Based on record review and interview, it was determined that for three (R1, R2 and R3) out of three residents reviewed for hospitalization, the facility failed to ensure that the physician conducted the required visits. Findings include: 1. Review of R1's clinical record revealed: 12/28/24 - R1 was admitted to the facility to the facility. 12/28/24 - R1 was examined by a physician and a Health Appraisal Visit documented the encounter in the electronic medical record (EMR). 4/10/24 - R1 was examined by a physician and a Health Appraisal Visit documented the encounter in the EMR. R1 went 104 days between physician visits. During the first 90 days of an admission to a skilled nursing facility, by regulation a patient must be examined every 30 days. 2. Review of R2's clinical record revealed: 5/1/18 - admission to the facility. 7/25/23 - R2 was examined by the physician and a Health Appraisal Visit documented the encounter in the EMR. 11/14/23 - R2 was examined by the physician and a Health Appraisal Visit documented the encounter in the EMR. R2 went 112 days between physician visits instead of the 60 days as required. 3/4/24 - R2 was examined by a physician and a Health Appraisal Visit documented the encounter in the EMR. R2 went 112 days between physician visits instead of the 60 days as required. 3. Review of R3's clinical record revealed: 7/18/23 - R3 was admitted to the facility. 10/31/23 - R3 was examined by a physician and a Health Appraisal Visit documented the encounter in the EMR. R3 went 105 days between physician visits. During the first 90 days of an admission to a skilled nursing facility, by regulation a patient must be examined every 30 days. 2/13/24 - R3 was examined by a physician and a Health Appraisal Visit documented the encounter in the EMR. 6/4/24 - R3 was examined by a physician and a Health Appraisal Visit documented the encounter in the EMR. R2 went 111 days between physician visits instead of the 60 days as required. 4/17/24 approximately 1:00 PM - During an interview with E3 (Quality Assurance/Infection Control Nurse) it was revealed that the physician visits occur with the quarterly assessments and a physicians' group round on residents once a week. When asked if the facility had evidence that the physicians' group see and examine each resident every every 60 days, E3 stated that all residents were seen quarterly but the physicians group rounds on residents that are sick and or require a visit by the physicians group. 6/17/24 at 2:20 PM - During an exit conference findings were reviewed with E1 (NHA) and E2 (ADON).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of the clinical record and other documentation as indicated, it was determined that for one (R3) out of one resident reviewed for abuse, the facility failed to ensure that R3, a non-verbal, medically challenged dependent teenager, was free from physical and verbal abuse from a staff person on 9/9/23, which caused R3 to cry. Based on observations of staff interactions with R3 during the current survey, staff interviews, record review since the 9/9/23 incident and consideration of the reasonable person concept revealed that R3 did not have a psychosocial outcome. Review and verification of the facility's immediate actions and no further incidents, the facility was in substantial compliance as of 9/26/23. The 9/9/23 incident was past non-compliance. Findings include: R3's clinical record revealed: 6/14/17 - R3 was admitted to the facility with diagnoses that included, but were not limited to, megalencephaly syndrome (chromosomal abnormality), chronic respiratory failure and tracheostomy. 12/6/18 - R3 was care planned for communication deficit related to cognitive deficit and trach/vent dependent. Interventions included, but were not limited to: - patient is unable to communicate verbally. Monitor facial expressions and vital sign changes; - speak slowly and clearly and repeat PRN (as needed). Communicate at eye level; and - maintain eye contact when interacting with resident. R3 was also care planned for significant and global developmental delays with severe intellectual disability. 