**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, residents' record review, review of a facility policy titled Abuse Prohibition, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to protect residents right to be from abuse perpetrated by staff of the facility. On 07/01/2023 Resident Identifier (RI) #398 was physically abused by Certified Nursing Assistant (CNA) #14. This deficiency was cited as the result of the investigation of complaint /report #AL00044697. The facility further failed to ensure RI #48 was free from abuse perpetrated by CNA #10. On 03/10/2024 RI #48 was physically abused by CNA #10. The facility further failed to substantiate the allegations as abuse. These deficient practices affected RI #48 and RI #398, two of four sampled residents reviewed for employee to resident abuse. This deficiency was cited as a result of the investigation of FRI/complaint/report numbers AL00044697 and AL00047200. After retrospective Quality Assurance review and at the direction of Centers for Medicare and Medicaid (CMS) Services Atlanta Location, the Statement of Deficiencies (FORM CMS-2567) was amended on 11/27/2024 to reflect facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or serious psychosocial harm to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect, and Exploitation. On 11/27/2024 at 2:40 PM, the Administrator was provided a copy of the IJ template and notified of the finding of immediate jeopardy and substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F 600- Free from Abuse and Neglect. The IJ began on 07/01/2023 and continued until 09/01/2024 when the survey team verified onsite that corrective actions had been implemented. On 09/02/2024 the immediate jeopardy was removed through implemented removal plans for F 607 and F 610, F 600 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. Findings include: Review of the facility's abuse policy titled, Abuse Prohibition, with a revision date of 10/24/2022, revealed the following: POLICY Centers prohibit abuse, mistreatment, neglect . for all patients . Federal Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse is any use of oral, written language that willfully includes disparaging and derogatory terms to patients or their families, or within hearing distance, regardless of their ability to comprehend, or disability . Examples of verbal abuse includes, but are not limited to: threats of harm; saying things to frightened a patient . Physical Abuse includes hitting slapping, pinching, kicking, etc. Mistreatment is defined as inappropriate treatment . of a patient . 1) RI #398 was admitted to the facility on [DATE], with diagnoses to include Cerebral Infarction, Hemiplegia, Affecting Right Dominant Side, and Anxiety Disorder,. A Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/26/2023, identified RI #398 as scoring a five of 15 on the Brief Interview of Mental Status (BIMS) indicating RI #398 had severely impaired cognition. The Alabama Department of Public Health Online Incident Reporting System form, dated 07/06/2023 documented: . Incident Type . Abuse - Physical . Incident Detail . Name(s) of resident(s) involved: (RI #398) . Name of staff member who became aware of the incident: (Social Worker [SW]) . Narrative summary of incident: Resident informed (his/her) family, who informed the Center Social worker that resident is claiming an unnamed staff member on Saturday night was rough during care . Describe any injury to the alleged victim . bruising on wrist . The facility's Allegation Summary, documented that the facility's investigation determined: On Thursday July 6, 2023 (RI #398) alleged than an unnamed CNA had been rough with care on the previous Saturday. (RI #398) had stated that the CNA had grabbed (his/her) wrist and that (he/she) had bruising on them . Center Investigation: The investigation consisted of interviews with residents and staff. Also included were skin assessments of residents. Center Finding: On Thursday July 6, 2023 it was stated to facility staff that (RI #398) was stating he/she had bruising on his/her wrists and that a CNA was rough during care on the previous Saturday . (RI #398) had some reddened areas on his/her wrist . Center Conclusions: This investigation is unable to substantiate abuse in this instance. Based on the investigation care provisions was being complicated and (RI #398) began striking the CNA. The CNA did grab his/her wrist in order to stop him/her from striking her . On 08/24/2024 at 4:25 PM a telephone interview was conducted with RI #398's Responsible Party (RP). When asked what she could tell the surveyor about an incident occurring on 07/01/2023, involving bruising to RI #398's wrists. The RP said when her sister visited the facility on 07/01/2023, RI #398 mentioned a lady that had not been nice to him/her. The RP said RI #398 said the staff member was always ugly to him/her and told him/her to ''shut up and threw his/her arms down. The RP said when she visited RI #398 on 07/02/2023, she noticed the dark red/purple to black bruises on RI #398's wrists. The RP said she notified the social worker. On 08/24/2024 at 4:45 PM, the surveyor conducted a telephone interview with RI #398's daughter. RI #398's daughter said RI #398 informed her the CNA was always mean to him/her, and they called that CNA big trouble. RI #398's daughter said RI #398 informed her the CNA grabbed him/her and was hurting him/her, and would not let him/her go. RI #398's daughter said on 07/02/2023 when she went to visit RI #398, she noticed the bruises on RI #398's wrist. RI #398's daughter said RI #398's RP reported the incident to facility staff. On 08/24/2024 at 5:13 PM, an interview was conducted with the SW. When asked what she could tell the surveyor about an incident involving RI #398 and CNA #14 occurring on 07/01/2023, the SW said RI #398's daughter called and stated a CNA was rough with RI #398. The SW said she reported this to the ADM. The SW said the CNA being rough with RI #398 would be consider physical abuse if it occurred. The facility's investigative file was reviewed and a typed statement signed by the DON on 07/06/2023, revealed the following: A resident (RI #398) . called his/her Sponsor (name of responsible party) on Saturday, July 1, 2023 with his/her cellphone and told her that Big Trouble grabbed his/her wrist and was rough with him/her. (He/She) stated she (the CNA) said . Don't call me anymore either. The Sponsor called the Social Worker (name of SW) and reported it to her on July 5, 2023 . The Social Worker went to the resident's room and she returned and stated the resident said that someone grabbed his wrist but (he's/she's) not telling her who it was. I then went to the resident's room with the charge nurse (LPN #22) . I observed red bruises to both forearms .The resident went on to say he/she was getting good care at the facility and proceeded to hug his assigned CNA (CNA #14) . Witness statements were obtained . One of the employees (CNA #14) that worked with the resident on the evening of July 1, 2023, stated during my investigation that the resident was fighting her that night and she had to hold his/her wrist to block him/her from hitting her. She stated she went and immediately reported to Charge Nurse (LPN #17) and another Nurse was standing there . Both Nurses were interviewed and they corroborated the story from (CNA #14) . The abuse allegation cannot be substantiated. On 08/25/2024 at 5:46 PM, an interview was conducted with the DON. The DON said she was made aware, by the ADM, of the incident involving RI #398 and CNA #14 on 07/06/2023. The DON said she was informed that CNA #14 had grabbed RI #398's wrist. The DON said when she did a head-to-toe assessment on RI #398, there were discolorations on RI #398's arms. When asked could CNA #14 have just walked away from RI #398 and reported the incident, the DON said CNA #14 could have but according to her statement she was trying to stop RI #398 from hitting her. The DON said RI #398 could sit up in the bed independently, but required a mechanical lift for transfer out of the bed and was not ambulatory or able to walk. The DON said the facility was not aware RI #398 nicknamed CNA #14 big trouble until after the ADM interviewed RI #398. The DON said CNA #14 resigned in October of 2023 due to personal reasons. Unsuccessful telephone attempts were made to contact CNA #14 on 08/24/2024 at 5:42 PM and on 08/25/2024 at 3:02 PM. Review of a Late Entry Progress Note for RI #398, dated 07/01/2023, documented by LPN #17 on 07/08/2023 revealed the following: During last rounds CNA was changing the resident and (he/she) got upset and was yelling and proceeded to hit the aide. To keep from getting hit the aide grabbed (his/her) forearm and moved away from (him/her). She came out of the room and informed the nurse at the desk . This nurse went into room to assess the resident. Resident was calm . On 08/27/2024 at 12:25 PM, a telephone interview was