflected the document did not reflect CNA #1's suspension. In an interview with the ADON on 2/2/16 at 6:15pm, she stated CNA #1 was suspended for 2 days, 1/20/16 and 1/21/16. On 2/3/16 at 11:41am, the surveyor requested the facility's assistance with obtaining an interview with CNA #1; surveyor attempts to contact CNA #1 by phone were unsuccessful. In an interview conducted with the ADM on 2/3/16 at 12:06pm the ADM stated she took immediate action in response to the allegations reported by staff by suspending CNA #1 from 1/18/16 to 1/25/16 without pay rather than opting to assign him to no-resident contact duties. Suspension meant CNA #1 was not allowed in the building. In review of the January 2016 staffing schedule, she acknowledged 5 of the 8 days of suspension were his scheduled off days. She stated CNA #1 resumed his normal work duties on 1/25/16. When asked why she needed a statement from Agency LVN #1, the nurse on duty when the incidents occurred, to determine the findings when she had witness statements from staff and corroborating resident statements,, she stated so far the allegation was he said-she said. She stated only Residents #1 and #2 were interviewed. She could not find an impartial person to interview the rest of the residents. The ADM stated no in-services had been conducted as a result of the investigation. --Review of the facility's Payroll Summary reports for the dates of 1/16/16 through 1/27/16 reflected CNA #1's time clock punch detail: 1. 1/16/16: in at 6:03p, out at 6:06a 2. 1/17/16: in at 6:15p, out at 5:58a 3. 1/25/16: in at 6:32p, out at 6:16a 4. 1/27/16: time in not documented, out at 1:19a, in at 2:14a, then out 6:05a.- Resident #5 Record review of Resident #5's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old female readmitted to the facility from the hospital on [DATE] and had [DIAGNOSES REDACTED]. Record review of Resident #5's MDS dated [DATE] reflected the resident was continent of bowel and bladder. Review reflected the resident was dependent upon staff for mobility and transfers. Review reflected a BIMS of 15 indicating intact cognition. Observation of Resident #5 conducted on 2/2/16 at 12:10pm reflected the resident was dependent upon a wheelchair for mobility. Confidential Interview E stated CNA #1 did not want to provide care to Resident #5. It was stated Resident #5 would push the call button to request assistance to the toilet. CNA #1 would turn off the call light without providing care and walk out of the room saying yeah, uh huh. It was stated Resident #5 had more than 1 episode of urinary incontinence due to CNA #1's refusal to provide care. It was stated Resident #5 had to receive incontinent care from CNA #6 during CNA #1's shift. It was stated CNA #1 had yelled at Resident #5 and had placed the resident's call light out of reach. Confidential Interview E stated CNA #1 had treated the resident in such a manner for weeks; the resident was intimidated by CNA #1 and reluctant to report mistreatment. Confidential Family Interview A was aware that Confidential Interview E did not report CNA #1's mistreatment for [REDACTED].#1 against the resident or loved ones and tearfully begged that Confidential Family A also not report. Interviews conducted with witnesses of CNA #1's mistreatment of [REDACTED].>a. Confidential Interview C stated Resident #4 had witnessed CNA #1 verbally abuse other residents. It was stated All I witnessed is verbal. Things you would not want said to you or ones you cared about. It was stated incidents went unreported for fear of retaliation because CNA #1 was a current employee. b. Confidential Interview G frowned, shook head, made a sign of the cross, then made a zipping motion across closed mouth when asked to describe CNA #1 and repeated the motion when assured statements would be kept confidential. Confidential Interview G had no issues with other staff. Record review of CNA #1's Employee Corrective Action Form dated 1/25/16, signed by the ADM and CNA #1 reflected CNA #1 received a written warning for verbal abuse and neglect. The Reason for Action was Employee was heard talking loud & harsh using curse words. Taking a resident's call light out of his reach. The document reflected Action Required: Take 2 extra courses on (electronic training program) & will be on probation for 1 month. He was suspended from 1-18-2016 till 1-25-16. Review of the facility's Education Completion Report for the dates of 1/1/16 through 2/3/16 reflected CNA #1 completed 2 courses on 1/21/16: Preventing, Recognizing, and Reporting Resident Abuse and Residents' Rights. The date due for both courses was 1/31/16. CNA #1 received 1 credit hour for each course. In an interview conducted with the ADM on 2/3/16 at 2:37pm, when asked what her findings were regarding the allegations of abuse made against CNA #1, she stated she had not made a determination. In review of the provider investigation report she submitted on 1/24/16 documenting CNA #1 was suspended pending the outcome of investigation, when asked why CNA #1 was allowed to resume normal work duties on 1/25/16 she stated she did not think his actions were abuse and that he was being monitored. When asked what monitoring was performed and by whom, she stated CNA #1 was not being monitored. When asked why CNA #1 was physically present in the facility on 1/21/16, a suspension day, to take 2 hours of his mandatory annual training, she stated she told him to leave the building when she saw him that day. In review of CNA #1's Employee Corrective Action Form dated 1/25/16, she stated the 2 modules CNA #1 completed was not part of the disciplinary action; they were mandatory annual training. CNA #1 did not complete the extra 2 training modules as disciplinary action. When asked what she considered placing call lights out of reach of residents, she stated abuse. When asked why she did not put protections in place when CNA #1 admitted to the incidents with Residents #1and #2, and only denied cursing and raising his voice during the incident with Resident #1, she stated she maybe should have terminated CNA #1. The ADM's inflection made the statement a question. She stated CNA #1 needed more training and monitoring. When asked why the facility investigation did not address the allegation regarding Resident #11, the ADM stated she spoke with Resident #11 and was told nothing happened. When asked if Resident #11's cognitive status allowed recall, she stated no. Resident #10 Review of Resident #10's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old male admitted to the facility from the hospital on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident #10's annual comprehensive MDS dated [DATE] reflected a BIMS of 6 indicating severe cognitive impairment. The resident had unclear speech (slurred or mumbled), could usually make self understood, could usually understand others and had minimal difficulty hearing. Review of ADLs reflected the resident required staff assistance with all ADLs except for eating; had functional limitations in range of motion to the upper and lower extremities and required a wheelchair for mobility. The resident was frequently incontinent of bowel and bladder. The MDS reflected hospice status. Observation of Resident #10 conducted during initial tour on 2/3/16 at 9:20am reflected the Resident was dependent upon a wheelchair for mobility. Confidential Interview B stated CNA #1's treatment of [REDACTED]. It was stated that Resident #2 pushed the call button at 9pm for urinary incontinent care during CNA #1's last shift. CNA #6 answered the call light and left the room without providing care. At 10:25pm, Resident #10 pushed the call button and CNA #1 responded. Resident #10 requested incontinent care when CNA #1 asked what he needed. Confidential Interview B stated Resident #10 told CNA #1 that he was wet with urine since 9pm. CNA #1 stated that rounds were not until 3am, took the resident's clock from the wall and left the room without providing care. It was stated this was not the only incident with CNA #1; it was the most recent. It was stated CNA #1 made Resident #10 feel insignificant and worthless. Review of the facility's Operational Policy and Procedure Manual for Long -Term Care, Resident Behavior and Facility Practices revised April 2015 showed the following procedures under the section titled Abuse Prevention: -Reporting Abuse to Facility Management: 4. Employees, facility consultants and/or attending physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the DON such reports may be made to the nurse supervisor on duty. 5. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator, DON, or charge nurse. 9. When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of time lapse since the incident occurred. -- -Reporting Abuse to State Agencies and Other Entities/Individuals: 2. Verbal/written notices to agencies will be made within 24 hours of the occurrence of such incident. Notices will include as appropriate: e. The names of all persons involved in the alleged incident. f. What immediate action was taken by the facility. 5. Should the allegations be true, the employee(s) will be terminated from employment.-- -Abuse investigations: 3. Investigations must include at a minimum 10 components including: interview any witnesses to the incident, interview staff members who have had contact with the resident during the period of the alleged incident; interview the resident's roommate, family members, and visitors; interview other residents to whom the accused employee provides care or services; and review all events leading up to the alleged incident. 8. Employees of the facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation. 14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, and other officials, within 5 working days of the reported incident.-- -Protection of Residents During Abuse Investigations: 1. During abuse investigations, residents will be protected from harm by: a. Employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended until the findings of the investigation have been reviewed by the Administrator. b. Should the employee(s) be reassigned to non-resident care duties, such assignment will not be in any part of the building which the resident frequents.-- -Preventing Resident Abuse: 2.i. Monitoring staff on all shifts to identify inappropriate behaviors toward residents (e.g., using derogatory language, rough handling of residents, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their clothing/beds, etc.)-- -Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures: 1. The Administrator has the overall responsibility for the coordination and implementation of our facility's abuse prevention program policies and procedures.-- Review of the operational manual, policy Recognizing Signs and Symptoms of Abuse/Neglect revised 1/2011 reflected the facility defined abuse as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish; defined neglect as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. Record review of the facility's Nursing Schedule dated February 2016 reflected CNA #1 was off 2/1/16-2/2/16 and was scheduled to work the 6p to 6a shift, 2/3/16-2/4/16. In an interview conducted with the ADM on 2/3/16 at 6:15pm, when asked what staff was on duty for the 6p-6a shift, she stated 2 CNA's from the day shift would be on duty and she called in a CNA who worked nights to come in on her scheduled day off. She stated CNA #1 and CNA #6 were scheduled but were no call, no shows. The facility was unable to assist the surveyor with obtaining an interview with CNA #1; he could not be reached by phone call or by text message. She stated the facility had made the decision to terminate CNA #1 because of something unrelated to the allegations under investigation pertaining to Residents #1, #2 and #11. When asked to clarify, the ADM stated Resident #10 made an allegation against CNA #1. The incident occurred on the last shift worked by CNA #1. CNA #1 answered Resident #10's call light twice, did not provide incontinent care either time, and removed his clock from his room so that the resident could not track how long he had been wet with urine. The first request for assistance was at 9pm; the second request at 10:25pm. The clock was removed from the room at 10:25pm. CNA #1 told the resident he could not provide care to the resident because rounds were not until 3. The facility's administrator ADON, BOM, and Regional Director of Operations were notified on 2/3/16 at 6:30pm that an Immediate Jeopardy situation had been identified due to the facility's failure to prevent CNA #1's abuse of residents and the failure to protect residents from further abuse by CNA #1 once allegations were made. The Plan of Removal was accepted on 2/4/16 and included the following interventions confirmed by the surveyor: 1. CNA #1 was terminated confirmed by review of the Employee Corrective Action form dated 2/3/16 and by observation that CNA #1 was not on duty during his scheduled shift on 2/3/16-2/4/16. 2. The facility initiated staff in-services on identification of abuse and neglect and reporting procedures. This was confirmed by observation of the staff meeting, review of in-service sign-in sheet and interviews with 4 direct care staff. Interviews with direct care staff confirmed staff knowledge of identifying and reporting abuse. 3. The licensed clinical social worker, also the therapist for several residents, was scheduled to provide staff in-services on abuse and neglect, psychiatric [DIAGNOSES REDACTED]. Interview with the clinical social worker confirmed the in-services would continue indefinitely as necessary. 4. The facility conducted resident satisfaction surveys; results reported to licensed clinical social worker for mental health care and follow-up. Observation of the clinical social worker performing rounds at the facility on 2/4/16, interview with residents affected by the deficient practice, interview with the clinical social worker, and records reviewed dated 2/3/16 documenting the resident satisfaction surveys confirmed the intervention was implemented. The facility was notified on 2/4/16 that at 5:12pm the IJ was removed. However, the facility remained out of compliance at a severity of potential for more than minimal harm with a scope identified as widespread. The facility will continue to provide aftercare to residents victimized by CNA #1; to in-service facility staff and agency staff; to monitor staff completion of computer based courses on abuse and to monitor orientation of new staff on abuse and reporting requirements. Review of the resident roster provided by the facility on 2/2/16 reflected a census of 36.

