Based on interview and record review the facility failed to ensure staff obtained the resident permission prior to checking for incontinence, and inappropriately touched a resident in her vaginal area. This affected one of three residents reviewed for abuse. This failure resulted under the reasonable person concept, in R1 expressing she felt angry, violated, she felt like V1 took something from her emotionally, she wanted to fight. R1 BIMs completed on 9/15/25 denotes in-part R1 was able to report correct year, R1 was able to report correct day of the week, R1 was able to repeat three words after first attempt. R1 face sheet shows diagnosis of fracture of shaft of left femur, chronic congestive heart failure, type two diabetes, atrial fibrillation, chronic kidney disease, COPD, history of DVT, anxiety disorder, major depression disorder, obesity, and GERD.R1's police report dated 9/19/25, denotes in-part report number 2xxx-xxxxx, offense criminal sexual abuse, R1 briefly spoke about this incident, in summary: R1 woke up to a male black fondling her vagina along the outside of her diaper. R1 told him to stop and get out, to which the CNA left. R1 wished to proceed with this incident criminally.On 9/22/25 at 11:28am R1, interviewed at hospital, R1 observed alert to person, place, and time. R1 described V1 as the alleged perpetrator. R1 said on 9/19/25 she was sleeping and something told her to wake up, R1 said she observed V1(CNA) hand between her legs under her brief touching her vagina. R1 described it like V1 was massaging her brief, and V1 hand touched her vagina. R1 describes that her brief was loose in the area where it gathers between the legs. R1 said she grabbed V1's hand and pushed it away. R1 said she asked V1 what he was doing and V1 said he was looking for some chicken. R1 said she told V1 to get the Fxxx out of her room. R1 said V1 left the room. R1 said she called her friend and daughter. R1 said her daughter called the police. R1 said she did not want to work with V1. R1 said she did not inform the Nurse, the Director of Nursing, the supervisor or the Administrator, that she did not want to work with V1. R1 said she would hold her urine when she worked with V1 because she did not want to work with V1. R1 said she did not want to work with V1 after she thought V1 got upset with her because he had to change her twice when she had diarrhea episode. R1 said she felt angry, violated, she fell like V1 took something from her emotionally, she wanted to fight.On 9/21/25 at 10:08am V1 (CNA) said he upon start of his shift he completed rounds informing all residents that he was their aide, including R1 and R1's daughter. V1 said throughout the shift he was checking on R1 to see if R1 needed anything. V1 said R1's daughter told him that R1 did not need anything every time. V1 said around 7:45pm he went to do rounds on R1. R1 was sleeping, he touched R1 lower leg to wake her. R1 woke up. V1 said he told R1 that I was there to make sure she is dry, R1 replied I think I'm dry, V1 said he told R1 I would like to check to make sure she was dry. V1 said he patted R1's brief, R1 was dry. V1 said he always let the residents know what he is about to do. V1 said he asked R1 if she needed anything and to have a good night. V1 said he did not round on R1 anymore after that. V1 said he did not provide incontinent care to R1 that shift, V1 said he figured that R1 family provided incontinent care to R1. V1 said he didn't think it was odd that R1 did not urinate that shift because he worked with R1 in the past and R1 did not urinate. V1 omitted getting permission to check R1's brief for incontinent episode. V1 said R1 is alert and orient, R1 is incontinent and in the past R1 would put the call light on if she needed to be changed of bowel movement. V1 said he worked with R1 a few times in the past.9/23/25 at 11:21am V9 (CNA) said when checking for incontinence and providing incontinence care, you should knock on the door, get permission to enter, announce yourself, inform the resident that you want to check and change their brief. V9 said if the resident is alert and orient, you should ensure to get permission before you touch them. If the resident refuses inform the nurse for guidance. V9 said if the resident is not alert and or has dementia, you should still announce yourself, inform the resident of the care you are planning to provide and keep them informed during the task. V9 said you check the brief by opening the Velcro, check the front, and also have the resident to turn to check the back because sometimes the resident brief looks dry in the front, and the brief is wet in the back. V9 said sometimes the brief is visibly soiled and you can see from the outside that it is wet. V9 said it is not the practice to pat/ massage or squeeze a brief.9/22/25 at 9:51am V5 (Director of Nursing) stated that the facility practice is to check the resident for incontinence, sometimes residents are not alert and orient, staff should announce themselves, inform the resident of what they are about to do. V5 said if a resident is alert and orient staff should get permission before touching a resident.9/22/25 at 3:35pm V11 (Social Service) stated she assessed R1's BIMS, V11 said R1 was alert and orient and forgetful of a few words during her assessment. 