conducted with LPN #17. LPN #17 said she did make the late entry concerning the incident involving RI #398. LPN #17 said she would consider the incident to be abuse. LPN #17 said she should have reported the incident to the abuse coordinator. On 08/28/2024 at 5:45 PM, an interview was conducted with the Registered Nurse/Nurse Practice Educator (NPE). The NPE said a CNA grabbing a resident by the wrist to keep the resident from hitting the CNA would be considered physical abuse. On 08/25/2024 at 4:40 PM an interview was conducted with the ADM. The ADM said according to the facility report, he was made aware of the incident involving RI #398 and CNA #14 on 07/06/2023. The ADM said RI #398 informed the Social Worker that on Saturday night (07/01/2023) an unnamed staff member was rough during care. The ADM said he reported the incident to ADPH (Alabama Department of Public Health) and initiated an investigation to identify the unnamed staff member. The ADM said during the investigation, CNA #14 stated RI #398 was hitting her and she stopped RI #398 by grabbing his/her wrists and reported it to LPN #17. The ADM said he did not substantiate the incident as abuse because he did not believe CNA #14 had any intention of harming RI #398. The ADM said he categorized the incident as physical abuse because the allegation was physical in nature. The ADM said he did not substantiate the incident as abuse because he did not believe CNA #14 had any intention of harming RI #398. When asked how it would make a reasonable person feel if someone grabbed them by the wrist and left bruising on them, the ADM said he would want it to stop. 2) RI #48 was admitted to the facility on [DATE], with diagnoses to include Alzheimer's Disease and Dementia. A Quarterly MDS assessment with an ARD of 01/02/2024 identified RI #48 had a BIMS score of 03 of 15 which indicated RI #48 had severe cognitive impairment. The Alabama Department of Public Health Online Incident Reporting System form, dated 03/10/2024 documented: . Incident Type . Abuse - Physical . Incident Detail . Name(s) of resident(s) involved: (RI #48) . Name of alleged perpetrator(s): (CNA #10) What was reported . It is alleged that (RI #48) grabbed (CNA #10) collar and (CNA #10) pushed (RI #48) back into the bed . Action(s) taken by the facility in response to the incident. Resident asses for injury, none noted, CNA #10 placed on administrative leave . The facility's incident summary, documented that the facility's investigation determined: Allegation Summary: On March 10, 2024 . Center Conclusion: This investigation is unable to substantiate abuse. (CNA #10) in attempting to remove (RI #48's) hand did result in (RI #48) losing his/her balance. The witnessing staff felt this situation could have been handled better and felt that frustration did play a factor in the interaction . An interview was conducted with Activity CNA #8 on 08/24/2024, at 11:59 AM. During this interview, CNA #8 recounted an incident that occurred on 03/10/2024, in which CNA #21, CNA #10 and she, were providing care to RI #48. CNA #8 stated that while they were providing care to RI #48, the resident pulled away from CNA #10. In response, CNA #10 placed both hands on RI #48's arms, turned the resident around, and shook him/her two to three times, resulting in RI #48's body hitting the footboard of the bed. CNA #8 indicated that she removed CNA #10's hands from RI #48 and then left the room to report the incident to Licensed Practical Nurse #11. An interview was conducted with LPN #11 on 08/24/2024, at 1:17 PM. During the interview, LPN #11 said that on 03/10/2023 CNA #8 reported that she felt CNA #10 was rough while attempting to provide care to RI #48. LPN #11 said she immediately went in the room and completed a body audit with no negative results found. LPN #11 then reported the incident to the weekend supervisor, administrator, responsible party, and medical doctor. LPN #11 reported that CNA #10 was sent home and did not return to work. LPN #11 said RI #48 had normal behavior the remainder of the day. LPN #11 said when a resident was combative, staff should leave the room and look for ways such as providing snacks to calm the resident. A telephone interview was conducted with CNA #10 on 08/26/2024, at 2:50 PM. During the interview, CNA #10 recalled that on 03/10/2024, she was assigned to care for RI #48 and sought assistance from CNA #8 and CNA #21. CNA #10 described an incident in which RI #48 grabbed her shirt, prompting her to grab RI #48's hand and wrist. She said that RI #48 was pulling on her shirt, and she had to tug twice before RI #48 released his/her grip. CNA #10 indicated that when she removed RI #48's hand from her shirt, it resulted in RI #48 falling over the bed. When questioned about her training for managing resistant residents, she stated that the protocol was to leave the room and return later. CNA #10 explained that she did not leave the room because RI #48 required a change, so she continued to provide care. When asked if she believed her actions were appropriate, she admitted that she could have left and returned later, which could have de-escalated the situation. CNA #10 said she did not consider her actions to be physical abuse, as RI #48 was examined and no redness or marks were observed. She acknowledged that she could have approached the situation differently. Following the incident, CNA #10 said she provided a verbal statement after the incident and clocked out for the day. A telephone interview was conducted with CNA #21 on 08/26/2024, at 3:18 PM. During the interview, CNA #21 recalled an incident from 03/10/2024, when she was requested to assist CNA #10 and CNA #8 in providing care to resident #48. CNA #21 said that resident #48 was upset and resisting care at that time. CNA #21 said RI #48 grabbed CNA #10's shirt collar and CNA #10 removed RI #48's hand. CNA #21 said CNA #10 turned RI #48 around and RI #48 fell onto the bed. CNA #21 said it was upsetting the way that CNA #10 handled RI #48 and reported the incident to the unit manager. When asked if she believed the actions she witnessed constituted abuse, she said yes, stating that this was the reason for her reporting the incident. In response to a question about her training for managing residents who resist care, she indicated that the guidance was to leave them alone and return at a later time. An interview was conducted with the ADM on 08/24/2024, at 4:54 PM. During the interview, the ADM said that he became aware of the incident involving RI #48 on 03/10/2024. He reported that an investigation was initiated, a report was submitted to the State Agency, and the employee, CNA #10, was suspended. The ADM noted that CNA #10 denied any allegations of being rough with RI #48, asserting that she was attempting to prevent the resident from hitting the bed. When questioned whether a staff member grabbing and placing a resident onto the bed could be classified as abuse, the ADM said that such an action would be considered abusive. He also mentioned that the resident was evaluated following the incident and found to have no injuries. Upon being asked if he believed RI #48 had been abused, he stated that he could not make a determination, as the accounts he received during the investigation were inconsistent. **************************************** 2) RI #48 was admitted to the facility on [DATE], with diagnoses to include Alzheimer's Disease and Dementia. A Quarterly MDS assessment with an ARD of 01/02/2024 identified RI #48 had a BIMS score of 03 of 15 which indicated RI #48 had severe cognitive impairment. The Alabama Department of Public Health Online Incident Reporting System form, dated 03/10/2024 documented: . Incident Type . Abuse - Physical . Incident Detail . Name(s) of resident(s) involved: (RI #48) . Name of alleged perpetrator(s): (CNA #10) What was reported . It is alleged that (RI #48) grabbed (CNA #10) collar and (CNA #10) pushed (RI #48) back into the bed . Action(s) taken by the facility in response to the incident. Resident asses for injury, none noted, CNA #10 placed on administrative leave . The facility's incident summary, documented that the facility's investigation determined: Allegation Summary: On March 10, 2024 . Center Conclusion: This investigation is unable to substantiate abuse. (CNA #10) in attempting to remove (RI #48's) hand did result in (RI #48) losing his/her balance. The witnessing staff felt this situation could have been handled better and felt that frustration did play a factor in the interaction . An interview was conducted with Activity CNA #8 on 08/24/2024, at 11:59 AM. During this interview, CNA #8 recounted an incident that occurred on 03/10/2024, in which CNA #21, CNA #10 and she, were providing care to RI #48. CNA #8 stated that while they were providing care to RI #48, the resident pulled away from CNA #10. In response, CNA #10 placed both hands on RI #48's arms, turned the resident around, and shook him/her