Based on observation, interview and record review the facility failed to maintain a quality assessment and assurance committee that evaluated systems and developed and implemented appropriate plans of action to correct identified quality deficiencies for 5 of 11 residents (#s 1, 2, 11, 5 and 10) reviewed for quality assurance. Following staff report of CNA #1's abuse of Residents #1, #2, and #11, the facility failed to utilize QAA meetings to thoroughly investigate and evaluate the safety and quality of care for all residents with whom CNA #1 had direct contact, and implement procedures to correct, monitor or prevent the abuse of other residents (#5 and #10). This deficient practice resulted in an identification of an Immediate Jeopardy (IJ) on 2/3/16. While the IJ was removed on 2/4/16, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as widespread. The facility was continuing to in-service staff on abuse prevention/identification/reporting and providing residents with mental health care. Failure of the QAA committee to function effectively caused mental and psychosocial harm to 5 residents (#s 1, 2, 11, 5 and 10) with the potential to harm the psychosocial well-being of the other 31 residents dependent upon staff assistance for care, by placing at risk for mistreatment and degradation through continued contact with CNA #1. Findings include: Resident #1 Record review of Resident #1's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old female admitted to the facility on [DATE] from a behavioral health facility and had [DIAGNOSES REDACTED]. Record review of Resident #1's admission comprehensive MDS dated [DATE] reflected a BIMS score of 15 indicating the resident was cognitively intact. Review of Resident #1's functional status reflected she was dependent upon staff assistance with all ADLs except for eating and was continent of bowel and bladder. The resident had range of motion impairment to both extremities of one side of the body and used a wheelchair for mobility. Observation of Resident #1 conducted on 2/2/16 at 12:36pm revealed the resident had functional limitations to the left side of the body and used a wheelchair for mobility. In an interview with the AD on 2/2/16 at 1:43pm, she stated on Saturday the 16th at 6:15pm, Resident #1 approached the nurses' station in her motorized wheelchair and asked for assistance with opening her snack. CNA #1 approached the nurses' station while yelling and cursing at Resident #1 for blocking the hallway by the nurses' station with her motorized wheelchair and directed her to move. CNA #1 used the control on the back of the chair to move the resident. The resident became very upset and shouted at CNA #1 to not touch her wheelchair voicing fear he would damage the chair. He responded by telling the resident that he would throw the chair out the door and the resident could leave with it. The AD reported the incident to the ADM the following Monday. She stated she should have reported the incidents when they occurred. Confidential Interview A stated that CNA #1 caused the resident anxiety; Resident #1 would rather risk incontinence and hold her bladder and bowels than to ask CNA #1 for assistance with toileting. Confidential Interview A stated Resident #1 could self-toilet and only required assistance with pulling down/pulling up the pants; the resident had use of only one hand. Confidential Interview A stated that CNA #1 called Resident #1 the expletive f***ing b**ch. It was stated, with head lowered and eyes filled with tears, that CNA #1's treatment of [REDACTED]. Confidential Interview A stated Resident #1 avoided asking CNA #1 for assistance because of the demeaning manner in which he spoke to Resident #1. It was stated Resident #1 did not feel comfortable voicing grievances about CNA #1; the process did not provide resolution. Resident #2 Record review of Resident #2's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old male admitted to the facility 9/20/13 from home and had [DIAGNOSES REDACTED]. Record review of Resident #2's comprehensive MDS dated [DATE] reflected the resident had a BIMS of 6 indicating severe cognitive impairment. Review reflected the resident was totally dependent upon staff for all ADLs except for eating and was incontinent of bowel and bladder. He had functional limitations in range of motion to the upper and lower extremities. Observation of Resident #2 conducted during the initial tour on 2/2/16 at 9:47am revealed the resident was dependent upon a Geri-chair for mobility and had no functional use of the lower extremities. During Confidential Interview B it was stated that CNA #1 had taken Resident #2's call light and placed it out of his reach and cursed him. It was stated the call light was taken from the resident for asking for coffee. It was stated CNA #1 told the resident his light would be taken away and the resident could not do anything about it. Confidential Interview B stated Resident #2 felt awful and belittled and it was obvious CNA #1 did not care about the residents. Confidential Interview B revealed Resident #2 was distressed and angered by CNA #1. In an interview with RN #1 on 2/3/16 at 3:28pm, he stated he did observe Resident #2's call light not within his reach and when he asked why, the resident stated CNA #1 took it away the night before for being on it too much. When asked if he had observed CNA #1 curse at residents, RN#1 paused, then stated CNA #1 has the language, (curses) but he had not observed it directed at residents. He stated it would not surprise him if CNA #1 cursed at residents. Resident #11 Review of Resident #11's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old male re-admitted to the facility on [DATE] from the hospital and had [DIAGNOSES REDACTED]. Record review of Resident #11's annual comprehensive MDS dated [DATE] reflected the resident's vision was severely impaired; his hearing was adequate. The resident had a BIMS of 5 indicating severe cognitive impairment and was not oriented to time and had difficulty with recall. Review of functional status reflected the resident was totally dependent upon staff for all ADLs except eating. He had functional limitations in range of motion of both upper and lower extremities and required a wheelchair for mobility. The resident was incontinent of bowel and bladder. Observation of Resident #11 conducted on 2/2/16 at 7:02pm revealed the resident was dependent upon a wheelchair for mobility and required extensive assistance with transfers. Observation revealed staff did not have to raise their voice when speaking to the resident; he had adequate hearing. In an interview with the AD on 2/2/16 at 1:43pm, she stated on Saturday 1/16/16, shortly after shift change, she was about to leave the facility after checking on her grandmother, a resident. She observed Resident #11 seated in his wheelchair in the hall across from the nurses' station. Resident #11 asked CNA #1 if it was his shower night, a question the resident asked each day, to which CNA #1 leaned down to place his face close to the resident's face and exclaimed no in a prolonged verbalization and raised voice. The resident responded by saying okay. Confidential Interview H stated Resident #11 was unable to remember any incidents involving CNA #1. Confidential Interview H stated Resident #11 was unable to recall what the resident had eaten for breakfast that day. --Record review of Form 3613-A Provider Investigation Report signed and dated by the ADM on 1/24/16 reflected: 1. The AD reported CNA #1's mistreatment of [REDACTED]. 2. On Saturday 1/16/16 at 6:15p, the AD was providing assistance to Resident #1 with opening a snack package at the facility's only nurses' station. Resident #1 was seated in her motorized wheelchair. CNA #1 approached the nurses' station while yelling and cursing at Resident #1 for blocking the hallway by the nurses' station with her motorized wheelchair and directed her to move. CNA #1 used the control located behind the resident's chair to propel the wheelchair without her approval. The resident shouted at CNA #1 to not touch her wheelchair voicing fear he would damage the chair. He responded by threatening to throw out the chair, if damaged, and told her she could leave the facility as well. The AD reported the incident to the ADM. The ADM's interview with Resident #1 corroborated the AD's incident report. The ADM reported this incident to the appropriate investigating authority. 3. CNA #1's written statement included with the Provider Investigation Report, dated 1/22/16 at 3:01pm reflected he told Resident #1 to stop blocking the area by the nurses' station, to go to her room, and propelled her wheelchair for her. CNA #1 documented Resident #1 had already been told not to crowd the nurses' station. CNA #1 wrote he did not curse at the resident and spoke to her kindly and respectfully. 4. Before the incident with Resident #1, the AD witnessed Resident #11 ask CNA #1 if it was his shower night and CNA #1 yell No directly into Resident #11's face. The resident asked that question daily. This incident was not reported to the appropriate authority and was revealed in the facility investigation. 5. On 1/17/16, RN #1 observed Resident #2 lying in bed with his call light not within his reach. Resident #2 reported CNA #1 placed the call light out of his reach the prior evening because the resident kept calling for assistance; the resident wanted coffee. Interview with the resident corroborated RN #1's statement. This incident was not reported to the appropriate authority and was revealed in the facility investigation. 6. CNA #1's written statement included in the facility investigation dated 1/21/16 at 10:38am documented he placed Resident #2's call light out of his reach. The statement reflected each time Resident #2 called for assistance he would state to CNA #1 nothing from you when CNA #1 asked what the resident needed. 7. CNA #1 was suspended pending the outcome of the investigation. 8. The facility's findings were inconclusive; the ADM documented she needed the agency nurse on duty when the incidents occurred to provide a statement before she could make a determination. The ADM documented she could not make a decision because the statements obtained were he-said, she-said. 9. The facility's documented immediate plan: a) Have an impartial person talk to each interviewable resident to ascertain whether the residents had witnessed the incidents or had similar incidents with CNA #1. b) Conduct in-services, one-on-one and in groups with all staff on abuse and reporting for 2 months or longer if needed.-- Record review of the facility's Nursing Schedule dated January 2016 reflected CNA #1 was assigned the 6p-6a shift with CNA #6. Review reflected CNA #1's schedule for the days of 1/18/16 to 1/25/16: off 1/18/16 and 1/19/16, on 1/20/16 and 1/21/16, off 1/22/16, 1/23/16 and 1/24/16, and back on duty 1/25/16. Review reflected 1/18/16-1/19/16 and 1/22/16-1/24/16 were scheduled off days per the rotation. Review reflected CNA #1's suspension pertained only to 1/20/16 and 1/21/16. Review reflected CNA #1 was scheduled to work 1/25/16-1/26/16 and 1/29/16-1/31/16. Review reflected the document did not reflect CNA #1's suspension. In an interview with the ADON on 2/2/16 at 6:15pm, she stated CNA #1 was suspended for 2 days, 1/20/16 and 1/21/16. On 2/3/16 at 11:41am, the surveyor requested the facility's assistance with obtaining an interview with CNA #1; surveyor attempts to contact CNA #1 by phone were unsuccessful. In an interview conducted with the ADM on 2/3/16 at 12:06pm the ADM stated she took immediate action in response to the allegations reported by staff by suspending CNA #1 from 1/18/16 to 1/25/16 without pay rather than opting to assign him to no-resident contact duties. Suspension meant CNA #1 was not allowed in the building. In review of the January 2016 staffing schedule, she acknowledged 5 of the 8 days of suspension were his scheduled off days. She stated CNA #1 resumed his normal work duties on 1/25/16. When asked why she needed a statement from Agency LVN #1, the nurse on duty when the incidents occurred, to determine the findings when she had witness statements from staff and corroborating resident statements, she stated so far the allegation was he said-she said. She stated only Residents #1 and #2 were interviewed. She could not find an impartial person to interview the rest of the residents. The ADM stated no in-services had been conducted as a result of the investigation. -Review of the facility's Payroll Summary reports for the dates of 1/16/16 through 1/27/16 reflected CNA #1's time clock punch detail: 1. 1/16/16: in at 6:03p, out at 6:06a 2. 1/17/16: in at 6:15p, out at 5:58a 3. 1/25/16: in at 6:32p, out at 6:16a 4. 1/27/16: time in not documented, out at 1:19a, in at 2:14a, then out 6:05a.