9/22/25 at 2:45pm V12 (Rehab Director) said R1 was dependent of staff for toileting, R1 needed one person assist with toileting, R1 could assist with turning.R1 care plan dated 9/16/25 denotes the resident denies having been exposed to trauma abuse/neglect prior to admission and denies having been the perpetrator of mistreatment, abuse, neglect, and/exploitation. The resident does not present with unusual risk in these areas at this time. The resident however does experience frailty/weakness. The resident will be treated with respect, dignity, and reside in the facility free of mistreatment (i.e., abuse/neglect) through the next review. Interventions are to conduct an Abuse/Trauma/Substance History assessment (as needed) to promote knowledge and understanding of residents past including social support system and coping mechanisms, and any history that may be useful towards the persons plan of care. Please encourage resident to maintain strong friendships and community involvement so that they are less likely to be isolated or lonely. Utilize person-centered care models that provide as much initiative, control, and self-determination as possible to address the persons physical, psychological, and social needs within a trusting, open, supportive and nonjudgmental professional relationship.R1 base line care plan dated 9/16/25 shows toileting not assessed.Facility policy titled Incontinence care with last revision date 4/20/2021, denotes in part to prevent excoriation and skin breakdown, discomfort and maintain dignity. Incontinent resident will be checked periodically in accordance with the assessed incontinent episode or appropriately every two hours and provided perineal and genital care after each episode. Explain the procedures to resident and bring equipment to bedside. Provide for privacy. perform hand hygiene and put on non sterile gloves. Facility policy abuse prevention and reporting effective date 11/28/2026 last revision date 10/24/22 denotes in-part; the facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of the residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrence of abuse neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment of the residents. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means abuse is the willful infliction of injury unreasonable confinement intimidation or punishment with resulting physical harm pain or mental anguish to a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent one resident (R1) from mental abuse caused by a staff member and failed to ensure the staff member had limited access to R1. This failure applied to one (R1) of three residents reviewed for abuse and resulted in R1 feeling on guard, untrusting and unsafe while living in the facility. Findings include: R1 is a [AGE] year old female who admitted to the facility 2/16/24. R1 has diagnoses that include Conversion disorder (functional neurological system disorder) and Generalized Anxiety Disorder for which she is receiving treatment in the facility. R1 is cognitively intact and uses a wheelchair for mobility according to the minimum data assessment dated [DATE]. On 8/21/24 at 8:34PM, R1 was observed resting in bed, alert and coherent. R1 was interviewed and expressed an incident with a staff member (V3) that occurred a few weeks ago. R1 said that one evening, she went to the kitchen because she was hungry and asked V3 Dietary Aid for some food. V3 refused to give any food or snacks and called R1 a beggar. R1 said that she believed V3 was upset with her because she offered V3 soda pops from her personal refrigerator, but later stopped. R1 said, when she was refused food and V3 called her a name, she reported it to V1 administrator and V4 Dietary Manager via a letter. After the letter was received, the administrator had a meeting with R1, R1's family member and V4 Dietary Manager to discuss the incident. The end result led to V3's termination. R1 continued and said that about three weeks later, V1 came to R1's room insisting that R1 give V3 another chance because V3 was remorseful, and she should forgive V3 as [R1 is] a good Christian woman. R1 began crying as she continued. R1 said V1 then brought V3 into her room to make V3 apologize to R1, however he just said a general apology, not anything that he did wrong. V1 rehired V3 to be a CNA (Certified Nursing Assistant). R1 said, I was okay thinking that I wouldn't see V3 much because V3 was working in the kitchen, but now as a CNA, I see V3 all over and V3 even comes in my room to drop off the meals and take the tray. R1 said I feel so guarded around V3 because I don't trust V3. There have even been times that V3 has backed me up into a wall away from the cameras where no one could see and say ugly things to me. R1 continued to cry and said I thought I did all the things right by reporting and I don't feel safe and secure when V3 is around. I am also concerned if what he is doing to me, he can be doing to others that can't defend themselves. On 9/21/24 at 1:10pm V4 Dietary Manager said they received a letter from R1 that said that while working as a dietary aid, V3 was coming to her room drinking her personal drinks and watching television. V4 said 'there is no reason for any dietary aid to be going into a resident's room. When R1 told V3 she didn't want him to come into her room anymore V3 refused R1 snacks such as cereal and sandwiches. These things are allowed to be given when the kitchen is open by any kitchen staff.' After V4 received the letter, Guest Services Manager, the Administrator and V4 had a meeting with R1 and R1's family member. After the meeting, V4 said that V1 Administrator