two to three times, resulting in RI #48's body hitting the footboard of the bed. CNA #8 indicated that she removed CNA #10's hands from RI #48 and then left the room to report the incident to Licensed Practical Nurse #11. An interview was conducted with LPN #11 on 08/24/2024, at 1:17 PM. During the interview, LPN #11 said that on 03/10/2023 CNA #8 reported that she felt CNA #10 was rough while attempting to provide care to RI #48. LPN #11 said she immediately went in the room and completed a body audit with no negative results found. LPN #11 then reported the incident to the weekend supervisor, administrator, responsible party, and medical doctor. LPN #11 reported that CNA #10 was sent home and did not return to work. LPN #11 said RI #48 had normal behavior the remainder of the day. LPN #11 said when a resident was combative, staff should leave the room and look for ways such as providing snacks to calm the resident. A telephone interview was conducted with CNA #10 on 08/26/2024, at 2:50 PM. During the interview, CNA #10 recalled that on 03/10/2024, she was assigned to care for RI #48 and sought assistance from CNA #8 and CNA #21. CNA #10 described an incident in which RI #48 grabbed her shirt, prompting her to grab RI #48's hand and wrist. She said that RI #48 was pulling on her shirt, and she had to tug twice before RI #48 released his/her grip. CNA #10 indicated that when she removed RI #48's hand from her shirt, it resulted in RI #48 falling over the bed. When questioned about her training for managing resistant residents, she stated that the protocol was to leave the room and return later. CNA #10 explained that she did not leave the room because RI #48 required a change, so she continued to provide care. When asked if she believed her actions were appropriate, she admitted that she could have left and returned later, which could have de-escalated the situation. CNA #10 said she did not consider her actions to be physical abuse, as RI #48 was examined and no redness or marks were observed. She acknowledged that she could have approached the situation differently. Following the incident, CNA #10 said she provided a verbal statement after the incident and clocked out for the day. A telephone interview was conducted with CNA #21 on 08/26/2024, at 3:18 PM. During the interview, CNA #21 recalled an incident from 03/10/2024, when she was requested to assist CNA #10 and CNA #8 in providing care to resident #48. CNA #21 said that resident #48 was upset and resisting care at that time. CNA #21 said RI #48 grabbed CNA #10's shirt collar and CNA #10 removed RI #48's hand. CNA #21 said CNA #10 turned RI #48 around and RI #48 fell onto the bed. CNA #21 said it was upsetting the way that CNA #10 handled RI #48 and reported the incident to the unit manager. When asked if she believed the actions she witnessed constituted abuse, she said yes, stating that this was the reason for her reporting the incident. In response to a question about her training for managing residents who resist care, she indicated that the guidance was to leave them alone and return at a later time. An interview was conducted with the ADM on 08/24/2024, at 4:54 PM. During the interview, the ADM said that he became aware of the incident involving RI #48 on 03/10/2024. He reported that an investigation was initiated, a report was submitted to the State Agency, and the employee, CNA #10, was suspended. The ADM noted that CNA #10 denied any allegations of being rough with RI #48, asserting that she was attempting to prevent the resident from hitting the bed. When questioned whether a staff member grabbing and placing a resident onto the bed could be classified as abuse, the ADM said that such an action would be considered abusive. He also mentioned that the resident was evaluated following the incident and found to have no injuries. Upon being asked if he believed RI #48 had been abused, he stated that he could not make a determination, as the accounts he received during the investigation were inconsistent. ****************************************************************************** On 09/01/2024 at 6:40 PM, the facility submitted an acceptable removal plan, which document: Date: August 30, 2024 On 7/6/23 RI #398's family reported to Center Social Worker that an unnamed CNA had been rough with RI #398 On 7/6/23 immediately after speaking with family, Center Social Worker notified the Administrator Administrator spoke with RI #398 on 7/6/23, administrator failed to document interview with resident which resulted in resident not being protected from potential further abuse During the interviews, on 7/6/23, DON discovered that CNA #14 had reported to LPN #17 that she had an instance on 7/1/23, in which she had grabbed RI #398's wrist in order to stop the resident from striking her. LPN #17 failed to notify the Administrator on 7/1/23 of the occurrence which delayed interventions to ensure the alleged staff member was removed from the situation and caused a failure to ensure resident safety during the intervening time. On 7/6/23 CNA #14 was placed on administrative leave pending the results of the investigation. RI #398 was discharged on May 21, 2024, from Merry wood Lodge Center. Certified Nursing Assistant #14 is no longer employed at Merry wood Lodge Center. CNA #14's last day worked was 10/14/23 Licensed Practical Nurse #17 is no longer employed at Merry [NAME] Lodge Center. LPN #17's last day worked was 7/20/23. On August 30, 2024, The Social Services Director and/or designee interviewed 47 residents deemed as interviewable with a BIMs score ranging from 8-15 regarding Staff being rough with the residents. No concerns were identified On August 30, 2024, Licensed Nurses completed skin assessment on 42 residents identified with severe cognitive impairment with a BIMs score ranging from 0-7 to identify suspicion of Abuse. No additional concerns were identified. On August 30, 2024, the Nurse Practice Educator and/or designee initiated 100% re-education with employees (full-time, part-time) in all disciplines (Nursing, Therapy, Housekeeping, Dietary, Laundry, Activities, and Administration) on Abuse Prohibition policy and procedure, including but not limited to, the definition, types of Abuse (Physical, Mental/Emotional, Neglect, Sexual, and Financial), prevention and supervision, identification, reporting of abuse, and trauma. Identification includes knowing the types of abuse, recognizes deliberate acts, noticing suspicious behaviors, suspicious events, suspicious injuries, trends or patterns. Additionally, education emphasized immediately protecting the resident when abuse is identified and that anyone can be a perpetrator of abuse. The primary method for protecting residents, following staff involved abuse allegations or incidents, will be immediately placing the accused staff member on administrative leave pending the results of investigation. Education included protocols for employees having knowledge of an alleged abuse incident for reporting abuse immediately including first reporting to their Supervisor, the Supervisor will report to the Director of Nursing and Administrator. Employees with knowledge may also report directly to the Administrator as well. Education was completed on August 31, 2024, with all staff present in the Center and for all staff available via telephone communication. The total number of employees educated was 110. The Nurse Practice Educator and/or designee will ensure employees unable to be reached after 3 attempts, those with scheduled time off, on leave of absence (FMLA), vacation, or PRN will be re-educated prior to returning to duty. New hires (full-time, part-time) will be educated on Abuse Prohibition policy during the orientation process by the Nurse Practice Educator or Director of Nursing Services. On 8/31/24 110 staff members were educated regarding Abuse Prohibition Policy including the ability to prevent abuse, identify signs and evidence of abuse, and report abuse to the charge nurse and ultimately to the Administrator. On August 30, 2024 Market President educated the Nursing Home Administrator on the implementation of the Abuse Prohibition policy and procedure to include screening of potential hires; training of employees; prevention of occurrences; identification of possible incidents or allegations which need investigation; conducting thorough investigations of incidents and allegations; protection of residents during investigations; and reporting of incidents, investigations, and center response to the results of the investigations. Education included ensuring the Administrator knows and understands that abuse is identified as the individual acts deliberately, the actions of the individual were deliberate in nature and not dependent on the intent of the individual. Administrator has been educated regarding protecting residents by ensuring the accused individual does not have access to repeat the abuse. The accused employee