-- Resident #5 Record review of Resident #5's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old female readmitted to the facility from the hospital on [DATE] and had [DIAGNOSES REDACTED]. Record review of Resident #5's MDS dated [DATE] reflected the resident was continent of bowel and bladder. Review reflected the resident was dependent upon staff for mobility and transfers. Review reflected a BIMS of 15 indicating intact cognition. Observation of Resident #5 conducted on 2/2/16 at 12:10pm reflected the resident was dependent upon a wheelchair for mobility. Confidential Interview E stated CNA #1 did not want to provide care to Resident #5. It was stated Resident #5 would push the call button to request assistance to the toilet. CNA #1 would turn off the call light without providing care and walk out of the room saying yeah, uh huh. It was stated Resident #5 had more than 1 episode of urinary incontinence due to CNA #1's refusal to provide care. It was stated Resident #5 had to receive incontinent care from CNA #6 during CNA #1's shift. It was stated CNA #1 had yelled at Resident #5 and had placed the resident's call light out of reach. Confidential Interview E stated CNA #1 had treated the resident in such a manner for weeks; the resident was intimidated by CNA #1 and reluctant to report mistreatment. Confidential Family Interview A was aware that Confidential Interview E did not report CNA #1's mistreatment for [REDACTED].#1 against the resident or loved ones and tearfully begged that Confidential Family A also not report. Interviews conducted with witnesses of CNA #1's mistreatment of [REDACTED].>a. Confidential Interview C stated Resident #4 had witnessed CNA #1 verbally abuse other residents. It was stated All I witnessed is verbal. Things you would not want said to you or ones you cared about. It was stated incidents went unreported for fear of retaliation because CNA #1 was a current employee. b. Confidential Interview G frowned, shook head, made a sign of the cross, then made a zipping motion across closed mouth when asked to describe CNA #1 and repeated the motion when assured statements would be kept confidential. Confidential Interview G had no issues with other staff. Record review of CNA #1's Employee Corrective Action Form dated 1/25/16, signed by the ADM and CNA #1 reflected CNA #1 received a written warning for verbal abuse and neglect. The Reason for Action was Employee was heard talking loud & harsh using curse words. Taking a resident's call light out of his reach. The document reflected Action Required: Take 2 extra courses on (electronic training program) & will be on probation for 1 month. He was suspended from 1-18-2016 till 1-25-16. Review of the facility's Education Completion Report for the dates of 1/1/16 through 2/3/16 reflected CNA #1 completed 2 courses on 1/21/16: Preventing, Recognizing, and Reporting Resident Abuse and Residents' Rights. The date due for both courses was 1/31/16. CNA #1 received 1 credit hour for each course. In an interview conducted with the ADM on 2/3/16 at 2:37pm, when asked what her findings were regarding the allegations of abuse made against CNA #1, she stated she had not made a determination. In review of the provider investigation report she submitted on 1/24/16 documenting CNA #1 was suspended pending the outcome of investigation, when asked why CNA #1 was allowed to resume normal work duties on 1/25/16 she stated she did not think his actions were abuse and that he was being monitored. When asked what monitoring was performed and by whom, she stated CNA #1 was not being monitored. When asked why CNA #1 was physically present in the facility on 1/21/16, a suspension day, to take 2 hours of his mandatory annual training, she stated she told him to leave the building when she saw him that day. In review of CNA #1's Employee Corrective Action Form dated 1/25/16, she stated the 2 modules CNA #1 completed was not part of the disciplinary action; they were mandatory annual training. CNA #1 did not complete the extra 2 training modules as disciplinary action. When asked what she considered placing call lights out of reach of residents, she stated abuse. When asked why she did not put protections in place when CNA #1 admitted to the incidents with Residents #1 and #2, and only denied cursing and raising his voice during the incident with Resident #1, she stated she maybe should have terminated CNA #1. The ADM's inflection made the statement a question. She stated CNA #1 needed more training and monitoring. When asked why the facility investigation did not address the allegation regarding Resident #11, the ADM stated she spoke with Resident #11 and was told nothing happened. When asked if Resident #11's cognitive status allowed recall, she stated no. Resident #10 Review of Resident #10's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old male admitted to the facility from the hospital on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident #10's annual comprehensive MDS dated [DATE] reflected a BIMS of 6 indicating severe cognitive impairment. The resident had unclear speech (slurred or mumbled), could usually make self understood, could usually understand others and had minimal difficulty hearing. Review of ADLs reflected the resident required staff assistance with all ADLs except for eating; had functional limitations in range of motion to the upper and lower extremities and required a wheelchair for mobility. The resident was frequently incontinent of bowel and bladder. The MDS reflected hospice status. Observation of Resident #10 conducted during initial tour on 2/3/16 at 9:20am reflected the Resident was dependent upon a wheelchair for mobility. Confidential Interview B stated CNA #1's treatment of [REDACTED]. It was stated that Resident #2 pushed the call button at 9pm for urinary incontinent care during CNA #1's last shift. CNA #6 answered the call light and left the room without providing care. At 10:25pm, Resident #10 pushed the call button and CNA #1 responded. Resident #10 requested incontinent care when CNA #1 asked what he needed. Confidential Interview B stated Resident #10 told CNA #1 that he was wet with urine since 9pm. CNA #1 stated that rounds were not until 3am, took the resident's clock from the wall and left the room without providing care. It was stated this was not the only incident with CNA #1; it was the most recent. It was stated CNA #1 made Resident #10 feel insignificant and worthless. Review of the facility's Operational Policy and Procedure Manual for Long -Term Care, Resident Behavior and Facility Practices revised April 2015 showed the following procedures under the section titled Abuse Prevention: -Reporting Abuse to Facility Management: 4. Employees, facility consultants and/or attending physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the DON such reports may be made to the nurse supervisor on duty. 5. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator, DON, or charge nurse. 9. When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of time lapse since the incident occurred. -- -Reporting Abuse to State Agencies and Other Entities/Individuals: 2. Verbal/written notices to agencies will be made within 24 hours of the occurrence of such incident. Notices will include as appropriate: e. The names of all persons involved in the alleged incident. f. What immediate action was taken by the facility. 5. Should the allegations be true, the employee(s) will be terminated from employment.-- -Abuse investigations: 3. Investigations must include at a minimum 10 components including: interview any witnesses to the incident, interview staff members who have had contact with the resident during the period of the alleged incident; interview the resident's roommate, family members, and visitors; interview other residents to whom the accused employee provides care or services; and review all events leading up to the alleged incident. 8. Employees of the facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation. 14. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, and other officials, within 5 working days of the reported incident.-- -Protection of Residents During Abuse Investigations: 1. During abuse investigations, residents will be protected from harm by: a. Employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended until the findings of the investigation have been reviewed by the Administrator. b. Should the employee(s) be reassigned to non-resident care duties, such assignment will not be in any part of the building which the resident frequents.-- -Preventing Resident Abuse: 2.i. Monitoring staff on all shifts to identify inappropriate behaviors toward residents (e.g., using derogatory language, rough handling of residents, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their clothing/beds, etc.)-- -Staff Responsible for Coordinating/Implementing Abuse Prevention Program Policies and Procedures: 1. The Administrator has the overall responsibility for the coordination and implementation of our facility's abuse prevention program policies and procedures.-- Review of the operational manual, policy Recognizing Signs and Symptoms of Abuse/Neglect revised 1/2011 reflected the facility defined abuse as willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish; defined neglect as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. Record review of the facility's policy and procedure dated April 2014, titled Quality Assurance and Performance Improvement (QAPI) Plan documents the following: Policy Statement: This facility shall develop, implement, and maintain, an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. Record review of the undated document entitled Position: Administrator reflected one essential job function of the ADM was to maintain a working knowledge of, and ensure compliance with, all governmental regulations and Company Quality Assurance Standards. Interview on 2/3/16 at 6:00 pm the Administrator stated that the committee meets monthly. She said that each department is supposed to fill out a form for any concerns it has and they go over it in the morning meetings. The staff brain storms on ways to fix an issue and if it does not work then go back to the drawing board. She was asked if the medical director was aware of the issue on abuse at the 1/19/16 QAA meeting and she said no but he was aware now of it. Record review of the facility's Nursing Schedule dated February 2016 reflected CNA #1 was off 2/1/16-2/2/16 and was scheduled to work the 6p to 6a shift, 2/3/16-2/4/16. In an interview conducted with the ADM on 2/3/16 at 6:15pm, when asked what staff was on duty for the 6p-6a shift, she stated 2 CNA's from the day shift would be on duty and she called in a CNA who worked nights to come in on her scheduled day off. She stated CNA #1 and CNA #6 were scheduled but were no call, no shows. The facility was unable to assist the surveyor with obtaining an interview with CNA #1; he could not be reached by phone call or by text message. She stated the facility had made the decision to terminate CNA #1 because of something unrelated to the allegations under investigation pertaining to Residents #1, #2 and #11. When asked to clarify, the ADM stated Resident #10 made an allegation against CNA #1. The incident occurred on the last shift worked by CNA #1. CNA #1 answered Resident #10's call light twice, did not provide incontinent care either time, and removed his clock from his room so that the resident could not track how long he had been wet with urine. The first request for assistance was at 9pm; the second request at 10:25pm. The clock was removed from the room at 10:25pm. CNA #1 told the resident he could not provide care to the resident because rounds were not until 3. The facility's administrator ADON, BOM, and Regional Director of Operations were notified on 2/3/16 at 6:30pm that an Immediate Jeopardy situation had been identified due to the facility's failure to prevent CNA #1's abuse of residents and the failure to protect residents from further abuse by CNA #1 once allegations were made. The Plan of Removal was accepted on 2/4/16 and included the following interventions confirmed by the surveyor: 1. CNA #1 was terminated confirmed by review of the Employee Corrective Action form dated 2/3/16 and by observation that CNA #1 was not on duty during his scheduled shift on 2/3/16-2/4/16. 2. The facility initiated staff in-services on identification of abuse and neglect and reporting procedures. This was confirmed by observation of the staff meeting, review of in-service sign-in sheet and interviews with 4 direct care staff. Interviews with direct care staff confirmed staff knowledge of identifying and reporting abuse. 3. The licensed clinical social worker, also the therapist for several residents, was scheduled to provide staff in-services on abuse and neglect, psychiatric [DIAGNOSES REDACTED]. Interview with the clinical social worker confirmed the in-services would continue indefinitely as necessary. 4. The facility conducted resident satisfaction surveys; results reported to licensed clinical social worker for mental health care and follow-up. Observation of the clinical social worker performing rounds at the facility on 2/4/16, interview with residents affected by the deficient practice, interview with the clinical social worker, and records reviewed dated 2/3/16 documenting the resident satisfaction surveys confirmed the intervention was implemented. The facility was notified on 2/4/16 that at 5:12pm the IJ was removed. However, the facility remained out of compliance at a severity of potential for more than minimal harm with a scope identified as widespread. The facility will continue to provide aftercare to residents victimized by CNA #1; to in-service facility staff and agency staff; to monitor staff completion of computer based courses on abuse and to monitor orientation of new staff on abuse and reporting requirements. Review of the resident roster provided by the facility on 2/2/16 reflected a census of 36.