12/17/20 - R3 was care planned for behavioral symptoms, including hitting staff and throwing equipment and disconnecting self-off vent/pulse ox and tube feeds. Interventions included, but not limited to: - avoid over-stimulation (e.g. noise, crowding, other aggressive residents); - maintain a calm environment and approach to the resident; - maintain a calm, slow, understandable approach with the resident; - patient cries to make needs known .; - redirect from inappropriate behavior. Provide re-orientation and cues PRN (as needed). Provide verbal reminders related to behaviors .; - when resident begins to become socially inappropriate/disruptive, provide comfort measures for basic needs (e.g. pain, hunger, toileting .). 8/11/23 - The quarterly MDS assessment documented that R3 had minimal difficulty hearing; was rarely/never understood; sometimes understands - responds adequately to simple, direct communication only; had adequate vision; and was severely impaired for daily decision making. 9/9/23 - The facility's incident report documented that approximately 2:30 PM while the CNA (E9) was in the resident's bathroom, she reported hurting (sic) a slap noise while [E10, RT] was in the room with the patient [R3] . The CNA exited the bathroom, and noted the child was crying. The CNA asked the [E10] if everything was ok, to which the [E10] replied the patient tried hitting her. [E10] has been placed on Administrative Leave, pending investigation. 9/9/23 (untimed) - During an interview with E1 (NHA) and E2 (DON), E10's verbal statement was documented by E1 (NHA) as follows: [E1]: [E10, RT] Can you share what happened with you and [R3] today? [E10]: While I was in her room this afternoon [R3] hit me. [E1]: Where did she hit you? [E10]: On my leg. [E1]: Did you touch [R3] at all after she hit you? [E10]: I swatted her away from me. [E1]: Can you please demonstrate? [E10]: Demonstrated on [E1's] arm a pushing away motion to the lower left arm. [E1]: Did you say anything to her? [E10]: I told her to stop hitting. [E1]: Is there anything else you would like to share? [E10]: No. At the conclusion of the interview, [E10] was asked to prepare a written statement and to forward that statement to the DON (E2) and Executive Director (E1). 9/9/23 at 5:42 PM - A nurse's note documented, Spoke with patients [F1, family member] at 1730 (5:30 PM). Informed [F1] of patient's interactions of the day. Patient is currently at her baseline, happy and playing quietly. 9/9/23 at 5:53 PM - A nurse's note documented, This nurse performed a skin check around 1530 (3:30 PM) and 1730 (5:30 PM) per administration. No bruises, red marks or open areas noted. Patient is currently in room watching tv, smiling and neuro status per baseline . MD (Medical Doctor) on call made aware. 9/9/23 at 7:05 PM - An emailed statement from E9 (CNA) to E1 (NHA) documented, Today around 2-3 pm I walked into [R3's] bathroom to document on her clipboard as [E10, RT] did her treatment. I heard commotion as she continued to talk to her in an unprofessional manner. I then intervened and asked her if everything was okay, when she then stated that [R3] is bad and is always swatting at somebody. 9/10/23 at 11:21 AM - A nurse's note documented, Skin assessment performed. Skin clean, dry and intact. No bruises or open areas noted . 9/11/23 - The facility submitted a five-day follow-up to the State Agency: On 09/09/23 it was reported by [E9, CNA] that at approximately 14:25 (2:25 PM) she heard commotion in [R3's] room, while she was in that patients bathroom. [E9] further stated that she could hear [E10, RT] speaking in a (sic) unprofessional manner towards the patient. [E9] left the bathroom to check on the patient and [E10] in the room. [E9] asked [E10] if everything was ok, to which she stated [E10] told her that [R3] had swatted at her. [E9] reported this incident to the charge nurse and [E10] was placed on administrative leave pending investigation. During an interview conducted with [E10] by the [E1, NHA] and [E2, DON] she admitted to swatting [R3] after she had struck [E10], and stated that she told [R3] to Stop Hitting. A review of the video camera footage was conducted by the NHA and DON on 09/09/2023 . shows the child sitting on the floor, which [E10] is straightening up items behind the child in room [XXX]. At approximately 14:23 (2:23 PM) something occurs to which [R3] makes a motion towards [E10]. [E10] pushes her away, then makes a slapping motion toward the child's left lower arm telling her to stop hitting. At which point [E9] is observed walking out of the bathroom into the room to check on the situation. At this point [E10] begins explaining to [E9] that [R3] had hit her. Actions taken: - [E10, RT] was placed on Administrative Leave on 09/09/2023; - Incident