is to be placed on administrative leave pending the results of the investigation. Education on August 30, 2024 also included ensuring the administrator knows his role and responsibility in implementing the abuse policy including investigations, identification, reporting, protection and involvement of QAPI. Administrator knows that staff not reporting abuse is a failure to follow policy and corrective action must be taken up to and including termination of employment. Compliance Date: September 1, 2024 *********************************************************** After review of documentation supporting the above correction actions, including the facility's investigation file, in-service/education records and staff interviews, the survey team verified the facility implemented corrective actions on 09/01/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, review of the facility's investigative file and review of the facility's abuse policy titled Abuse Prohibition, the facility failed to ensure the abuse policy was implemented following an incident of staff to resident physical abuse. The facility failed to ensure the incident was identified by licensed staff as abuse and protective measures were immediately implemented to prevent further potential abuse. The facility further failed to ensure the incident was reported to the Administrator (ADM) within two hours and thoroughly investigated to identify that abuse occurred and to ensure appropriate actions were taken to prevent further potential abuse. On 07/01/2023, Certified Nursing Assistant (CNA #14) reported to Licensed Practical Nurse (LPN) #17 that she grabbed Resident Identifier (RI) #398's wrists to keep RI #398 from hitting her. The incident was not reported to the ADM and no protective measures were implemented until the family reported the incident on 07/06/2023. On 07/06/2023 red and purple discolorations were noted on RI #398 's bilateral arms and wrists. The ADM failed to substantiate the allegation of physical abuse despite the CNA stating that she grabbed RI #398's wrists. The facility allowed CNA #14 to return to work at the facility. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or serious psychosocial harm to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect, and Exploitation. On 08/30/2024 at 7:32 PM, the ADM and Director of Nursing (DON) were provided a copy of the IJ template and notified of the finding of immediate jeopardy and substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F 607- Develop/Implement Abuse/Neglect, etc. Policies. The IJ began on 07/01/2023 and continued until 09/01/2024 when the survey team verified onsite that corrective actions had been implemented. On 09/02/2024 the immediate jeopardy was removed, F 607 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of complaint /report #AL00044697. Findings include: Cross-Reference F 610, F 835 and F 867. Review of the facility's abuse policy titled, Abuse Prohibition, with a revision date of 10/24/2022, revealed the following: POLICY Center prohibit abuse . for all patients . The Center will implement an abuse prohibition program through the following: . Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; Protection of patients during investigations; Reporting of incidents, investigations, and Center response to the results of their investigations. Federal Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Physical Abuse includes hitting slapping, pinching, kicking, etc. as well as controlling behavior through corporal punishment . Mistreatment is defined as inappropriate treatment . of a patient . PROCESS . 6. Staff will identify events- such as . occurrences . that may constitute abuse . 6.1 Anyone who witnesses an incident of suspected abuse . is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of shift worked. 6.1.1 The notified supervisor will report the suspected abuse immediately to the Administrator . RI #398 was admitted to the facility on [DATE], with diagnoses to include Cerebral Infarction, Hemiplegia, Affecting Right Dominant Side, and Anxiety Disorder. RI #398's Quarterly Minimum Data Set assessment with an Assessment Reference Date of 06/26/2023, identified RI #398 as scoring 5 of 15 on the Brief Interview of Mental Status, which indicated that RI #398 had severely impaired cognition. Review of a Late Entry Progress Note for RI #398, dated 07/01/2023, documented by LPN #17, an agency/contract staff member, on 07/08/2023 revealed the following: During last rounds CNA was changing the resident and (he/she) got upset and was yelling and proceeded to hit the aide. To keep from getting hit the aide grabbed (his/her) forearm and moved away from (him/her). She came out of the room and informed the nurse at the desk . This nurse went into room to assess the resident. Resident was calm . On 08/27/2024 at 12:25 PM, a telephone interview was conducted with LPN #17. LPN #17 said she did make the late entry concerning the incident involving RI #398; and she would consider the incident to be abuse. LPN #17 said she should have reported the incident to the abuse coordinator. Review of the assignment sheets for the unit RI #398 resided on revealed CNA #14 continued to provide care to RI #398 on 07/02/2023 on the 2 PM to 10 PM shift, on 07/03/2023 on the 2 PM to 10 PM shift, on 07/04/2023 on the 2 PM to 10 PM and 10 PM to 6 AM shifts and on 07/05/2023 on the 6 PM to 2 PM shift. The Alabama Department of Public Health Online Incident Reporting System form, dated 07/06/2023 documented: . Incident Type . Abuse - Physical . Incident Detail . Name(s) of resident(s) involved: (RI #398) . Name of staff member who became aware of the incident: (Social Worker [SW]) . Narrative summary of incident: Resident informed (his/her) family, who informed the Center Social worker that resident is claiming an unnamed staff member on Saturday night was rough during care . Describe any injury to the alleged victim . bruising on wrist . The facility's Allegation Summary, documented that the facility's investigation determined: On Thursday July 6, 2023 (RI #398) alleged than an unnamed CNA had been rough with care on the previous Saturday. (RI #398) had stated that the CNA had grabbed (his/her) wrist and that (he/she) had bruising on them . Center Investigation: The investigation consisted of interviews with residents and staff. Also included were skin assessments of residents. Center Finding: On Thursday July 6, 2023 it was stated to facility staff that (RI #398) was stating he/she had bruising on his/her wrists and that a CNA was rough during care on the previous Saturday . (RI #398) had some reddened areas on his/her wrist . Center Conclusions: This investigation is unable to substantiate abuse in this instance. Based on the investigation care provisions was being complicated and (RI #398) began striking the CNA. The CNA did grab his/her wrist in order to stop him/her from striking her . On 08/28/2024 at 5:45 PM, an interview was conducted with the Registered Nurse/Nurse Practice Educator (NPE). The NPE said grabbing a resident by the wrist would be considered physical abuse. The NPE said when the incident was reported to LPN #17, she should have ensured the resident was safe, even if that meant sending the CNA home. The NPE said this incident should have been reported to the ADM immediately. On 08/25/2024 at 5:46 PM, an interview was conducted with the DON. The DON said CNA #14 was suspended for six days after the allegation. The DON said CNA #14 resigned in October of 2023 due to personal reasons. On 08/30/2024 at 4:58 PM, an interview was conducted with the DON. The DON said the facility's concern with LPN #17 was she had a lack of caring for residents and violated company policy. The DON said LPN #17 did not complete an assessment on RI #398 at the time of the incident. On 08/25/2024 at 4:40 PM an interview was conducted with the ADM. The ADM said according to the facility report he was made aware of the incident involving RI #398 and CNA #14 on 07/06/2023. The ADM said RI #398 informed the Social Worker that on Saturday night (07/01/2023) an unnamed staff member was rough during care. The ADM said he reported the incident to ADPH (Alabama Department of Public Health) and initiated an investigation to identify the unnamed staff member. The ADM said during the investigation CNA #14 stated RI #398 was hitting her and she stopped RI #398 by grabbing his/her wrists and reported it to LPN #17. The ADM said he did not substantiate the incident as abuse because he did not believe CNA #14 had any intention of harming RI #398. On 08/28/2024 at 11:00 AM, a follow-up interview was conducted with the ADM. The ADM said LPN #17 should have reported the incident to him. When asked how RI #398 was protected from further potential harm from 07/01/2023 until 07/06/2023, the ADM said RI #398 was not protected. The ADM said he did not investigate how RI #398 obtained the bruises to his/her wrist because