Based on observation, interview and record review the facility failed to ensure residents had the right to be free from verbal abuse and mental abuse for 5 of 11 residents (#s 1, 2, 11, 5 and 10) reviewed for abuse: 1. CNA #1 cursed, yelled, threatened, and moved Resident #1 against her will. Resident #1 risked incontinent episodes, though continent, each 12 hour night shift worked by CNA #1 to avoid requesting his assistance to the toilet. CNA #1 caused Resident #1 anxiety and distress. 2. CNA #1 placed the call light out of the reach of Resident #2, who was bedbound, and cursed and yelled at the resident. Resident #2 was distressed by CNA #1 and felt belittled. 3. CNA #1 yelled in the face of Resident #11, who had moderate intellectual disability, for repeating a question. 4. Resident #5, who was continent, had incontinent episodes because CNA #1 would not provide her with assistance to the toilet. CNA #1 placed Resident #5's call light out of reach. CNA #1 caused Resident #5 distress, anxiety and fear of retaliation. 5. The facility allowed CNA #1 to continue providing unsupervised direct care to residents after allegations of abuse had been made against him resulting in further mistreatment of [REDACTED]. CNA #1 did not provide incontinent care to Resident #10 and removed the clock from the resident's room so the resident could not tell how long he had been wet with urine. CNA #1's mistreatment of [REDACTED]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 2/3/16. While the IJ was removed on 2/4/16, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as widespread. The facility was continuing to in-service staff on abuse prevention/identification/reporting and providing residents with mental health care. The facility's failure to ensure residents were free from verbal and mental abuse caused mental and psychosocial harm to 5 residents (#s 1, 2, 5, 11, and 10) with the potential to harm the psychosocial well-being of the other 31 residents dependent upon staff assistance for care, by placing at risk for mistreatment and degradation through continued contact with CNA #1. Findings include: Resident #1 Record review of Resident #1's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old female admitted to the facility on [DATE] from a behavioral health facility and had [DIAGNOSES REDACTED]. Record review of Resident #1's admission comprehensive MDS dated [DATE] reflected a BIMS score of 15 indicating the resident was cognitively intact. Review of Resident #1's functional status reflected she was dependent upon staff assistance with all ADLs except for eating and was continent of bowel and bladder. The resident had range of motion impairment to both extremities of one side of the body and used a wheelchair for mobility. Observation of Resident #1 conducted on 2/2/16 at 12:36pm revealed the resident had functional limitations to the left side of the body and used a wheelchair for mobility. In an interview with the AD on 2/2/16 at 1:43pm, she stated on Saturday the 16th at 6:15pm, Resident #1 approached the nurses' station in her motorized wheelchair and asked for assistance with opening her snack. CNA #1 approached the nurses' station while yelling and cursing at Resident #1 for blocking the hallway by the nurses' station with her motorized wheelchair and directed her to move. CNA #1 used the control on the back of the chair to move the resident. The resident became very upset and shouted at CNA #1 to not touch her wheelchair voicing fear he would damage the chair. He responded by telling the resident that he would throw the chair out the door and the resident could leave with it. The AD reported the incident to the ADM the following Monday. She stated she should have reported the incidents when they occurred. Confidential Interview A stated that CNA #1 caused the resident anxiety; Resident #1 would rather risk incontinence and hold her bladder and bowels than to ask CNA #1 for assistance with toileting. Confidential Interview A stated Resident #1 could self-toilet and only required assistance with pulling down/pulling up the pants; the resident had use of only one hand. Confidential Interview A stated that CNA #1 called Resident #1 the expletive f***ing b**ch. It was stated, with head lowered and eyes filled with tears, that CNA #1's treatment of [REDACTED]. Confidential Interview A stated Resident #1 avoided asking CNA #1 for assistance because of the demeaning manner in which he spoke to Resident #1. It was stated Resident #1 did not feel comfortable voicing grievances about CNA #1; the process did not provide resolution. Resident #2 Record review of Resident #2's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old male admitted to the facility 9/20/13 from home and had [DIAGNOSES REDACTED]. Record review of Resident #2's comprehensive MDS dated [DATE] reflected the resident had a BIMS of 6 indicating severe cognitive impairment. Review reflected the resident was totally dependent upon staff for all ADLs except for eating and was incontinent of bowel and bladder. He had functional limitations in range of motion to the upper and lower extremities. Observation of Resident #2 conducted during the initial tour on 2/2/16 at 9:47am revealed the resident was dependent upon a Geri-chair for mobility and had no functional use of the lower extremities. During Confidential Interview B it was stated that CNA #1 had taken Resident #2's call light and placed it out of his reach and cursed him. It was stated the call light was taken from the resident for asking for coffee. It was stated CNA #1 told the resident his light would be taken away and the resident could not do anything about it. Confidential Interview B stated Resident #2 felt awful and belittled and it was obvious CNA #1 did not care about the residents. Confidential Interview B revealed Resident #2 was distressed and angered by CNA #1. In an interview with RN #1 on 2/3/16 at 3:28pm, he stated he did observe Resident #2's call light not within his reach and when he asked why, the resident stated CNA #1 took it away the night before for being on it too much. When asked if he had observed CNA #1 curse at residents, RN#1 paused, then stated CNA #1 has the language, (curses) but he had not observed it directed at residents. He stated it would not surprise him if CNA #1 cursed at residents. Resident #11 Review of Resident #11's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old male re-admitted to the facility on [DATE] from the hospital and had [DIAGNOSES REDACTED]. Record review of Resident #11's annual comprehensive MDS dated [DATE] reflected the resident's vision was severely impaired; his hearing was adequate. The resident had a BIMS of 5 indicating severe cognitive impairment and was not oriented to time and had difficulty with recall. Review of functional status reflected the resident was totally dependent upon staff for all ADLs except eating. He had functional limitations in range of motion of both upper and lower extremities and required a wheelchair for mobility. The resident was incontinent of bowel and bladder. Observation of Resident #11 conducted on 2/2/16 at 7:02pm revealed the resident was dependent upon a wheelchair for mobility and required extensive assistance with transfers. Observation revealed staff did not have to raise their voice when speaking to the resident; he had adequate hearing. In an interview with the AD on 2/2/16 at 1:43pm, she stated on Saturday 1/16/16, shortly after shift change, she was about to leave the facility after checking on her grandmother, a resident. She observed Resident #11 seated in his wheelchair in the hall across from the nurses' station. Resident #11 asked CNA #1 if it was his shower night, a question the resident asked each day, to which CNA #1 leaned down to place his face close to the resident's face and exclaimed no in a prolonged verbalization and raised voice. The resident responded by saying okay. Confidential Interview H stated Resident #11 was unable to remember any incidents involving CNA #1. Confidential Interview H stated Resident #11 was unable to recall what the resident had eaten for breakfast that day. --Record review of Form 3613-A Provider Investigation Report signed and dated by the ADM on 1/24/16 reflected: 1. The AD reported CNA #1's mistreatment of [REDACTED]. 2. On Saturday 1/16/16 at 6:15p, the AD was providing assistance to Resident #1 with opening a snack package at the facility's only nurses' station. Resident #1 was seated in her motorized wheelchair. CNA #1 approached the nurses' station while yelling and cursing at Resident #1 for blocking the hallway by the nurses' station with her motorized wheelchair and directed her to move. CNA #1 used the control located behind the resident's chair to propel the wheelchair without her approval. The resident shouted at CNA #1 to not touch her wheelchair voicing fear he would damage the chair. He responded by threatening to throw out the chair, if damaged, and told her she could leave the facility as well. The AD reported the incident to the ADM. The ADM's interview with Resident #1 corroborated the AD's incident report. The ADM reported this incident to the appropriate investigating authority. 3. CNA #1's written statement included with the Provider Investigation Report, dated 1/22/16 at 3:01pm reflected he told Resident #1 to stop blocking the area by the nurses' station, to go to her room, and propelled her wheelchair for her. CNA #1 documented Resident #1 had already been told not to crowd the nurses' station. CNA #1 wrote he did not curse at the resident and spoke to her kindly and respectfully. 4. Before the incident with Resident #1, the AD witnessed Resident #11 ask CNA #1 if it was his shower night and CNA #1 yell No directly into Resident #11's face. The resident asked that question daily. This incident was not reported to the appropriate authority and was revealed in the facility investigation. 5. On 1/17/16, RN #1 observed Resident #2 lying in bed with his call light not within his reach. Resident #2 reported CNA #1 placed the call light out of his reach the prior evening because the resident kept calling for assistance; the resident wanted coffee. Interview with the resident corroborated RN #1's statement. This incident was not reported to the appropriate authority and was revealed in the facility investigation. 6. CNA #1's written statement included in the facility investigation dated 1/21/16 at 10:38am documented he placed Resident #2's call light out of his reach. The statement reflected each time Resident #2 called for assistance he would state to CNA #1 nothing from you when CNA #1 asked what the resident needed. 7. CNA #1 was suspended pending the outcome of the investigation. 8. The facility's findings were inconclusive; the ADM documented she needed the agency nurse on duty when the incidents occurred to provide a statement before she could make a determination. The ADM documented she could not make a decision because the statements obtained were he-said, she-said.