was initially reported to DHS (Department of Health Services/State Agency) on 09/09/2023; - Resident was assessed for injury on 09/09/2023 and [F1, family member]/physician were notified. No bruising was noted after the incident on 09/09 or on 09/10; - [Name of] Police were contacted on 09/11/2023 Report #[YY-YY-YYYYY]; - [S1's name], Ombudsman notified on 09/11/2023. Conclusion: In this writer's opinion, Resident Abuse occurred. The first motion by [E10, RT] was not abusive and looked reactionary and as move to protect herself, the second motion where [E10] swatted/slapped [R3] on the left arm was Abusive in my opinion. It is recommended that the employee be terminated, and that this incident be reported to her professional licensing board. 9/11/23 at 3:15 PM - E10's (RT) written statement emailed to E1 (NHA) was as follows: . my account of the alleged incident involving Resident [initials of R3] on 9/9/23 . On the day in question, I wheeled [initials of R3] in her gait trainer to her room for her respiratory treatment. After situating herself nicely on the mat in her room, she began to hit me multiple times as she often does out of anger for being led from the living room. Because of this ongoing negative behavior, I have had to become a little creative in coming up with ways to distract her to redirect her physical behavior. I have danced, [NAME] to her, given her hand or foot massages, and played the . or shoe toss back and forth. On this day however her hitting was exceptionally worse than usual. I found myself having to block shots with my arms and even caught her arm a couple of times mid swing placing it on her lap while sternly saying that we do not hit. My correction and not allowing myself to be hit seemed to anger her more, so as I waited for the treatment to finish, I sang to the video and waved my arm back and forth to prevent her from raising her hand and striking me. As I stated, there was light contact. It came from the backswing of a wave and my fingertips barely touched her left arm. It's possible that the combination of all the above with the light touch and stern correction hurt her feelings, which is why when charge asked about anything occurring, I had no idea why she would be crying. This behavior is more the rule than the exception and occurs regularly. Though there was no deliberation, and the vantage point of the reporter did not give a clear view of the event, I am in 100% agreement with the report to preserve the rights of the resident, even at my expense. I trust that the combination of the video and this account will be what is needed to clear myself . 9/12/23 - The facility's QAPI Committee reviewed the 9/9/23 staff to resident abuse incident. 9/26/23 - E1 (NHA) provided evidence that staff were educated on this day about abuse incident and the importance of reporting during the general staff meeting. Review of the facility's surveillance footage provided to the State Agency revealed: - at 14:23:31 (hour:minute:second), R3 turns her head to left, with left hand swatted/hit E10's (RT) left lower leg. R3's right back hand covering mouth. E10 swats at R3's left hand while stepping back and bending down to R3's face and says, Stop it. Don't you hit. E10 appears to grab the left lower arm of R3 with her right gloved hand and pushed R3's left lower arm down to the floormat while pointing with her finger and stating, Put your hand down. Put it down. Put it down. We're not playing that. RT stated, You need some manners girl while standing behind R3 working with the medical equipment. - at 14:23:46, E9 (CNA) asked E10 if everything was okay. E10 said, I'm hollering at her because she hit me. I'm tired of her hitting me. She knows better. She knows exactly what she is doing. That's what I do with my kids yell at them. - at 14:25:00, R3 turns head to left and E10 said, You better stop looking around behind you. You hit me that's it. E10 was bent over behind R3 and continues to organize medical equipment. E10 stated, You better knock it off girl. R3 was stilled turned to the left where E10 was bent over. - at 14:25:17, E10 responds, Turn around I'm not doing anything to you. - at 14:25:36, E10 said, Turn around and watch the show while pointing her finger toward the TV. R3 was watching E10. E10 responds, I'm fixing things turn around. Cry all you want. I don't care. You hit me. You're in trouble. - at 14:25:56, R3 reached out with left hand and E10 pushed