initiated an investigation into the issue and V3 was let go by Human Resources a day or two after. V4 found out V3 was terminated when V4 was told to remove V3 from the schedule. On 9/21/24 at 1:23pm V5 Human Resources Director said that V5 was aware of an incident with R1 who stated that V3 called her a beggar. I spoke with V1, who followed up with V3 and I was told to terminate V3 for discourteous behavior which is based off the handbook and facility policies. Employee Disciplinary Report reviewed for V3 dates the incident 9/2/24 with facts: Employee displayed improper conduct and discourteous behavior with patient which has resulted in termination. The report was dated 9/5/24 by V5. V3 was interviewed via phone on 9/19/24 and 9/21/24. During both interviews, V3 was evasive, omissive and unprofessional. During the interview on 9/19/24 at 10:16pm V3 said that V3 was irritated about being questioned by this Surveyor. When V3 was asked about any incident that occurred involving R1 and V3, V3 said he was told about it by an unknown staff member, and that there was no allegation brought against him. V3 also said that he had never been suspended or terminated. On 9/21/24 at 4:05pm, V3 said that there was a day that R1 came to the kitchen to ask for food, but the staff were about to leave and V3 told R1 the kitchen was closed. V3 said R1 always come to the kitchen asking for food, and V3 didn't give her any when she asked. V3 said V1 investigated an allegation against him but V3 didn't take the accusation seriously. Then V3 said I got fired for some b*****t. V3 said V1 Administrator asked V3 to come back as a CNA and was asked to apologize to R1. V3 said, he went to R1's room with V1 but said, I didn't apologize, I just said I'm sorry. On 9/21/24 at 2:45pm V1 Administrator said V1 was unaware that R1 was emotionally upset that V3 became a CNA and is giving direct care in the facility because V1 believed that after V3 issued an apology, R1 had forgiven V3. V1 said V3 should not be going into R1's room or giving care to R1, however it's possible that R1 would see V3 working elsewhere in the facility. Concern form dated 9/2/24 taken by V1 Administrator stated, Resident stated a dietary aide went into her room and took a beverage. Corrective actions taken: Writer interview the dietary aide (V3) Dietary aide stated he removed the dietary tray after mealtime. Offer to replace beverage declined. Abuse Prevention and Reporting policy revised 4/22 states in part; The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. 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. The abuse policy was acknowledged and electronically signed by V3 on 8/27/24 at 4:10PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 6/8/2024 at 11:45am V18 (LPN) stated, when there is a fall or injury we have to document in the electronic medical record and complete risk management section. We get a statement from the CNA and follow the fall protocol, we document in the medical record. There is a lot of documentation that we have to do if there is a fall. We call the doctor, the POA, and the DON. On 6/8/2024 at 11:56am surveyor continued interview with V18 and asked V18 if a resident sustains an injury when the CNA is using a mechanical lift, what is supposed to occur. V18 stated, the CNA has to tell the nurse right away. The nurse has to come and assess right away and make sure the resident if okay and safe. I would have the resident put back in the bed or stop the transfer depending on my assessment. I would do a full body assessment, get vitals, contact the doctor, family and DON. I would have to get a statement from the CNAs that were there, follow the fall policy, and fill out the risk management information which is in the computer. There is also a fall packet with questions that have to be completed. The nurse has to be involved in assessing the resident, documenting in the nurses note, notify the doctor, and family member. The DON has to be notified for any resident that has a fall, injury or abuse. Surveyor asked V18 what is the purpose of having 2 people present when using a mechanical lift. V18 stated, to make sure the resident does not get injured and does not fall. One person controls the mechanical lift and the other person makes sure the resident does not sustain any injury like hit their arm, leg or head. We know how to transfer because of the colored dot on the door by the residents name. On 6/8/2024 at 12:16pm surveyor asked V20 (CNA) if she had training on how to use mechanical lift. V20 stated, yes we have to use 2 people, put a pad underneath and lift mechanical lift. One person does the mechanical lift and the other person makes sure the resident does not move because the resident's head could get hit or legs. If the resident falls or gets injured when using the mechanical lift, I call the nurse and let them know what happened. I have to tell the nurse what happened because we are supposed to let the nurse or supervisor know what happened. The nurse will come and check the resident and does an assessment and will ask the resident of they are okay and I follow the directions of the nurse. On 6/8/2024 at 12:51pm surveyors asked V1 about the incident that occurred on 4/26/24. V1 stated, we talked to both CNAs, but they did not tell us everything. V1 stated V13 (CNA) and V14 (CNA) received discipline after the 4/26/24 incident and were in-serviced, but shortly after that they both quit so the discipline did not