-- Record review of the facility's Nursing Schedule dated January 2016 reflected CNA #1 was assigned the 6p-6a shift with CNA #6. Review reflected CNA #1's schedule for the days of 1/18/16 to 1/25/16: off 1/18/16 and 1/19/16, on 1/20/16 and 1/21/16, off 1/22/16, 1/23/16 and 1/24/16, and back on duty 1/25/16. Review reflected 1/18/16-1/19/16 and 1/22/16-1/24/16 were scheduled off days per the rotation. Review reflected CNA #1's suspension pertained only to 1/20/16 and 1/21/16. Review reflected CNA #1 was scheduled to work 1/25/16-1/26/16 and 1/29/16-1/31/16. Review reflected the document did not reflect CNA #1's suspension. --Review of the facility's Payroll Summary reports for the dates of 1/16/16 through 1/27/16 reflected CNA #1's time clock punch detail: 1. 1/16/16: in at 6:03p, out at 6:06a 2. 1/17/16: in at 6:15p, out at 5:58a 3. 1/25/16: in at 6:32p, out at 6:16a 4. 1/27/16: time in not documented, out at 1:19a, in at 2:14a, then out 6:05a.-- On 2/3/16 at 11:41am, the surveyor requested the facility's assistance with obtaining an interview with CNA #1; surveyor attempts to contact CNA #1 by phone were unsuccessful. In an interview conducted with the ADM on 2/3/16 at 12:06pm the ADM stated she took immediate action in response to the allegations reported by staff by suspending CNA #1 from 1/18/16 to 1/25/16 without pay rather than opting to assign him to no-resident contact duties. Suspension meant CNA #1 was not allowed in the building. In review of the January 2016 staffing schedule, she acknowledged 5 of the 8 days of suspension were his scheduled off days. She stated CNA #1 resumed his normal work duties on 1/25/16. When asked why she needed a statement from Agency LVN #1, the nurse on duty when the incidents occurred, to determine the findings when she had witness statements from staff and corroborating resident statements, she stated so far the allegation was he said-she said. Resident #5 Record review of Resident #5's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old female readmitted to the facility from the hospital on [DATE] and had [DIAGNOSES REDACTED]. Record review of Resident #5's MDS dated [DATE] reflected the resident was continent of bowel and bladder. Review reflected the resident was dependent upon staff for mobility and transfers. Review reflected a BIMS of 15 indicating intact cognition. Observation of Resident #5 conducted on 2/2/16 at 12:10pm reflected the resident was dependent upon a wheelchair for mobility. Confidential Interview E stated CNA #1 did not want to provide care to Resident #5. It was stated Resident #5 would push the call button to request assistance to the toilet. CNA #1 would turn off the call light without providing care and walk out of the room saying yeah, uh huh. It was stated Resident #5 had more than 1 episode of urinary incontinence due to CNA #1's refusal to provide care. It was stated Resident #5 had to receive incontinent care from CNA #6 during CNA #1's shift. It was stated CNA #1 had yelled at Resident #5 and had placed the resident's call light out of reach. Confidential Interview E stated CNA #1 had treated the resident in such a manner for weeks; the resident was intimidated by CNA #1 and reluctant to report mistreatment. Confidential Family Interview A was aware that Confidential Interview E did not report CNA #1's mistreatment for [REDACTED].#1 against the resident or loved ones and tearfully begged that Confidential Family A also not report. Interviews conducted with witnesses of CNA #1's mistreatment of [REDACTED].>a. Confidential Interview C stated Resident #4 had witnessed CNA #1 verbally abuse other residents. It was stated All I witnessed is verbal. Things you would not want said to you or ones you cared about. It was stated incidents went unreported for fear of retaliation because CNA #1 was a current employee. b. Confidential Interview G frowned, shook head, made a sign of the cross, then made a zipping motion across closed mouth when asked to describe CNA #1 and repeated the motion when assured statements would be kept confidential. Confidential Interview G had no issues with other staff. In an interview conducted with the ADM on 2/3/16 at 2:37pm, when asked what her findings were regarding the allegations of abuse made against CNA #1, she stated she had not made a determination. In review of the provider investigation report she submitted on 1/24/16 documenting CNA #1 was suspended pending the outcome of investigation, when asked why CNA #1 was allowed to resume normal work duties on 1/25/16 she stated she did not think his actions were abuse and that he was being monitored. When asked what monitoring was performed and by whom, she stated CNA #1 was not being monitored. When asked why CNA #1 was physically present in the facility on 1/21/16, a suspension day, to take 2 hours of his mandatory annual training, she stated she told him to leave the building when she saw him that day. When asked what she considered placing call lights out of reach of residents, she stated abuse. When asked why she did not put protections in place when CNA #1 admitted to engaging in the incidents with Residents #1 and #2, and only denied cursing and raising his voice during the incident with Resident #1, she stated she maybe should have terminated CNA #1. The ADM's inflection made the statement a question. She stated CNA #1 needed more training and monitoring. When asked why the facility investigation did not address the allegation regarding Resident #11, the ADM stated she spoke with Resident #11 and was told nothing happened. When asked if Resident #11's cognitive status allowed recall, she stated no. Resident #10 Review of Resident #10's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old male readmitted to the facility from the hospital on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident #10's annual comprehensive MDS dated [DATE] reflected a BIMS of 6 indicating severe cognitive impairment. The resident had unclear speech (slurred or mumbled), could usually make self understood, could usually understand others and had minimal difficulty hearing. Review of ADLs reflected the resident required staff assistance with all ADLs except for eating; had functional limitations in range of motion to the upper and lower extremities and required a wheelchair for mobility. The resident was frequently incontinent of bowel and bladder. The MDS reflected hospice status. Observation of Resident #10 conducted during initial tour on 2/3/16 at 9:20am reflected the resident was dependent upon a wheelchair for mobility. Confidential Interview B stated CNA #1's treatment of [REDACTED]. It was stated that Resident #2 pushed the call button at 9pm for urinary incontinent care during CNA #1's last shift. CNA #6 answered the call light and left the room without providing care. At 10:25pm, Resident #10 pushed the call button and CNA #1 responded. Resident #10 requested incontinent care when CNA #1 asked what he needed. Confidential Interview B stated Resident #10 told CNA #1 that he was wet with urine since 9pm. CNA #1 stated that rounds were not until 3am, took the resident's clock from the wall and left the room without providing care. It was stated this was not the only incident with CNA #1; it was the most recent. It was stated CNA #1 made Resident #10 feel insignificant and worthless. Record review of the facility's Nursing Schedule dated February 2016 reflected CNA #1 was off 2/1/16-2/2/16 and was scheduled to work 2/3/16-2/4/16. In an interview conducted with the ADM on 2/3/16 at 6:15pm, when asked what staff was on duty for the 6p-6a shift, she stated 2 CNA's from the day shift would be on duty and she called in a CNA who worked nights to come in on her scheduled day off. She stated CNA #1 and CNA #6 were scheduled but were no call, no shows. The facility was unable to assist the surveyor with obtaining an interview with CNA #1; he could not be reached by phone call or by text message. She stated the facility had made the decision to terminate CNA #1 because of something unrelated to the allegations under investigation pertaining to Residents #1, #2 and #11. When asked to clarify, the ADM stated Resident #10 made an allegation against CNA #1. The incident occurred on the last shift worked by CNA #1. CNA #1 answered Resident #10's call light twice, did not provide incontinent care either time, and removed his clock from his room so that the resident could not track how long he had been wet with urine. The first request for assistance was at 9pm; the second request at 10:25pm. The clock was removed from the room at 10:25pm. CNA #1 told the resident he could not provide care to the resident because rounds were not until 3. The facility's administrator ADON, BOM, and Regional Director of Operations were notified on 2/3/16 at 6:30pm that an Immediate Jeopardy situation had been identified due to the facility's failure to prevent CNA #1's abuse of residents and the failure to protect residents from further abuse by CNA #1 once allegations were made. The Plan of Removal was accepted on 2/4/16 and included the following interventions confirmed by the surveyor: 1. CNA #1 was terminated confirmed by review of the Employee Corrective Action form dated 2/3/16 and by observation that CNA #1 was not on duty during his scheduled shift on 2/3/16-2/4/16. 2. The facility initiated staff in-services on identification of abuse and neglect and reporting procedures. This was confirmed by observation of the staff meeting, review of in-service sign-in sheet and interviews with 4 direct care staff. Interviews with direct care staff confirmed staff knowledge of identifying and reporting abuse. 3. The licensed clinical social worker, also the therapist for several residents, was scheduled to provide staff in-services on abuse and neglect, psychiatric [DIAGNOSES REDACTED]. Interview with the clinical social worker confirmed the in-services would continue indefinitely as necessary. 4. The facility conducted resident satisfaction surveys; results reported to licensed clinical social worker for mental health care and follow-up. Observation of the clinical social worker performing rounds at the facility on 2/4/16, interview with residents affected by the deficient practice, interview with the clinical social worker, and records reviewed dated 2/3/16 documenting the resident satisfaction surveys confirmed the intervention was implemented. The facility was notified on 2/4/16 that at 5:12pm the IJ was removed. However, the facility remained out of compliance at a severity of potential for more than minimal harm with a scope identified as widespread. The facility will continue to provide aftercare to residents victimized by CNA #1; to in-service facility staff and agency staff; to monitor staff completion of computer based courses on abuse and to monitor orientation of new staff on abuse and reporting requirements. Review of the resident roster provided by the facility on 2/2/16 reflected a census of 36.