it away. Video ended at 14:26:04. *14:00 = 2:00 PM 5/24/24 at 11:02 AM - During an interview, E11 (RN) confirmed that she was the charge nurse on 9/9/23. E11 stated that E9 (CNA) said that she was in the bathroom and she heard the [E10, RT] say R3's name stop. E11 stated that E9 told her that she heard what it sounded like a slap and when E9 looked over at R3 she was crying. E11 stated that when R3 cries the resident exhibits facial redness, no tears. When R3 was angry, the resident will put out her trach, throw things around her and/or she will hit you. When she grabs or hits you the resident is trying to communicate something she wants. E11 stated that R3 has had the grabbing/hitting behavior before this incident. E11 stated that R3 can't communicate and can't understand why she can't have things when she wants it. E11 stated that it is acceptable to tell her to stop hitting. However, E11 stated it was not acceptable at the facility to hit any child or yell at a child. E11 stated that she requested E10 (RT) to leave the patient floor and immediately checked on R3. E11 stated that upon her assessment, R3 was completely as baseline and performed a skin check with no injuries or signs of pain. E11 stated that R3 would exhibit pain by crying with mouth wide open/no noise. E11 stated that R3 appeared happy as she was clapping while watching her favorite movie, Frozen. E11 immediately notified E2 (DON) and remembered that E1 (NHA) and E2 (DON) arrived at the facility super quick to review the surveillance camera footage. E11 also stated that she notified the physician. 5/24/24 at 12:45 PM - During an interview, E12 (RN) confirmed that she was R3's assigned nurse on 9/9/23 during the incident. E12 stated that she went into R3's room to administer medications and the charge nurse (E11) came into the room informing her of the incident and performed a full body skin assessment. E12 stated that on that day R3 was more agitated than usual right from the beginning of the shift. E12 stated that this usually happened on weekends when R3 was not in a structured environment. When asked if R3 was acting any different after the incident, E12 (RN) stated No. I would not have known had I not been told about the incident. 5/24/24 at 12:56 PM - Surveyor left voicemail for E10 (RT) and as of 5/28/24 at 8:38 AM, no return call was received. 5/28/24 at 10:15 AM - During an interview, E1 (NHA) stated that E10 was immediately suspended on 9/9/23 pending the investigation. E10 never returned to the facility and was terminated on 9/13/23 by phone. E1 stated that QAPI Committee reviewed the incident and staff were in-serviced for abuse prevention on 9/26/23. When asked if there have been any abuse incidents since 9/9/23, E1 stated no. When asked how you assure retaliation does not occur when staff report an allegation of abuse, E1 stated that in this case he wrote a letter to E9 stating how she did the right thing for reporting it. E1 stated that he encourages staff to report and educates staff by using a real life example of an allegation of abuse that occurred in the past at another facility. E1 stated that he tells his staff to trust the process. 5/28/24 at 11:27 AM - During an interview, E2 (DON) confirmed that she was notified by E11 (RN/Charge Nurse) and E10 was removed from patient care and suspended then terminated. When asked if any medical interventions were done, E2 stated no medical interventions were required. R3 was back to baseline with no noted changes. E2 stated that R3 had behaviors of swatting/hitting prior to and after the 9/9/23 incident. Verification of the facility's immediate actions taken after the 9/9/23 incident included: - suspended E10 (RT) on 9/9/23 and then terminated on 9/13/23; - assessed R1 after incident and continued to monitor; - notified F1 (R1's representative) and the Physician on 9/9/23; - other residents were assessed by nursing on 9/9/24 and 9/10/24; - conducted a facility investigation and maintained evidence; - conducted a QAPI Committee review on 9/12/23; - reported incident to the State Agency, Ombudsman's Office, local law enforcement and Delaware Professional Regulations Agency; and - in-serviced all staff regarding the facility's abuse policy and reporting on 9/26/23. The facility was in substantial compliance as of 9/26/23. 5/28/24 at 2:00 PM - Findings were reviewed with E1 (NHA), E2 (DON), E4 (Medical Director) and a representative from the Ombudsman's Office.