he was not aware of the bruising at the time of the investigation. The ADM said he did not have a documented interview with CNA #14 or LPN #17. ************************************************************ On 09/01/2024 at 6:40 PM, the facility submitted an acceptable removal plan, which document: F-607-Development and implementation of written Abuse Prohibition policies. On 7/6/23 RI #398's family reported to Center Social Worker that an unnamed CNA had been rough with RI #398 On 7/6/23 immediately after speaking with family, Center Social Worker notified the Administrator Administrator spoke with RI #398 on 7/6/23, administrator failed to document interview with resident which resulted in resident not being protected from potential further abuse During the interviews, on 7/6/23, DON discovered that CNA #14 had reported to LPN #17 that she had an instance on 7/1/23, in which she had grabbed RI #398's wrist in order to stop the resident from striking her. LPN #17 failed to notify the Administrator on 7/1/23 of the occurrence which delayed interventions to ensure the alleged staff member was removed from the situation and caused a failure to ensure resident safety during the intervening time. On 7/6/23 CNA #14 was placed on administrative leave pending the results of the investigation. RI #398 was discharged on May 21, 2024, from Merry wood Lodge Center. Certified Nursing Assistant #14 is no longer employed at Merry wood Lodge Center. CNA #14's last day worked was 10/14/23 Licensed Practical Nurse #17 is no longer employed at Merry [NAME] Lodge Center. LPN #17's last day worked was 7/20/23. On August 30, 2024, The Social Services Director and/or designee interviewed 47 residents deemed as interviewable with a BIMs score ranging from 8-15 regarding Staff being rough with the residents. No concerns were identified On August 30, 2024, Licensed Nurses completed skin assessment on 42 residents identified with severe cognitive impairment with a BIMs score ranging from 0-7 to identify suspicion of Abuse. No additional concerns were identified. On August 30, 2024, the Nurse Practice Educator and/or designee initiated 100% re-education with employees (full-time, part-time) in all disciplines (Nursing, Therapy, Housekeeping, Dietary, Laundry, Activities, and Administration) on Abuse Prohibition policy and procedure, including but not limited to, the definition, types of Abuse (Physical, Mental/Emotional, Neglect, Sexual, and Financial), prevention and supervision, identification, reporting of abuse, and trauma. Identification includes knowing the types of abuse, recognizes deliberate acts, noticing suspicious behaviors, suspicious events, suspicious injuries, trends or patterns. Additionally, education emphasized immediately protecting the resident when abuse is identified and that anyone can be a perpetrator of abuse. The primary method for protecting residents, following staff involved abuse allegations or incidents, will be immediately placing the accused staff member on administrative leave pending the results of investigation. Education included protocols for employees having knowledge of an alleged abuse incident for reporting abuse immediately including first reporting to their Supervisor, the Supervisor will report to the Director of Nursing and Administrator. Employees with knowledge may also report directly to the Administrator as well. Education was completed on August 31, 2024, with all staff present in the Center and for all staff available via telephone communication. The total number of employees educated was 110. The Nurse Practice Educator and/or designee will ensure employees unable to be reached after 3 attempts, those with scheduled time off, on leave of absence (FMLA), vacation, or PRN will be re-educated prior to returning to duty. New hires (full-time, part-time) will be educated on Abuse Prohibition policy during the orientation process by the Nurse Practice Educator or Director of Nursing Services. On August 30, 2024 Market President educated the Nursing Home Administrator on the implementation of the Abuse Prohibition policy and procedure to include screening of potential hires; training of employees; prevention of occurrences; identification of possible incidents or allegations which need investigation; conducting thorough investigations of incidents and allegations; protection of residents during investigations; and reporting of incidents, investigations, and center response to the results of the investigations. Education included ensuring the Administrator knows and understands that abuse is identified as the individual acts deliberately, the actions of the individual were deliberate in nature and not dependent on the intent of the individual. Administrator has been educated regarding protecting residents by ensuring the accused individual does not have access to repeat the abuse. The accused employee is to be placed on administrative leave pending the results of the investigation. Education on August 30, 2024 also included ensuring the administrator knows his role and responsibility in implementing the abuse policy including investigations, identification, reporting, protection and involvement of QAPI. Administrator knows that staff not reporting abuse is a failure to follow policy and corrective action must be taken up to and including termination of employment. Compliance Date: September 1, 2024 *********************************************************** After review of documentation supporting the above correction actions, including the facility's investigation file, in-service/education records and staff interviews, the survey team verified the facility implemented corrective actions on 09/01/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, review of the facility's abuse policy titled, Abuse Prohibition, review of Facility Reported Incidents (FRIs) received by the Alabama State Survey Agency, and review of the facility's investigative files, the facility failed to ensure an allegation of staff to resident physical abuse was thoroughly investigated to identify that abuse occurred, determine if bruising was a result of the abuse, and take appropriate action to prevent further potential abuse. On 07/01/2023, Certified Nursing Assistant (CNA #14) reported to Licensed Practical Nurse (LPN) #17 that she grabbed Resident Identifier (RI) #398's wrists to keep RI #398 from hitting her. The incident was not reported to the Administrator (ADM) and no protective measures were implemented until 07/06/2023. On 07/06/2023 red and purple discolorations were noted on RI #398 's bilateral arms and wrists. The ADM failed to substantiate the allegation of physical abuse despite the CNA stating that she grabbed RI #398's wrists. The facility's investigation did not determine the cause of the bruising. The facility allowed CNA #14 to return to work at the facility. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect, and Exploitation. On 08/30/2024 at 7:32 PM, the ADM and Director of Nursing (DON) were provided a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy; substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F 610-Investigate/Prevent/Correct Alleged Violations. The IJ began on 07/01/2023 and continued until 09/01/2024 when the survey team verified onsite that corrective actions had been implemented. On 09/02/2024 the immediate jeopardy was removed, F 610 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of complaint/report #AL00044697. Further the facility failed to thoroughly investigate three allegations of resident on resident abuse and two incidents of injury of unknown origin. These failures did not rise to the level of immediate jeopardy and included the following allegations: 2) On 04/19/2023 RI #148 hit RI #25. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00043994. 3) On 08/22/2023 RI #51 hit RI #600. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00045350. 4) On 10/30/2023 RI #198 was observed with bruising around the right eye and was complaining of left hip pain. The facility identified the allegation as injury of unknown origin and failed to thoroughly investigate. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00046026. 5) On 11/14/2023 RI #598 alleged she/he was experiencing back pain from being pushed down to the floor. The facility failed to thoroughly investigate the injury of unknown origin involving RI #598. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00046185. 