**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, staff interviews, personnel file review, and policies and procedures, the facility failed to ensure one sampled resident (#158) was free from staff to resident abuse, which resulted in psychosocial harm as evidenced by increased yelling, screaming, agitation, and the resident being afraid of the staff member. The census was 55. The deficient practice could result in other residents being abused. Findings include: Resident #158 was admitted to the facility on [DATE] with diagnoses that included dementia, Parkinson's disease, chronic pain syndrome, depressive episodes and anxiety. The resident was discharged from the facility on January 16, 2020 to hospice. Review of a care plan initiated on January 10, 2019, revealed that the resident exhibited behaviors of physical and verbal aggression towards staff as evidenced by a history of physical behaviors of resisting cares, and yelling which were related to a diagnosis of cognitive impairment. Interventions included to reassure, re-approach at a different time, redirect and reorient. The care plan also included the resident had verbal behavior as evidenced by loud outbursts. Interventions included to provide calm, non-rushed environment. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognition impairment. The MDS assessment included the resident had physical behavioral symptoms directed toward others 4 to 6 days of the 7-day lookback period, verbal behavioral symptoms directed towards others daily, other behavioral symptoms not directed toward others 1 to 3 days of the 7-day lookback period, and rejected care 4 to 6 days of the 7-day lookback period. The assessment also included the resident was total dependent for transfer and toilet use, required extensive assistance for bed mobility and dressing, and limited assistance for personal hygiene. Review of the facility's Investigation Report dated October 7, 2019 revealed that on October 2, 2019 at approximately 6:00 AM, a Certified Nursing Assistant (CNA/staff #94) witnessed another CNA (staff #93) place a rag and then a pillow over the resident's face as they were providing care. CNA #94 stated that she was beginning her shift and went into the resident's room to assist the night shift CNA (staff #93) because she heard the resident calling out. Staff #94 reported seeing the alleged perpetrator (staff #93) place a cloth on the resident's mouth, which the resident removed. She further reported that as the care progressed the resident continued to yell out and then staff #93 placed a pillow across the resident's face. At this point the CNA (staff #94) reported that she removed the pillow and talked to the resident to calm the resident. Review of the Investigation Report revealed a body assessment was completed on resident #158 after it was reported at 3:00 PM on October 2, 2019 and that there were no signs of injury or bruising. The investigation report included the following witness statement for staff #94 dated October 2, 2019 at 3:15 PM: - I clocked in at 6:00 AM on October 2, 2019 and went to my scheduled hall. As I entered the hall I could hear resident #158 screaming very loudly in her room where she was being changed and dressed by CNA #93. I asked if CNA #93 needed help and started assisting with the resident's care. The resident was still screaming as we continued to get her clothes on when staff #93 tried to silence the resident by putting a rag onto her mouth, telling me that the resident just needed something to bite down on. The resident did not like this and removed the rag and shortly after, CNA #93 placed a pillow over the resident's face while trying to have a conversation with me. I removed the pillow and remained quiet and tried to calm the resident down verbally. We finished the care and CNA #93 gave me report and then clocked out. Staff #93's (alleged perpetrator) statement dated October 3, 2019, included that when she starting dressing the resident, the resident behavior escalated to yelling and the resident resisted getting her shirt on by holding her arms down. During this time CNA #94 came in because it was 6:00 AM, and she assisted with dressing and Hoyering. Everything went normal with the care, and once the resident was in her chair she was content. We finished rounds for the hall and everything else went good until 6:30 AM when I clocked out. A student CNA's (staff #301) statement dated October 3, 2019, included that on October 2, 2019, staff #301 started the shift as a CNA student for clinicals arriving on the hall a few minutes after 6:00 AM. Staff #301 heard as well as others, a resident yelling, screaming very upset but did not go to see what was going on. Staff #301 stated a resident made the comment that resident #158 is not usually that voicetourous, the resident was obviously upset about something. Another student CNA's (staff #302) statement dated October 3, 2019, revealed that on October 2, 2019, staff #94 was demonstrating how to properly change a resident, when she told them of an incident that happened that morning. Staff #302 stated staff #94 stated that she had come onto her shift on the [NAME] hall and heard the resident screaming very loudly, that she was concerned so she went to see what was going on and noticed that staff #93 was cleaning the resident who was very agitated, and that staff #93 was not explaining to the resident what she was doing or what she needed the resident to do. The student CNA statement included staff #94 stated that she tried to calm the resident down when staff #93 shoved a rag in the resident's mouth and placed a pillow on top of the resident's face. Staff #302 statement further revealed staff #94 told her that she was in shock and did not know what to do or say. The statement included staff #94 stated that they then went into another resident's room and that resident asked staff #93 if she was going to work the next night to which staff #93 replied she did and then this resident asked staff #93 what she was going to do with her and that staff #93 stated that she was going to kill her, laughed and told the resident to just shut up. The report included resident #158's family was notified of the incident on October 3, 2019. The family member stated that she had talked to the resident on Friday and Saturday and the resident was