Based on observation, interview and record review the facility failed to implement its policy and procedure that prohibited mistreatment, neglect, and abuse of 5 of 11 residents (#s 1, 2, 11, 5 and 10) reviewed for abuse. 1. CNA #1 cursed, yelled, threatened, and moved Resident #1 against her will. Resident #1 risked incontinent episodes, though continent, each 12 hour night shift worked by CNA #1 to avoid requesting his assistance to the toilet. CNA #1 caused Resident #1 anxiety and distress. 2. CNA #1 placed the call light out of the reach of Resident #2, who was bedbound, and cursed and yelled at the resident. Resident #2 was distressed by CNA #1 and felt belittled. 3. CNA #1 yelled in the face of Resident #11, who had moderate intellectual disability, for repeating a question. 4. Resident #5, who was continent, had incontinent episodes because CNA #1 would not provide her with assistance to the toilet. CNA #1 placed Resident #5's call light out of reach. CNA #1 caused Resident #5 distress, anxiety and fear of retaliation. 5. The facility allowed CNA #1 to continue providing unsupervised direct care to residents after allegations of abuse had been made against him resulting in further mistreatment of [REDACTED]. CNA #1 did not provide incontinent care to Resident #10 and removed the clock from the resident's room so the resident could not tell how long he had been wet with urine. CNA #1's mistreatment of [REDACTED]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 2/3/16. While the IJ was removed on 2/4/16, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as widespread. The facility was continuing to in-service staff on abuse prevention/identification/reporting and providing residents with mental health care. The facility's failure to ensure implementation of its policy and procedure prohibiting the mistreatment of [REDACTED].#s 1, 2, 5, 11, and 10) with the potential to harm the psychosocial well-being of the other 31 residents dependent upon staff assistance for care, by placing at risk for mistreatment and degradation through continued contact with CNA #1. Findings include: Resident #1 Record review of Resident #1's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old female admitted to the facility on [DATE] from a behavioral health facility and had [DIAGNOSES REDACTED]. Record review of Resident #1's admission comprehensive MDS dated [DATE] reflected a BIMS score of 15 indicating the resident was cognitively intact. Review of Resident #1's functional status reflected she was dependent upon staff assistance with all ADLs except for eating and was continent of bowel and bladder. The resident had range of motion impairment to both extremities of one side of the body and used a wheelchair for mobility. Observation of Resident #1 conducted on 2/2/16 at 12:36pm revealed the resident had functional limitations to the left side of the body and used a wheelchair for mobility. In an interview with the AD on 2/2/16 at 1:43pm, she stated on Saturday the 16th at 6:15pm, Resident #1 approached the nurses' station in her motorized wheelchair and asked for assistance with opening her snack. CNA #1 approached the nurses' station while yelling and cursing at Resident #1 for blocking the hallway by the nurses' station with her motorized wheelchair and directed her to move. CNA #1 used the control on the back of the chair to move the resident. The resident became very upset and shouted at CNA #1 to not touch her wheelchair voicing fear he would damage the chair. He responded by telling the resident that he would throw the chair out the door and the resident could leave with it. The AD reported the incident to the ADM the following Monday. She stated she should have reported the incidents when they occurred. Confidential Interview A stated that CNA #1 caused the resident anxiety; Resident #1 would rather risk incontinence and hold her bladder and bowels than to ask CNA #1 for assistance with toileting. Confidential Interview A stated Resident #1 could self-toilet and only required assistance with pulling down/pulling up the pants; the resident had use of only one hand. Confidential Interview A stated that CNA #1 called Resident #1 the expletive f***ing b**ch. It was stated, with head lowered and eyes filled with tears, that CNA #1's treatment of [REDACTED]. Confidential Interview A stated Resident #1 avoided asking CNA #1 for assistance because of the demeaning manner in which he spoke to Resident #1. It was stated Resident #1 did not feel comfortable voicing grievances about CNA #1; the process did not provide resolution. Resident #2 Record review of Resident #2's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old male admitted to the facility 9/20/13 from home and had [DIAGNOSES REDACTED]. Record review of Resident #2's comprehensive MDS dated [DATE] reflected the resident had a BIMS of 6 indicating severe cognitive impairment. Review reflected the resident was totally dependent upon staff for all ADLs except for eating and was incontinent of bowel and bladder. He had functional limitations in range of motion to the upper and lower extremities. Observation of Resident #2 conducted during the initial tour on 2/2/16 at 9:47am revealed the resident was dependent upon a Geri-chair for mobility and had no functional use of the lower extremities. During Confidential Interview B it was stated that CNA #1 had taken Resident #2's call light and placed it out of his reach and cursed him. It was stated the call light was taken from the resident for asking for coffee. It was stated CNA #1 told the resident his light would be taken away and the resident could not do anything about it. Confidential Interview B stated Resident #2 felt awful and belittled and it was obvious CNA #1 did not care about the residents. Confidential Interview B revealed Resident #2 was distressed and angered by CNA #1. In an interview with RN #1 on 2/3/16 at 3:28pm, he stated he did observe Resident #2's call light not within his reach and when he asked why, the resident stated CNA #1 took it away the night before for being on it too much. When asked if he had observed CNA #1 curse at residents, RN#1 paused, then stated CNA #1 has the language, (curses) but he had not observed it directed at residents. He stated it would not surprise him if CNA #1 cursed at residents. Resident #11 Review of Resident #11's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old male re-admitted to the facility on [DATE] from the hospital and had [DIAGNOSES REDACTED]. Record review of Resident #11's annual comprehensive MDS dated [DATE] reflected the resident's vision was severely impaired; his hearing was adequate. The resident had a BIMS of 5 indicating severe cognitive impairment and was not oriented to time and had difficulty with recall. Review of functional status reflected the resident was totally dependent upon staff for all ADLs except eating. He had functional limitations in range of motion of both upper and lower extremities and required a wheelchair for mobility. The resident was incontinent of bowel and bladder. Observation of Resident #11 conducted on 2/2/16 at 7:02pm revealed the resident was dependent upon a wheelchair for mobility and required extensive assistance with transfers. Observation revealed staff did not have to raise their voice when speaking to the resident; he had adequate hearing. In an interview with the AD on 2/2/16 at 1:43pm, she stated on Saturday 1/16/16, shortly after shift change, she was about to leave the facility after checking on her grandmother, a resident. She observed Resident #11 seated in his wheelchair in the hall across from the nurses' station. Resident #11 asked CNA #1 if it was his shower night, a question the resident asked each day, to which CNA #1 leaned down to place his face close to the resident's face and exclaimed no in a prolonged verbalization and raised voice. The resident responded by saying okay. Confidential Interview H stated Resident #11 was unable to remember any incidents involving CNA #1. Confidential Interview H stated Resident #11 was unable to recall what the resident had eaten for breakfast that day. --Record review of Form 3613-A Provider Investigation Report signed and dated by the ADM on 1/24/16 reflected: 1. The AD reported CNA #1's mistreatment of [REDACTED]. 2. On Saturday 1/16/16 at 6:15p, the AD was providing assistance to Resident #1 with opening a snack package at the facility's only nurses' station. Resident #1 was seated in her motorized wheelchair. CNA #1 approached the nurses' station while yelling and cursing at Resident #1 for blocking the hallway by the nurses' station with her motorized wheelchair and directed her to move. CNA #1 used the control located behind the resident's chair to propel the wheelchair without her approval. The resident shouted at CNA #1 to not touch her wheelchair voicing fear he would damage the chair. He responded by threatening to throw out the chair, if damaged, and told her she could leave the facility as well. The AD reported the incident to the ADM. The ADM's interview with Resident #1 corroborated the AD's incident report. The ADM reported this incident to the appropriate investigating authority. 3. CNA #1's written statement included with the Provider Investigation Report, dated 1/22/16 at 3:01pm reflected he told Resident #1 to stop blocking the area by the nurses' station, to go to her room, and propelled her wheelchair for her. CNA #1 documented Resident #1 had already been told not to crowd the nurses' station. CNA #1 wrote he did not curse at the resident and spoke to her kindly and respectfully. 4. Before the incident with Resident #1, the AD witnessed Resident #11 ask CNA #1 if it was his shower night and CNA #1 yell No directly into Resident #11's face. The resident asked that question daily. This incident was not reported to the appropriate authority and was revealed in the facility investigation. 5. On 1/17/16, RN #1 observed Resident #2 lying in bed with his call light not within his reach. Resident #2 reported CNA #1 placed the call light out of his reach the prior evening because the resident kept calling for assistance; the resident wanted coffee. Interview with the resident corroborated RN #1's statement. This incident was not reported to the appropriate authority and was revealed in the facility investigation. 6. CNA #1's written statement included in the facility investigation dated 1/21/16 at 10:38am documented he placed Resident #2's call light out of his reach. The statement reflected each time Resident #2 called for assistance he would state to CNA #1 nothing from you when CNA #1 asked what the resident needed. 7. CNA #1 was suspended pending the outcome of the investigation. 8. The facility's findings were inconclusive; the ADM documented she needed the agency nurse on duty when the incidents occurred to provide a statement before she could make a determination. The ADM documented she could not make a decision because the statements obtained were he-said, she-said.