6) On 06/25/2024 RI #60 slapped RI #9. This deficiency was cited as a result of a Facility Reported Incident, complaint/report number AL00048245. Findings Include: Cross-Reference F 600, F 835, and F 867. Review of the facility's abuse policy titled, Abuse Prohibition, with a revision date of 10/24/2022, revealed the following: POLICY Center prohibit abuse, mistreatment . for all patients. This includes, . any physical . restraint not required to treat the patient's medical symptoms . The Center will implement an abuse prohibition program through the following: . Identification of possible incidents or allegations which need investigation; Investigation of incidents and allegations; Protection of patients during investigations; and Reporting of incidents, investigations, and Center response to the results of their investigations. Federal Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Physical Abuse includes hitting slapping, pinching, kicking, etc. (etcetera) . Injuries of unknown source are defined as an injury with both of the following conditions. The source of the injury was not observed by any person or the source of the injury could not be explained by the patient; and The injury is suspicious because of the intent of the injury or the location of the injury (e.g., (for example) the injury is located in an area not generally vulnerable to trauma) . Mistreatment is defined as inappropriate treatment . of a patient . PROCESS . 6. Staff will identify events - such as suspicious bruising of patients, occurrences, patterns. and trends that may constitute abuse - and determine the direction of the investigation. This also includes patient-to-patient abuse . 7.8 The investigation will be thoroughly documented within the Risk Management Portal. Ensure that documentation of witnessed interviews is included . 1) RI #398 was admitted to the facility on [DATE], with diagnoses to include Cerebral Infarction, Unspecified, Hemiplegia, Unspecified Affecting Right Dominant Side and Anxiety Disorder. A Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/26/2023, identified RI #398 as scoring a 5 of 15 on the Brief Interview of Mental Status (BIMS) indicating RI #398 had severely impaired cognition. The Alabama Department of Public Health Online Incident Reporting System form, dated 07/06/2023 documented: . Incident Type . Abuse - Physical . Incident Detail . Name(s) of resident(s) involved: (RI #398) . Name of staff member who became aware of the incident: (Social Worker [SW]) . Narrative summary of incident: Resident informed (his/her) family, who informed the Center Social worker that resident is claiming an unnamed staff member on Saturday night was rough during care . The facility's Allegation Summary, documented that the facility's investigation determined: On Thursday July 6, 2023 (RI #398) alleged than an unnamed CNA had been rough with care on the previous Saturday. (RI #398) had stated that the CNA had grabbed (his/her) wrist and that (he/she) had bruising on them . Center Finding: On Thursday July 6, 2023 it was stated to facility staff that (RI #398) was stating (he/she) had bruising on (his/her) wrists and that a CNA was rough during care on the previous Saturday . Center Conclusions: This investigation is unable to substantiate abuse in this instance. Based on the investigation care provisions was being complicated and (RI #398) began striking the CNA. The CNA did grab (his/her) wrist in order to stop (him/her) from striking her . The facility's investigative file was reviewed and a WITNESS INTERVIEW RECORD statement dated 07/06/2023, signed by CNA #14 documented the following: . I worked with (him/her) Saturday. When I was changing (him/her) (he/she) begin to hit me and I Told (him/her) to stop and (he/she) didn't And I When (went) and got the nurse And Told her what (he/she) was doing And When you try To give (him/her) patient care (he/she) begin to fight. Review of a Late Entry Progress Note for RI #398, dated 07/01/2023, documented by an agency staff member, LPN #17 on 07/08/2023 revealed the following: During last rounds CNA was changing the resident and (he/she) got upset and was yelling and proceeded to hit the aide. To keep from getting hit the aide grabbed (his/her) forearm and moved away from (him/her). She came out of the room and informed the nurse at the desk . On 08/25/2024 at 4:40 PM an interview was conducted with the ADM. The ADM said according to the facility report he was made aware of the incident involving RI #398 and CNA #14 on 07/06/2023. The ADM said RI #398 informed the Social Worker that an unnamed staff member on Saturday night (07/01/2023) was rough during care. The ADM said he reported the incident to ADPH and initiated an investigation to started to try to identify the unnamed staff member. The ADM said the investigation revealed CNA #14 stated RI #398 was hitting her and she stopped RI #398 by grabbing his/her wrists and reported it to LPN #17. The ADM said he did not substantiate the incident as abuse because he did not believe CNA #14 had any intention of harming RI #398. When asked how it would make a reasonable person feel if someone grabbed them by the wrist and left bruising on them, the ADM said he would want it to stop. On 08/28/2024 at 11:00 AM, a follow-up interview was conducted with the ADM. When asked how he investigated the alleged abuse occurring with RI #398 on 07/01/2023, the ADM said he interviewed any staff that worked from 07/01/2023 to 07/06/2023. The ADM said he was not aware RI #398 had bruises until the surveyor informed him on 08/25/2024. The ADM said he interviewed CNA #14, LPN #17 and LPN #7, but did not document they had been interviewed. When asked if he should have kept a record of the staff being interviewed, the ADM said yes. 2) RI #25 was admitted to the facility on [DATE]. A Quarterly MDS assessment with an ARD date of 01/28/2023, identified RI #25 as scoring a 10 of 15 on the BIMS, indicating RI #25 had moderate impaired cognition. RI #148 was admitted to the facility on [DATE]. A Quarterly MDS assessment with an ARD date of 03/10/2023, identified RI #148 as scoring a 6 of 15 on the BIMS, indicating RI #148 had severe impaired cognition. The Alabama Department of Public Health Online Incident Reporting System form, dated 04/19/2023 documented: . Incident Type . Other Facility Incidents . Incident Detail . Name(s) of resident(s) involved: (RI #25 and RI #148) . Narrative summary of how injury was discovered: Reportedly RI #148 hit RI #25 on his/her arm while in the dining area. When asked why RI #148 states that RI #25 was in his way . A review of the facility's investigation summary documented: .On April 19, 2023, it was reported that RI #148 had struck the arm of RI #25. When asked RI #148 stated he/she needed him/her to move out of his/her way. RI #148 was attempting to exit the dining area and from his/her perspective RI #25 was impeding his/her route out of the dining room . At this time we are unable to substantiate abuse occurred based on the fact that RI #148 had no intent to harm RI #25 but to merely compel him/her to relocate . Review of the facility's investigative file revealed no documentation of interviews completed during the investigation. An interview was conducted with the ADM on 08/26/2024, at 4:20 PM. During the interview, the ADM was asked about the documentation of any interviews related to the investigation involving RI #148 and RI #25. The ADM said that he had conducted interviews with RI #148, as well as with witnesses and other residents present in the dining room. When questioned about the location of these interviews, he stated that he typically retained and submitted them with the investigation; however, he was unable to locate any interviews associated with this case. The ADM said the importance of documenting all statements was to ensure sufficient information was available for a thorough assessment of the situation and the formulation of an appropriate action plan. 3) RI #51 was admitted to the facility on [DATE] with a Diagnosis to include but not limited to: Chronic Obstructive Pulmonary Disease and Alzheimer's Disease. A review of RI #51's Quarterly MDS ARD of 07/20/2023, indicated RI #51 had a Brief Interview of Mental Status BIMS score of 15 of 15, which indicated intact cognition. RI #51 ambulated independently with assistance of a walker on the unit. RI #600 was originally admitted to the facility on [DATE], discharged on 07/07/2023 and readmitted on [DATE] with Diagnosis of Dementia with Behavioral Disturbance. A review of RI #600's care plan revealed he/she had the potential to exhibit physical behaviors and noted a prior physical altercation with a resident on 07/07/2023. A review of RI #600's Quarterly MDS with an ARD of 08/8/2023, indicated a BIMS score of 4 of 15 which indicated RI #600's cognition was severely impaired. He/she ambulated independently on the unit with no assistive device. On 08/22/2023 at 8:10 PM, the Alabama Department of Public Health (ADPH) Incident Reporting System documented RI #51 alleged RI #600 hit him/her on the upper back when he/she tried to redirect. Review of the facility's investigation summary revealed: . On 08/22/2023 it was alleged by RI #51 that RI #600 had struck him/her back and arm after he/she had tried to direct RI #600 to change directions in the hall. Center Investigation: The Center investigation included interviews with staff on the unit at the time of alleged