**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of policy and procedures and resident and staff interviews, the facility failed to protect vulnerable residents' rights to be free from abuse by failing to ensure residents were protected from mental and verbal abuse for 4 (Residents #699, # 700, #800 and #850) of 4 residents reviewed for allegations of abuse. The findings included: The facility policy Abuse, Neglect and Exploitation implemented 3/1/22 (revised 3/1/23) documented, It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse. Instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse and mental abuse. Mental abuse includes but is not limited to humiliation, harassment, threats of punishment or deprivation. Review of the facility investigation documented an allegation was made by Resident #699 and Resident #700 involving concerns about inappropriate verbal interactions and improper care practices by a certified nursing assistant (CNA) Staff A during evening care period the allegation includes potential and verbal threats and failure to follow proper hygiene procedures. The allegation occurred on 4/17/25 at 3:29 p.m. Review of the clinical record revealed Resident #699 a [AGE] year-old female (YOF) readmitted on [DATE] with diagnoses including chronic respiratory failure with hypoxia, heart failure and anxiety. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date (ARD) of 2/27/25 documented Resident #699's cognitive skills for daily decision making were intact. On 5/7/25 at 9:00 a.m., in an interview Resident #699 said, Certified Nursing Assistant (CNA) Staff A, was nasty and she was big, and I was afraid of her. She would not listen to me when I tried to tell her about the steps for my shower. She said to me, Shut up or I will leave you in this chair and not come back. She did not use the lift like she should have to get me up. She just picked me up out of bed and was rough and put me in the wheelchair (w/c). I told her I needed to use the bathroom, that is how they always do it, but she was nasty. She did not hit me, but she was rough. I couldn't stand and she grabbed me and put me in the w/c. I was afraid she would leave me in the w/c. I had a bowel movement (BM) in my brief during the shower; and she did not take it off. The CNA washed me in the w/c with the dirty brief on. I tried to tell her how to do it to make it easier for her and she told me, I know what I'm doing, she did not listen to me. I was shaking and afraid she would do something to me. She did not want to put me in the shower chair, and she washed me with the BM diaper on and in my w/c. She ruined my w/c cushion and the w/c. There was BM all over it and it was wet. The CNA brought me back to the room full of BM and picked me up and put me in bed. She was mean and rough. She told me again if I said anything she would leave me in the w/c and not come back. She made me shut up. She was a big lady. I was afraid of her, and I did not want to see her again. Resident #699 said, About a week later the police came in and asked me about it and took my statement. He told me the CNA had been fired. I think the facility should have told me, because every time the door opened, I was afraid she was back, or she would retaliate against me or have someone else do it. That was my biggest fear that she would come back. It would have made me feel more comfortable if I knew the CNA was not here anymore. I was afraid she was going to come back, and they should have told me she was not here anymore. They left me feeling afraid for a week. I was very upset. Review of the clinical record revealed Resident #700 a 65 YOF admitted on [DATE] with diagnoses including chronic pain and major depressive disorder. The Quarterly MDS dated [DATE] documented the resident was independent with her care needs. The MDS noted Resident #700's cognitive skills for daily decision making were intact. On 5/7/25 at 8:30 a.m., in an interview Resident #700 said, I was very respectful and nice to CNA Staff A. I don't remember her name but for a week prior to the incident she would come in the room to bring ice and what not and did not really bother us but she was not friendly or nice. You could tell she was not happy with the job, but she never said anything. Resident #700 said, On 4/17/25 on 3 p.m., to 11 p.m., shift, I don't know the exact time, the CNA came into the room and my roommate Resident #699 had asked for a shower. The CNA got mad and said it was not her time. We explained to her that they changed our showers to 3-11 p.m. The CNA was thick, strong and built like a linebacker. She looked mean like she would hurt you. I tried to explain to her, and she looked right at me in the eyes like she wanted to hurt me and said, Shut up. I was a social worker and I'm mostly independent so I help my roommate out when I can. My roommate was telling her how she usually gets her shower, they bring the shower chair in, and they take her to the bathroom for a BM and then wheel her to the shower room. The CNA said, Don't tell me how to do my job, I know what I'm doing. I watched her pick my roommate up out of bed without the lift and she was rough and slammed her into the w/c. My roommate was shaking, and I could see she was afraid and getting anxious. She left the room without toileting her and returned a while later. My roommate had a BM in the brief because she did not toilet her. The CNA gave her a shower in the w/c in the soiled brief. It took her 45 minutes to get her back in bed and clean her up. I was watching her with my roommate, and she was rough and mean. She was moving her around in bed like a bag of wet cement. My roommate was saying stop but she kept up. There was BM everywhere on the cushion in the w/c and it stunk. I told my roommate we need to report it, but she was afraid of retaliation, so I called her daughter and told her. The next morning, I told the nurse. Then the Management Team came in and spoke to us about it. They had the police in about a week after that to get our statements and I told him everything. The facility did not tell us the CNA was no longer working here. My poor roommate was afraid, and they should have told us she was no longer employed here. I saw how she was handling my roommate, and I tried to tell her how to do it, but she was not listening to me and she turned and glared at me with a look that said she would hurt me. We have been roommates for years and we look out for each other, so I was watching how she got her in and out of the bed. She was very rough with her, and she was shaking, she was afraid. I think the facility did what they were supposed to do because that first week we had so many people here asking us about it and we told them just like we are telling you. The story did not change, and it will not change because it is the truth. On 5/7/25 