-- Record review of the facility's Nursing Schedule dated January 2016 reflected CNA #1 was assigned the 6p-6a shift with CNA #6. Review reflected CNA #1's schedule for the days of 1/18/16 to 1/25/16: off 1/18/16 and 1/19/16, on 1/20/16 and 1/21/16, off 1/22/16, 1/23/16 and 1/24/16, and back on duty 1/25/16. Review reflected 1/18/16-1/19/16 and 1/22/16-1/24/16 were scheduled off days per the rotation. Review reflected CNA #1's suspension pertained only to 1/20/16 and 1/21/16. Review reflected CNA #1 was scheduled to work 1/25/16-1/26/16 and 1/29/16-1/31/16. Review reflected the document did not reflect CNA #1's suspension. --Review of the facility's Payroll Summary reports for the dates of 1/16/16 through 1/27/16 reflected CNA #1's time clock punch detail: 1. 1/16/16: in at 6:03p, out at 6:06a 2. 1/17/16: in at 6:15p, out at 5:58a 3. 1/25/16: in at 6:32p, out at 6:16a 4. 1/27/16: time in not documented, out at 1:19a, in at 2:14a, then out 6:05a.- On 2/3/16 at 11:41am, the surveyor requested the facility's assistance with obtaining an interview with CNA #1; surveyor attempts to contact CNA #1 by phone were unsuccessful. In an interview conducted with the ADM on 2/3/16 at 12:06pm the ADM stated she took immediate action in response to the allegations reported by staff by suspending CNA #1 from 1/18/16 to 1/25/16 without pay rather than opting to assign him to no-resident contact duties. Suspension meant CNA #1 was not allowed in the building. In review of the January 2016 staffing schedule, she acknowledged 5 of the 8 days of suspension were his scheduled off days. She stated CNA #1 resumed his normal work duties on 1/25/16. When asked why she needed a statement from Agency LVN #1, the nurse on duty when the incidents occurred, to determine the findings when she had witness statements from staff and corroborating resident statements, she stated so far the allegation was he said-she said. Resident #5 Record review of Resident #5's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old female readmitted to the facility from the hospital on [DATE] and had [DIAGNOSES REDACTED]. Record review of Resident #5's MDS dated [DATE] reflected the resident was continent of bowel and bladder. Review reflected the resident was dependent upon staff for mobility and transfers. Review reflected a BIMS of 15 indicating intact cognition. Observation of Resident #5 conducted on 2/2/16 at 12:10pm reflected the resident was dependent upon a wheelchair for mobility. Confidential Interview E stated CNA #1 did not want to provide care to Resident #5. It was stated Resident #5 would push the call button to request assistance to the toilet. CNA #1 would turn off the call light without providing care and walk out of the room saying yeah, uh huh. It was stated Resident #5 had more than 1 episode of urinary incontinence due to CNA #1's refusal to provide care. It was stated Resident #5 had to receive incontinent care from CNA #6 during CNA #1's shift. It was stated CNA #1 had yelled at Resident #5 and had placed the resident's call light out of reach. Confidential Interview E stated CNA #1 had treated the resident in such a manner for weeks; the resident was intimidated by CNA #1 and reluctant to report mistreatment. Confidential Family Interview A was aware that Confidential Interview E did not report CNA #1's mistreatment for [REDACTED].#1 against the resident or loved ones and tearfully begged that Confidential Family A also not report. Interviews conducted with witnesses of CNA #1's mistreatment of [REDACTED].>a. Confidential Interview C stated Resident #4 had witnessed CNA #1 verbally abuse other residents. It was stated All I witnessed is verbal. Things you would not want said to you or ones you cared about. It was stated incidents went unreported for fear of retaliation because CNA #1 was a current employee. b. Confidential Interview G frowned, shook head, made a sign of the cross, then made a zipping motion across closed mouth when asked to describe CNA #1 and repeated the motion when assured statements would be kept confidential. Confidential Interview G had no issues with other staff. In an interview conducted with the ADM on 2/3/16 at 2:37pm, when asked what her findings were regarding the allegations of abuse made against CNA #1, she stated she had not made a determination. In review of the provider investigation report she submitted on 1/24/16 documenting CNA #1 was suspended pending the outcome of investigation, when asked why CNA #1 was allowed to resume normal work duties on 1/25/16 she stated she did not think his actions were abuse and that he was being monitored. When asked what monitoring was performed and by whom, she stated CNA #1 was not being monitored. When asked why CNA #1 was physically present in the facility on 1/21/16, a suspension day, to take 2 hours of his mandatory annual training, she stated she told him to leave the building when she saw him that day. When asked what she considered placing call lights out of reach of residents, she stated abuse. When asked why she did not put protections in place when CNA #1 admitted to engaging in the incidents with Residents #1 and #2, and only denied cursing and raising his voice during the incident with Resident #1, she stated she maybe should have terminated CNA #1. The ADM's inflection made the statement a question. She stated CNA #1 needed more training and monitoring. When asked why the facility investigation did not address the allegation regarding Resident #11, the ADM stated she spoke with Resident #11 and was told nothing happened. When asked if Resident #11's cognitive status allowed recall, she stated no. Resident #10 Review of Resident #10's Admission Face Sheet dated 11/18/15 reflected the resident was a [AGE] year old male readmitted to the facility from the hospital on [DATE] and had [DIAGNOSES REDACTED]. Review of Resident #10's annual comprehensive MDS dated [DATE] reflected a BIMS of 6 indicating severe cognitive impairment. The resident had unclear speech (slurred or mumbled), could usually make self understood, could usually understand others and had minimal difficulty hearing. Review of ADLs reflected the resident required staff assistance with all ADLs except for eating; had functional limitations in range of motion to the upper and lower extremities and required a wheelchair for mobility. The resident was frequently incontinent of bowel and bladder. The MDS reflected hospice status. Observation of Resident #10 conducted during initial tour on 2/3/16 at 9:20am reflected the Resident was dependent upon a wheelchair for mobility. Confidential Interview B stated CNA #1's treatment of [REDACTED]. It was stated that Resident #2 pushed the call button at 9pm for urinary incontinent care during CNA #1's last shift. CNA #6 answered the call light and left the room without providing care. At 10:25pm, Resident #10 pushed the call button and CNA #1 responded. Resident #10 requested incontinent care when CNA #1 asked what he needed. Confidential Interview B stated Resident #10 told CNA #1 that he was wet with urine since 9pm. CNA #1 stated that rounds were not until 3am, took the resident's clock from the wall and left the room without providing care. It was stated this was not the only incident with CNA #1; it was the most recent. It was stated CNA #1 made Resident #10 feel insignificant and worthless. Record review of the facility's Nursing Schedule dated February 2016 reflected CNA #1 was off 2/1/16-2/2/16 and was scheduled to work 2/3/16-2/4/16. In an interview conducted with the ADM on 2/3/16 at 6:15pm, when asked what staff was on duty for the 6p-6a shift, she stated 2 CNA's from the day shift would be on duty and she called in a CNA who worked nights to come in on her scheduled day off. She stated CNA #1 and CNA #6 were scheduled but were no call, no shows. The facility was unable to assist the surveyor with obtaining an interview with CNA #1; he could not be reached by phone call or by text message. She stated the facility had made the decision to terminate CNA #1 because of something unrelated to the allegations under investigation pertaining to Residents #1, #2 and #11. When asked to clarify, the ADM stated Resident #10 made an allegation against CNA #1. The incident occurred on the last shift worked by CNA #1. CNA #1 answered Resident #10's call light twice, did not provide incontinent care either time, and removed his clock from his room so that the resident could not track how long he had been wet with urine. The first request for assistance was at 9pm; the second request at 10:25pm. The clock was removed from the room at 10:25pm. CNA #1 told the resident he could not provide care to the resident because rounds were not until 3. The facility's administrator ADON, BOM, and Regional Director of Operations were notified on 2/3/16 at 6:30pm that an Immediate Jeopardy situation had been identified due to the facility's failure to prevent CNA #1's abuse of residents and the failure to protect residents from further abuse by CNA #1 once allegations were made. The Plan of Removal was accepted on 2/4/16 and included the following interventions confirmed by the surveyor: 1. CNA #1 was terminated confirmed by review of the Employee Corrective Action form dated 2/3/16 and by observation that CNA #1 was not on duty during his scheduled shift on 2/3/16-2/4/16. 2. The facility initiated staff in-services on identification of abuse and neglect and reporting procedures. This was confirmed by observation of the staff meeting, review of in-service sign-in sheet and interviews with 4 direct care staff. Interviews with direct care staff confirmed staff knowledge of identifying and reporting abuse. 3. The licensed clinical social worker, also the therapist for several residents, was scheduled to provide staff in-services on abuse and neglect, psychiatric [DIAGNOSES REDACTED]. Interview with the clinical social worker confirmed the in-services would continue indefinitely as necessary. 4. The facility conducted resident satisfaction surveys; results reported to licensed clinical social worker for mental health care and follow-up. Observation of the clinical social worker performing rounds at the facility on 2/4/16, interview with residents affected by the deficient practice, interview with the clinical social worker, and records reviewed dated 2/3/16 documenting the resident satisfaction surveys confirmed the intervention was implemented. The facility was notified on 2/4/16 that at 5:12pm the IJ was removed. However, the facility remained out of compliance at a severity of potential for more than minimal harm with a scope identified as pattern. The facility will continue to provide aftercare to residents victimized by CNA #1; to in-service facility staff and agency staff; to monitor staff completion of computer based courses on abuse and to monitor orientation of new staff on abuse and reporting requirements. Review of the resident roster provided by the facility on 2/2/16 reflected a census of 36.