event and interview with RI #51. RI #600 is not able to be interviewed. Center Findings: This event was unwitnessed and only reported by RI #51 . According to RI #51 he/she was attempting to redirect RI #600 in the hallway. During this interaction it was alleged at RI #600 struck RI #51 in the back twice and arm once .both assessed for injury. None noted. RI #600 was monitored and assessed for aggressive behavior . Center Actions Taken: . Allegation reported to ADPH Resident RPs and MD notified of occurrence RI #600 monitored for aggressive behavior, none noted RI #51 and RI #600 assessed for injury, none noted RI #51 educated regarding to inform staff if another resident is to be redirected . The facility investigative file was reviewed and revealed no documented evidence of where RI #51 was interviewed. No documented evidence where education was provided to RI #51. Further, the facility investigative file revealed no documented evidence that RI # 600's behavior was monitored to ensure no physically aggressive behavior occurred after the alleged incident. On 08/24/2024 at 4:16 PM, RI #51 was interviewed and recalled the incident on 08/22/2023 when he/she was hit by RI #600. RI #51 said that RI #600 had wandered into his/her room and attempted to take a personal item. When RI #51 provided redirection, RI #600 hit him/her on the back. On 08/24/2024 at 5:10 PM CNA #12 was interviewed and revealed RI #600 exhibited behaviors towards others. CNA #12 said she was working down the hall when she heard RI #51 talking to RI #600 saying do not go in his/her room. CNA #12 said RI #600 was a firecracker, and his/her behavior was unpredictable. When he/she heard the argument, he/she went down the hall quickly to intervene. This was when RI #51 reported that RI #600 hit him/her when redirected. CNA #12 said RI #51 was initially upset, but did calm down. On 08/25/2024 at 4:55 PM, the ADM was interviewed about the allegation between RI #51 and RI # 600 on 08/22/2023. The ADM noted the incident was reported by RI# 51, investigated by the facility, and actions put in place. When asked about documentation from resident interviews and behavioral monitoring for RI #600 for aggressive behavior, the ADM said there was unfortunately no documented evidence of the above actions. The ADM agreed there should be more documentation for a thorough investigation. 4) RI #198 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Anoxic Brain Damage, Expressive Language Disorder, Parkinson's, Vascular Dementia, Long Term (current) use of Aspirin and History of Falling. An Annual MDS assessment with an ARD date of 09/14/2023, identified RI #198 as scoring a 3 of 15 on the BIMS, indicating RI #198 had severely impaired cognition. The Alabama Department of Public Health Online Incident Reporting System form, dated 10/30/2023 documented: . Incident Type . Injuries of Unknown Source . Date and time of when staff became aware of the incident: . 10/30/2023 .Time: 04:00 PM . Incident Detail . Name(s) of resident(s) involved: (RI #198) . Narrative summary of how injury was discovered: Resident discovered with bruising over . (his/her) right eye and complaining of pain in (his/her) left hip. Resident unable to state how injuries occurred and no incidence have been reported explaining how injuries occurred . Review of the facility's investigation summary revealed: . On 10/30/23 it was reported that (RI #198) had bruising around his/her eye and was complaining of hip pain. The origin of these concerns were not known . Center Investigation: The Center investigation included interviews with staff providing care for (RI #198). X-rays were also taken. Center Findings: At the time X-rays did not show a fracture . At this time staff do not report having seen or witnessed any incident that would have explained the injury and pain noted . Resident is unable to provide any information as to the origin of the discoloration over (his/her) eye . Center Actions Taken: . Injuries reported to MD (Medical Doctor) and RP (Representative) Injury reported to ADPD Resident assessed for additional injury; none noted Xray obtained, no acute fractures noted Investigation completed . Review of the facility's investigative file revealed a WITNESS INTERVIEW RECORD statement had not been obtained from CNA #10, the CNA providing care for RI #128 on the 6 AM to 2 PM shifts, on 10/28/2023, 10/29/2023, and 10/30/2023. On 08/26/2024 at 12:50 PM, a telephone interview was conducted with CNA #10, the CNA providing care for RI #198 on the 6 AM to 2 PM shifts, on 10/28/2023, 10/29/2023 and 10/30/2023. CNA #10 said she did recall RI #198 having a bruise to one of his/her eyes back in October of last year but could not remember which eye it was and could not describe how the bruise looked. CNA #10 said she got RI #198 out of bed around 10:30 AM on 10/29/2023, because RI #198 was becoming fidgety. CNA #10 said when she got RI #198 out of bed she placed RI #198 in his/her geriatric chair and left RI #198 in his/her room. CNA #10 said probably around lunch time she went back to check on RI #198 and noticed RI #198 had the bruise. CNA #10 said she took RI #198 to the nurse to show the nurse the bruise. When asked did she write a statement about what she had observed, CNA #10 said no one asked her to write a statement about what she witnessed. On 08/28/2024 at 9:38 AM, an interview was conducted with the ADM. The ADM said RI #198's bruise was considered an injury of unknown origin because the bruise was from an unknown source. When asked how an investigation was conducted to determine if abuse or neglect occurred, the ADM said staff who had provided care for RI #198 a couple of days before the bruise was identified were interviewed. The surveyor showed the ADM the assignment sheet for 10/28/2023 and 10/29/2023 and asked the ADM which CNA provided care to RI #198 on the 6 AM to 2 PM shift. The ADM said CNA #10. The ADM said looking at the interviews collected during his investigation he did not see where CNA #10 completed a Witness Interview. The ADM said since CNA #10 provided care for RI #198 during the time frame the bruise was observed, she should have completed a Witness Interview Record form. The ADM said since CNA #10's statement was not obtained, this was probably not a thorough investigation. 5) RI #598 was admitted to the facility on [DATE] with a Diagnosis of Dementia with Behavioral Disturbance. A review of RI #598's Quarterly MDS with an ARD of 06/15/2023 revealed he/she scored a 10 of 15 on the BIMS which indicated RI #598's cognition was moderately impaired. He/she ambulated on the unit independently with assistance of a walker. RI # 598's balance during transitions was coded as not steady, but able to stabilize without staff assistance. RI #598 was care planned for the potential to demonstrate verbal outburst towards others. A review of RI #598's care plan documented 11/08/2023 he/she exhibited verbal outbursts toward staff. A review of RI #598's medical record documented that on 11/13/2023 at 7:35 PM RI #598 started an argument with another resident, became agitated, cursing, and required staff intervention. On 11/14/2023 at 7:11 AM, the Alabama Department of Public Health Online Incident Reporting System form documented . RI #598 of our memory care unit stated to nurse that he/she had back pain because he/she was pushed down to the floor last night. He/she was unable to state by whom. Review of the facility's investigation summary revealed: . On 11/14 2023 RI #598, a resident in our memory care unit, claimed that he/she was having back pain. Nurse treated for pain and RI #598 claimed he/she was pushed down to the floor on the night before. Unable to state who or where. Center Investigation: Investigation included interviews with staff that had worked with RI # 598. Center Findings: RI # 598 is unable to state how, why or who pushed him/her down on the night shift. X-ray were taken, no fractures noted. Some mild osteoarthritis was noted. No other signs of injury were found. Staff interviewed stated they did not witness a fall, nor any incident of RI #598 being pushed. They did not find him/her on the floor at any point on the shifts. Center Actions Taken: . ADPH notified MD and RP notified Resident assessed for injury, none noted Resident treated for pain with good effect X-Ray of back taken, no fracture noted Resident monitored for change in behaviors or interactions with others, none noted Social Services provided as needed . A review of the facility investigative file revealed no staff or resident interviews were conducted prior to 11/14/2023 when RI #598 complained of back pain from being pushed down the night before. Further, the facility file revealed no documentation from staff that witnessed the altercation on 11/13/2023. No documentation that the incident on 11/13/2023 was investigated. On 08/26/2024 at 2:54 PM, the ADM was interviewed and said the facility investigation concluded there were no