at 9:45 a.m., in an interview with Licensed Practical Nurse (LPN) Staff C said, I was not here the night it happened with CNA Staff A. I work the 7 a.m., to 3 p.m., shift and this occurred on the 3-11 shift. Resident #700 told me what had happened, and I had her fill out a grievance form and I assisted Resident #699 to fill hers out. I went right to the Administrator and gave her the grievance forms and told her what they said had happened. That is all I know, really. Like I said, I was not here when it happened. Further review of the facility investigation documented The allegation was determined to be unsubstantiated based on the investigation findings; the CNA's behavior was found inconsistent with facility standards. The CNA was found to have violated the facilities Code of Conduct and Resident Rights policies through the use of inappropriate and unprofessional communication. The facility reported a second allegation of abuse to the State Agency involving Resident #800 and #850. The report documented on 4/25/25 at 5:00 a.m., two residents have raised concerns alleging a staff member, CNA Staff B, displayed aggressive behavior toward them in their shared room. In addition, Staff D reported witnessing concerning interactions involving CNA Staff B and the residents. The residents have voiced concerns regarding their comfort and feelings of safety within their room. Supportive measures have been initiated, including increased monitoring and emotional support. Review of the clinical record revealed Resident #850 was an 84 YOF with an admission date of 3/21/25. Diagnoses included a fracture of the right fibula, dementia and chronic pain syndrome. The admission MDS dated [DATE] indicated the resident required substantial to maximum assistance with toileting, showers, bed mobility and personal hygiene. The MDS noted Resident #850's cognitive skills for daily decision making were intact. On 5/8/25 at 8:30 a.m., in an interview Resident #850 said on 4/25/25 the CNA that night came in to change her and her roommate Resident #800. CNA Staff B pulled my covers back and moved my gown up, then said she would be right back. The CNA did not come back for 45 minutes. I was at that point covered in urine and cold. I had taken my wet gown off and thrown it in the corner. I was in a fetal position and so cold. The CNA began mumbling things in a different language and was rough when pulling the wet pad out from under me. She was mumbling something in a different language the whole time. She then sprayed me with cold water to clean me, and I said, please don't do that but she continued to do it. I felt abused, hurt and I don't think I was being taken care of. I was so scared to say something. If I had said something, who knows what she would have done the next night. Resident #850 said being left uncovered for 45 minutes felt demeaning and hurtful. She said she was never physically hit; the CNA was just rough when changing me and mumbling things. Resident #850 was observed tearful and emotional during the interview. Resident #850 said the same thing happened similarly the week before with this CNA, but she did not report it. Prior to that incident, the resident said the CNA came in and yelled, it's 12:00 a.m., turn the television off. Resident #850 said, She then pulled my curtain shut and put my remote out of reach so I couldn't turn it back on. Resident #800, an 83 YOF with an admission date of 3/13/25 and diagnoses including chronic kidney disease Stage 3, Hypertensive heart disease, Type 2 diabetes Mellitus, and major depressive disorder. The Medicare 5-day MDS dated [DATE] documented the resident's cognitive skills for daily decision making were moderately impaired. On 5/8/25 at 11:27 a.m., in interview with Resident #800, said she did not know about the incident on 4/25/25 with CNA Staff B. She said she was probably sleeping at the time and did not remember the incident. The resident said, I just felt uncomfortable when she was around me, she was not nice. On 5/8/25 at 9:30 a.m., in an interview, Central Supply Staff D, said, on 4/25/25 at around 5 a.m., I was doing rounds, and I was in Resident #800 and #850's room. I felt the CNA Staff B was verbally abusive, she was just very short with Resident #850. These folks are here in our care and if we don't care we shouldn't be here. CNA Staff B was very short the way she was talking with her and I saw her be rough with her. I saw her. She jerked Resident #850's arm when she was trying to get her arm in her sweater. She was rough and I had been told by Resident #850 that the CNA was mean to her all the time. About a week ago I was taking with Resident #850 on the way to a doctor's appointment because I also drive the facility van. The resident said I'm afraid of my night aid, she is very mean, and she said it was Staff B. CNA Staff B was very big and intimidating, she gave me a look when I said something to her about what I saw, but she did not say anything to me. Resident #850 said she was intimidated, she never said Staff B hit her. I reported it to the nurse on duty at the time because the Director of Nursing (DON) was not here. The DON did speak with me about what I saw. That is what I observed, I felt like the CNA treated Resident #850 worse when I was not in the room because I could call her on it and the resident could not. I visit the room most every day. Further review of the facility investigation documented, Due to a lack of definitive evidence to confirm or disprove the allegation, the findings are classified as inconclusive. However, based on administration concerns related to customer service, CNA Staff B's employment has been terminated. On 5/7/25 at 10:50 a.m., in an interview the Administrator said she had reposted her phone number and spoke with everyone about abuse, not really abuse but customer service. We reach out to family and residents to make sure they are ok. This company is all about customer service and right now it is not acceptable. We have a new leadership team, and we are not tolerating it. The Administrator confirmed there was no documentation of the increased monitoring after the allegations. The Administrator said, I spoke with the residents; skin sweeps were done and there were no injuries. I re-educated the staff on customer service. I think that is the problem, customer service is not where it needs to be. On 5/8/25 at 8:45 a.m., in an interview the Administrator said regarding the abuse/neglect allegations, I have done education, and the Regional Nurse Consultant is reviewing that now because it is on-going and we want to make sure everyone is on the list. I did education and we have online learning and there is a lot of things about customer service. I have told the staff to take care of themselves and not work a lot of overtime because that can lead to issues.