telling her that a CNA taking care of her that is pregnant is abusing her on the night shift, that the resident stated she was hit and abused by the CNA and had bruises on her hands and arms. The family member stated resident #158 is scared and terrified of her. Further review of the Investigation report revealed resident #158 was interviewed on October 4, 2019 and stated she slams me into the wall and hit me. Girl told me she has 4 kids she is pregnant, works at night When asked if she wanted to share anything else the resident stated help me. Resident #158 stated she would scream at her and hit her. The report included an interview on October 4, 2019 with the resident whose room staff #93 and staff #94 went into after providing care for resident #158. This resident stated that a blonde girl at night throws her weight around, wants to get rid of people, she'll be here tonight, afraid drag me outside. NOC shift, blonde hair and pregnant, she scares me, she is mean and angry, she has piercing eyes tells people to shut up. The report included that on October 4, 2021 a Licensed Practical Nurse had stated that resident #158 was yelling louder than normal. The investigation report documentation dated October 4, 2019 by the Director of Nursing (DON/staff #303) revealed that no bruising was noted on any resident. Further review of the Investigation Report included a skin assessment form dated October 10, 2019, which revealed resident #158 had an old small bruise on the left medial arm, below the elbow. The Administrator (staff #304) wrote in the investigation report on October 7, 2021 that he had spoken with the investigating officer who stated that based off of the interviews he had conducted and due to eyewitness account that CNA #93 did place the rag over the resident's mouth and the pillow over the resident's face, and due to two residents being afraid of staff #93, the officer felt it was in the best interest of the residents to terminate staff #93. Review of the personnel file for the alleged perpetrator (staff #93) revealed the CNA had received education/orientation for abuse, and resident rights. The file included an Employee Termination form dated 10/10/2019 that an allegation of abuse was brought against staff #93 and that after investigating the allegation, it was determined that two residents on the [NAME] unit were afraid of staff #93 and that they were not able to continue employment due to the residents being afraid of her. The file also included staff #93 had been educated on resident abuse and customer service on July 29, 2019, and that the impact of residents being afraid of employees negatively affects the well-being of the residents. A telephone interview was attempted with the resident's family member on October 18, 2021 at 11:50 PM. There was no answer and no option to leave a message. A telephone interview was attempted on October 19, 2021 at 2:49 PM with the alleged perpetrator (CNA/staff #93). The person answering the call stated that the number was now a business, and they were not familiar with staff #93. A telephone interview was attempted on October 19, 2021 at 2:57 PM with the witness (CNA/staff #94). There was no answer and no voicemail available to leave a message. An interview was conducted October 20, 2021 at 9:24 AM with the DON (staff #43), who stated that she was employed at the facility when the incident occurred in 2019. She stated that it was related to resident abuse, that the witness (CNA/staff #94) was coming on shift and the alleged perpetrator (CNA/staff #93) was going off shift. She stated that it was reported by staff #94 that staff #93 had put a pillow over a resident's face while changing the resident. She further stated that this does not meet the facility expectation for resident care. The DON stated that there was an investigation conducted, and the alleged perpetrator (staff #93) did not return to work and was terminated, but she is not aware of the reason. An interview was conducted on October 20, 2021 at 10:15 AM with an LPN (staff #73), who stated that she has worked at the facility since July 2019. She stated that she is familiar with resident (#158) and that she was very confused, combative, resistant to care and refused a lot of care. She stated that she was aware of an incident with a staff member and the resident. Staff #73 stated that she was working on the unit that day and the CNA (staff #94) told her that the night shift CNA (staff #93) had put something over the resident's mouth. The LPN stated that the residents had not reported concerns to her regarding the alleged perpetrator, prior to the incident. She stated that staffing was consistent at the time, and that this type of treatment was totally unexpected from this CNA. An interview was conducted on October 20, 2021 at 10:52 AM with a CNA (staff #78) who stated that she has worked at the facility for over 3 years. Staff #78 stated new employees receive orientation that includes a handbook, review the abuse policy, resident rights and Hand in Hand Crisis to Care (dementia and Alzheimer's) training, and that they also receive these in-services annually. She stated that she is familiar with the resident that she had a diagnosis of dementia. Staff #78 stated that most of her contact with the resident was in the dining room and that she did not have any behavior issues with resident #158. She further stated that she was aware of the staff to resident incident that occurred. Staff #78 stated that she did not see any abuse/behaviors toward residents from staff #93 and she was not aware of any complaints from residents about staff #93. Review of the facility policy titled, Abuse Prevention Program, revealed that residents have the right to be free from abuse, and corporal punishment. The facility is committed to protecting residents from abuse by anyone including facility staff, other residents or any other individual. Review of the facility policy titled, Abuse Prohibition, revealed that the facility will train employees to provide for the protection of residents and for the prevention, identification, and reporting of abuse, exploitation, neglect, and mistreatment. At the time of new hire orientation, all employees will be educated regarding abuse. Ongoing mandatory training is provided to all employees regarding identifying and reporting abuse.