witnesses to a fall, or incident of RI #598 being pushed down the night before. When the ADM was asked if staff/resident witness statements were conducted days prior to 11/14/2023 to assist in determining if abuse did or did not occur, the ADM said no. The ADM agreed that more interviews should have been completed and documented. The ADM said he was not aware of an incident that occurred on 11/13/2023; therefore, no witness statements obtained nor investigated. When asked if the incident on 11/13/2023 should have been investigated further, the ADM said yes. 6) RI #9 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Schizoaffective Disorder, Depressive Type. An admission MDS assessment with an ARD date of 04/04/2024, identified RI #9 had a BIMS of 5 of 15 which indicated that RI #9 had severely impaired cognition. RI #60 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Adjustment Disorder. A Quarterly MDS assessment with an ARD date of 06/20/2024, identified RI #60 as scoring a 12 of 15 on the BIMS, indicating RI #60 had moderate impaired cognition. The Alabama Department of Public Health Online Incident Reporting System form, dated 06/25/2024 documented: . Incident Type . Other Facility Incidents . Incident Detail . Name(s) of resident(s) involved: (RI #9 and RI #60) . Narrative summary of how injury was discovered: RI # 9 was in another residents room, RI #60 came by and attempted to redirect RI #9 out of the room. RI #60 allegedly slapped RI #9's hand and told him/her they should not be in this room. RI #60 denies slapping RI #9 . A review of the facility's five day summary documented: . On June 25, 2024 it was alleged that RI #60 pinched the hand of RI #9 . This was a witnessed resident to resident altercation. Staff witnessing the incident were interviewed. Residents were also interviewed . At this time abuse cannot be substantiated in this instance. RI #60 simply did not understand that RI #9 was an invited guest in the room and . did not intend to cause harm to RI #9 . Both residents were assessed for injury, none noted . Review of the facility's investigative file revealed no documentation of interviews completed during the investigation. An interview was conducted with the ADM on 08/27/2024, at 12:13 PM. During the interview, the ADM was asked about the documentation of any interviews related to the investigation involving RI #60 and RI #9. He acknowledged that he spoke with those involved in the investigation but had not documented the interviews. He said that he should have documented the interviews. The ADM said the importance of documenting statements would be to provide an accurate and clear understanding of the events, which was essential for formulating an accurate action plan. *************************************************************** On 09/01/2024 at 6:40 PM, the facility submitted an acceptable removal plan, which document: Date: August 30, 2024 F-610-Investigate/Prevent/Correct Alleged Violation On 7/6/23 Center Social Worker was notified by RI#398's family regarding resident RI#398 stating a CNA had been rough during care. On 7/6/23 Center Social worker notified Center Administrator of the allegation Center administrator on 7/6/23 spoke with RI#398 regarding the occurrence. The Administrators failure to obtain the resident's statement, statements from other residents, and potential witness statements resulted in the facility not investigating thoroughly to include determining the cause of the injury to RI# 398 wrist/forearms and implement appropriate corrective actions to prevent further potential abuse. RI #398 was discharged on May 21, 2024, from Merry wood Lodge Center. On August 30, 2024 Market President educated the Nursing Home Administrator on the implementation of the Abuse Prohibition policy and procedure to include screening of potential hires; training of employees; prevention of occurrences; identification of possible incidents or allegations which need investigation; conducting thorough investigations of incidents and allegations; notifying and reviewing each investigation with the Market Clinical Lead before completion; protection of residents during investigations; and reporting of incidents, investigations, and center response to the results of the investigations to include identifying abuse and taking appropriate action for prevention of abuse. Administrator has been trained and understands his role and responsibility in ensuring a thorough investigation is completed. Administrator has been trained on the steps to a thorough investigation. These include identification of an alleged occurrence, ensure all alleged occurrences are reported to the Administrator, protect the resident(s),reporting the event, assess resident for injury, perform and document interviews with all Interviewable residents, interviewing all witnesses and all staff in the Center at the time, reviewing pertinent chart documentation such as progress notes, care plans, physician's order, diagnoses and any other clinical documentation appropriate to the investigation. Investigating bruises and injuries are also a key component to investigation. Developing appropriate conclusions, including substantiation or not correctly, and also developing appropriate actions to take in order to prevent future occurrences from occurring. The Center QAPI Committee which included the Market Clinical Lead by way of phone, business office manager, MDS coordinator, dietary manager, office assistant, recreation director, nurse practice educator, admissions director, social services director, medical records, environmental services supervisor, dietary supervisor, Director of Nursing Services, and Administrator met on 9/1/24 at 12:45 pm to discuss staff on resident incidents after the incident occurring on 7/1/2023. Two were identified reviewed to determine if correct determination was made and if appropriate corrective action has been taken the findings are as follows: RI# 81 event dated 1/2/24- Based on QAPI review, thorough investigation was not completed, the determination remains appropriate, the actions taken at the time were appropriate however QAPI committee determines that additional actions needed to be taken these additional actions taken include: Accused CNA no longer works at Merry [NAME] Lodge, her last day of work at the Center was March 10, 2024. On 8/31/24 47 residents were interviewed regarding rough treatment from staff and 42 residents skin assessments were completed for any signs of abuse, none were noted. On 8/31/24 110 staff members were re-educated regarding Abuse Prohibition Policy including the ability to prevent abuse, identify signs and evidence of abuse, and report abuse to the charge nurse and ultimately to the Administrator. On 8/30/24 Administrator was educated regarding conducting thorough investigations and protecting residents during the investigation. Administrator was also educated regarding identifying abuse as a part of the thorough investigation process and implementing corrective actions to prevent further occurrences. Administrator was also instructed to review all reportable events with Market Clinical Lead prior to finalizing investigation protocols. On 8/31/24 QAPI committee was educated regarding thoroughly reviewing all reportable events during the QAPI process for thoroughness of the investigation, appropriateness of the determination, and any further corrective actions that may need to be taken. RI #48-Event dated 3/10/24- Based on QAPI review, a thorough investigation was not completed, the determination was incorrect, the corrective actions taken at the time were appropriate however the QAPI committee has determined additional actions necessary to be taken. These actions include: Accused CNA no longer works at Merry [NAME] Lodge, her last day of work at the Center was March 10, 2024. On 8/31/24 47 residents were interviewed regarding rough treatment from staff and 42 residents skin assessments were completed for any signs of abuse, none were noted. On 8/31/24 110 staff members were re-educated regarding Abuse Prohibition Policy including the ability to prevent abuse, identify signs and evidence of abuse, and report abuse to the charge nurse and ultimately to the Administrator. On 8/30/24 Administrator was educated regarding thorough investigations and protecting residents during the investigation. Administrator was also educated regarding identifying abuse as a part of the thorough investigation process and implementing corrective actions to prevent further occurrences. Administrator was also instructed to review all reportable events with Market Clinical Lead prior to finalizing investigation protocols. On 8/31/24 QAPI committee was educated regarding thoroughly reviewing all reportable events during the QAPI process for thoroughness of the investigation, appropriateness of the determination, and any further corrective actions that may need to be taken. On 09/01/2024 at 4:[TRUNCATED]