Based on observation, interview and record review, the facility failed to establish infection control measures to help prevent the transmission of infection and disease by bloodborne pathogens for 7 of 7 residents with diabetes (#s 1, 5, 6, 8, 9, 10, 11). The facility failed to: a) ensure that lancing devices were not used on multiple residents to obtain blood for blood glucose tests. Two of 2 LVNs (LVN 1, 3) were observed performing blood glucose tests using the same pen lancing device on 6 of 7 residents (#s 1, 5, 6, 8, 9, 11), observed receiving blood glucose tests. b) follow policies and procedures for performing blood glucose tests to prevent the spread of bloodborne pathogens. The facility had a policy forbidding the use of lancing devices (e.g., fingerstick devices) for more than one resident. Fingerstick devices touch the skin and come in close proximity to blood with every use. Even if the lancet is changed between each use there is potential for blood to contaminate the device. Bloodborne pathogens such as Hepatitis B, Hepatitis C and HIV could potentially be transmitted from one person to another. These failures resulted in the identification of an IJ on 12/18/12 at 3:07 PM. While the IJ was removed prior to exit on 12/20/12 at 4:15 PM, the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not Immediate Jeopardy" and a scope of "Pattern". These failures involved 7 residents with diabetes requiring use of a lancing device to obtain blood by fingerstick for blood glucose testing. These failures placed these 7 residents at risk of bloodborne infections. Non-IJ The facility failed to: a) ensure blood glucose meters were cleaned and disinfected after each use and between use for more than one resident. One of one LVN (LVN 1) observed performing blood glucose tests, failed to clean/disinfect the glucometer device after each use and between residents for 5 of 7 residents (#s 1, 6, 8, 9, 11) observed receiving blood glucose tests. b) establish policies and procedures for cleaning and disinfecting blood glucose meters after each use when used for more than one resident. c) The facility failed to ensure 3 staff (LVN #1, CNA #1, NA #1) washed/sanitized their hands when necessary and used gloves in a sanitary manner. d) The facility failed to ensure 2 used wound measurement devices were not placed in 2 resident's (#1, 2) clinical records. The a) and b) failures involved 7 residents with diabetes requiring use of a glucometer for blood glucose testing. These failures placed these 7 residents at risk of bloodborne infections. The c) failure could affect the 20 residents identified as being incontinent and the d) failure could affect the 2 residents identified with pressure sores. The findings included: 1. On 12/10/12 at 11:15 AM, LVN #1 performed an Accucheck (obtaining a blood sample to determine blood glucose levels) on resident #6. LVN #1 punctured resident #6's fingertip with a lancet placed into a fingerstick pen device (device with a lancet that punctures the skin) obtaining a blood sample which she placed onto the test strip in the glucometer. At 11:18 AM, LVN #1 punctured resident #11's fingertip with a new lancet placed into the same lancing device used on resident #6. At 11:21 AM, LVN #1 punctured resident #9's fingertip with a new lancet placed into the same lancing device used on residents #6 and #11. At 11:25 AM, LVN #1 punctured resident #8's fingertip with a new lancet placed into the same lancing device used on residents #6, #11, and #9. At 11:31 AM, LVN #1 punctured resident #1's fingertip with a new lancet placed into the same lancing device used on residents #6, #11, #9, and #8. 2. On 12/18/12 at 11:15 AM, LVN #3 performed an Accucheck on resident #9. LVN #3 punctured resident #9's fingertip with a lancet placed into a fingerstick pen device obtaining a blood sample which she placed onto the test strip in the glucometer. At 11:31 AM, LVN #3 punctured resident #5's fingertip with a new lancet placed into the same lancing device used on resident #9. 3. Review of the charts of the 7 residents the facility identified as receiving fingersticks for blood glucose, revealed that 1 of the 7 had a [DIAGNOSES REDACTED]. Review of the medical record for resident #8 revealed he was admitted to the facility on [DATE] with a medical [DIAGNOSES REDACTED]. The record documented resident #8 has a history of being a carrier of Hepatitis C. This [DIAGNOSES REDACTED]. 4. In an interview on 12/10/12 at 11:43 AM, LVN #1 said there was only one lancet device. At 1:50 PM, the DON said that there was only one lancing device and the staff use a new lancet every time. The DON said that the facility policy doesn't require them to get separate lancing devices. 5. The facility policy Blood Sampling dated 2001; revised April 2012 documents that the purpose of the procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of blood borne diseases to residents and employees. The section General guidelines documents "Single-resident use finger stick devices (pen-like devices) should never be used by more than one resident." 6. On 12/18/12 at 12:39 PM, the surveyor called ARKRAY, maker of the multi-lancet finger stick device. At 12:45 PM, the representative said the device not designed for multi-person use. The representative referred to the instruction manual. Page 31 of the Akray Glucocard Blood Glucose Monitoring system documented "Warning- Lancing devices and lancets are for single-patient use only." At 1:45 PM, the DON said the facility was using the lance device prior to her employment with the facility in April 2010. At 2:09 PM, the administrator called a representative of Gulf South as the facility did not receive any instructions with the pen lancet device. At 2:12 PM, the surveyor asked the DON how they knew how to use the finger stick device if they did not receive any instructions with it. The DON stated that the Nursing Policy Manual is at the nurse's station and all of the nurses are in-serviced and oriented to its location and are told to call her with any questions. The surveyor informed the DON and administrator, as they were unaware, that their 4/12 policy for Blood Sampling-Capillary (Finger Sticks) documented that the use of the lancet device was for single resident use. 7. The administrator and DON were notified of an IJ on 12/18/12 at 3:07 PM. A copy of CMS S & C 10-28-NH was provided. 8. The facility submitted a plan of removal for the IJ dated 12/18/12 documenting the following: "It is Ralls Nursing Home's Plan of Action to use the Single Use Lancets and Sanitize the Quintet Glucometer with Clorox Germicidal Wipes effective immediately. The multi-lancet device has been removed and only single use lancets are available. Each charge nurse will sign an in-service prior to their shift acknowledging the disinfection instructions and use of the single use lancets." 9. On 12/18/12 at 5:15 PM, the surveyors verified the multi-lancet devices had been removed from the facility. The administrator said all the nurses would be in-serviced twice as the nurses were attending the facility Christmas party that night and would be told about the procedural changes. The administrator confirmed the nurses would sign the acknowledgement in-service as they came on shift. On 12/19/12 at 8:58 AM, LVN #3 confirmed the nurses had been in-serviced the evening before and she had to sign before her shift today. While the IJ was reduced on 12/18/12 at 5:15 PM, the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not Immediate Jeopardy" and a scope of "Pattern" as the facility must monitor their action plan over time to ensure the corrections for this issue are effective. There were 7 residents with diabetes requiring use of a lancing device to obtain blood by fingerstick for blood glucose testing according to the list provided by the DON. Non-IJ findings 1. On 12/10/12 at 11:15 AM, LVN #1 put gloves in her pants pocket and got a small tote tray (like a phlebotomy tray) from the medication room. She put on the gloves she had in her pants pocket, handled the glucometer, lancing device, an alcohol pad, resident #6's finger, a syringe, a bottle of insulin and the sharps container all while wearing the same gloves. LVN #1 did not clean or disinfect the glucometer prior to using it on resident #6. LVN #1 failed to wash or sanitize her hands before leaving the room. 2. On 12/10/12 at 11:18 AM, LVN #1 put on the gloves she had in her pants pocket, handled the glucometer, lancing device, an alcohol pad, resident #11's finger, a syringe, a bottle of insulin and the sharps container all while wearing the same gloves. LVN #1 did not clean or disinfect the glucometer prior to using it on resident #11. LVN #1 failed to wash or sanitize her hands before leaving the room. 3. On 12/10/12 at 11:21 AM, LVN #1 put on the gloves she had in her pants pocket, handled the glucometer, lancing device, an alcohol pad, resident #9's finger, a syringe, a bottle of insulin and the sharps container all while wearing the same gloves. LVN #1 did not clean or disinfect the glucometer prior to using it on resident #9. LVN #1 failed to wash or sanitize her hands before leaving the room. 4. On 12/10/12 at 11:25 AM, LVN #1 put on the gloves laying on top of the tote tray, handled the glucometer, lancing device, an alcohol pad, resident #8's finger, a syringe, a bottle of insulin and the sharps container all while wearing the same gloves. LVN #1 did not clean or disinfect the glucometer prior to using it on resident #8. LVN #1 failed to wash or sanitize her hands before leaving the room. LVN #1 went to the medication room and washed her hands. 5. on 12/10/12 at 11:31 AM, after coming out of the medication room, LVN #1 put gloves on top of the tote containing all the blood glucose supplies. LVN #1 put gloves on, handled the lancing device, but failed to wipe the glucometer. 6. On 12/18/12 at 11:22 AM, LVN #3 did not clean or disinfect the glucometer prior to performing the blood glucose check for resident #9. At 11:40 AM, LVN #3 continued on to resident #5 to perform her blood glucose check. She had wiped the glucometer with an alcohol pad and placed it on the non-sanitized medication cart so it was not disinfected prior to use on resident #5. The facility policy Blood Sampling dated 2001; revised April 2012 documents that the purpose of the procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of blood borne diseases to residents and employees. The section General guidelines documents "Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses." There were not any specific instructions regarding how to clean/disinfect the glucometers. On 12/28/12 at 2:12 PM, the surveyor asked how the facility was cleaning the device as there was not a policy specifically for that procedure. The DON stated that her instructions were to wipe down the glucometer with alcohol and those instructions were given person to person since there wasn't a written policy. The instructions for the Quintet glucometer referred to CMS TAG F 441. It indicated that CMS created guidelines in order to help long term care facilities establish and maintain infection control programs. Per CMS TAG 441 (December 2009), "blood glucose meters, as well as all other resident care equipment, need to be cleaned and disinfected after each individual use to avoid possible cross contamination." The article stresses the importance of cleaning and disinfecting the blood glucose monitors and other long term care devices, due to they can be contaminated with pathogens, such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), Hepatitis C Virus (HCV), and others. "These viruses can be transmitted between residents if equipment is shared without cleaning and disinfecting between uses." The meter even needs to be cleaned after each use for an individual resident. The CDC article titled, "Frequently Asked Questions (FAQs) regarding Assisted Blood Glucose Monitoring and Insulin Administration", indicated that individuals who perform blood glucose monitoring must be aware of basic safe practices to protect against infections transmission. The article states that, "whenever possible blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. <http://www.cdc.gov/injectionsafety/providers/blood-glucose-monitor>. Interview with CNA #1 at 2:47 PM on 12/10/12 indicated that he keeps several pairs of gloves in his pockets to use while providing care. On 12/10/12 at 4:35 PM, NA #1 said she puts 2 or 3 gloves on at a time and just takes one off at a time when she cares for a resident. During an interview with the ADON on 12/10/12 at 4:10 PM, she indicated she was in charge for Infection Control. She stated that she keeps track of which resident is on antibiotics on a monthly basis. She said the MA gives her a list of who is receiving antibiotics and she puts it into the computer and that the facility has quarterly meetings to address infection control. She stated she was new at the facility but provided a copy of the infection Control Guidelines for all Nursing Procedures, revised October 2010. In the guidelines, it is also noted that employees must wash hands for ten to fifteen seconds using antimicrobial or non -antimicrobial soap and water under the following conditions: a) Before and after direct contact with residents b) When hands a visibly dirty or soiled c) After contact with blood, body fluids, secretions, mucous membranes or non-intact skin d) After removing gloves In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] for all the following situations: a) Before and after direct contact with residents b) Before donning sterile gloves c) Before performing any non-surgical invasive procedures d) After removing gloves. The 12/18/12 CMS 672 documented 20 residents were frequently incontinent of bladder. Wound measurement device 1. In reviewing Resident #1's medical record, the surveyor came across the actual wound measuring device for her right heel wound dated 10/9/12, taped into the chart. 2. In reviewing Resident #2's medical record, surveyor came across the actual wound measuring device for her left heel dated 10/5/12, taped into the chart. 3. On 12/20/12 at 12:34 PM, the DON and LVN #2 were interviewed regarding what the facility policy and procedure was for measuring wounds. They stated they used the Barefoot Medical plastic measuring device; they are one time use only. They measure the wounds, copy it, and then throw it away. They indicated they also wiped off the copier when done. 4. On 12/20/12 at 3:30 PM, surveyors pointed out the original measuring devices just taped into the chart to the DON. She replied, "Well, it isn't the side that touched the resident." The DON then replied, "It was worth a try." 5. Review of the Wound Care Policy 2001; revised October 2010 provides guidelines for the care of wounds to promote healing and the steps in the procedure for wound dressing; however, it does not address guidelines on measuring wounds. 6. The 12/18/12 CMS 672 documented 2 residents with pressure sores.