mean anything. Surveyor asked if they have been able to get in touch with V13 or V14. V1 stated, no. On 6/8/2024 at 1:02pm V19 stated, when a resident falls or is injured when using a mechanical lift, the nurse has to assess the patient, check range or motion, do vital signs and head to toe assessment, call doctor, if the resident is on blood thinners, the resident will be sent to the hospital, call family. We have to fill out risk assessment and complete the fall protocol and document in nursing notes what happened. Surveyor asked if the nurse is required to document in the medical record. V19 stated, Yes, if not documented, it was not done. We have to also notify DON, supervisor, and family. Surveyor attempted to call V13 and V14 on 6/8/2024 without a response. During the course of the survey, V13 and V14 failed to returned surveyor's call. During course of survey, facility did not produce any evidence/documentation regarding staff training/education regarding the use of mechanical lift/injury prevention. Based on interview and record review, the facility failed to safely transfer a resident with a mechanic lift. This failure resulted in staff transferring R2 to bed from wheelchair via mechanical lift, during the transfer R2's left foot bumped the footboard which resulted in fracture to the left distal tibia. This failure affected 1 resident (R2) in a sample of 5 reviewed for accidents. Findings include, Facility's reportable to state agency (4/29/24) documents in part: R2 was observed by floor nurse exhibiting s/s (signs and symptoms) of pain. PRN (as needed) pain medication given and effective. MD (doctor) made aware and gave an order for x-ray. The X-ray showed a fracture to the left distal tibia. Family and MD made aware, orders received to transfer resident to the ED (emergency department) for further evaluation and treatment. Family made aware of transfer. Upon investigation it was found that on 4/26/24 V14 (CNA) stated that as she and V13 (CNA) were transferring R2 to bed from wheelchair via mechanical lift. During the transfer, R2's weight shifted causing her left foot to bump the footboard. R2 was safely positioned in bed, and V12 (LPN) was summoned to assess R2. V12-V14 all stated that R2 did not complain of pain or discomfort at this time. V12 stated that she assessed R2 and noted no visible signs of injury no bruising, redness or swelling and no skin alterations to that area. V13 and V14 went on to assist R2 with ADL (incontinence care) care in bed and R2 still did not display any signs of discomfort. R2 rested comfortably in bed for the rest of their shift. R2 was assessed for pain every shift, daily, with out change until 4/29/24. On 4/29/24 Staff nurse noticed the area to be tender to touch. PRN pain medications given with effectiveness. Ice pack applied and leg elevated. MD made aware with order for x-ray. Family notified. X-ray results showed fracture of distal tibia. MD made aware with order to send R2 out to hospital for evaluation and treatment. Family made aware. R2 remains in the hospital at this time and plan of care will be updated upon her return. R2 was alert and oriented with a BIMS (Brief Interview for Mental Status) of 9 (meaning moderately impaired). R2's diagnosis included but are not limited to: Altered Mental Status, History of Falling, Difficulty in Walking, Muscle Weakness. On 6/8/24 at 9:25 am, V12 (Licensed Practical Nurse ) said she recalls the incident. V12 said, on 4/26/24 she (V12) and V14 (Certified Nursing Assistant) were assigned to R2. V12 said, V14 came and got her and said that upon transferring R2, her foot hit the foot board, she assessed the resident and there was no pain, no bruising was noted and that was it. V12 said, she does not recall writing a progress note about this incident. V12 said, with mechanical lifts there needs to be 2 people. When asked V12 should this incident be reported to V2 (Director of Nursing), V12 said no, because R2 didn't complain of pain, she was normal upon inspection, there was nothing alarming for V12 to go further. V12 said, she has been working in the facility for little over 3 years. Review of R2's progress notes affirms V12 did not document R2 hitting her leg on the foorboard on 4/26/24. On 6/8/24 at 10:20 am V2 (Director of Nursing) said on 4/29 V17 (LPN) asked for V2 to go and see R2's left ankle as the resident was complaining of pain. V2 said, facility sent R2 to the hospital, at that point V2 started to ask questions to what happened and she got many witness statements. V2 said, her investigation revealed that V14 (Certified Nursing Assistant) and V13 (Certified Nursing Assistant) were transferring R2 via mechanical lift and the pad shifted, as they were lowering her down R2 hit her foot on the foot board, it has a wood foot board. R2's assigned CNA was V14 and V13 was orienting. V2 said, V13 was a cna who just started working at the facility and just needed a 3 day orientation. V2 said, both V13 and V14 could not explain how the mechanical lift pad shifted. V2 said, per their statements, V13 was guiding the lift while V14 was operating the mechanical lift. V2 said both staff said they hooked the pad on the lift, when they were lowering R2 down, the pad shifted and when she hit her foot, they got the nurse immediately. V2 said, staff could not explain how the pad shifted causing the injury, that it jsut happened. V2 said, regarding procedure for a resident incident it, there should be an incident report opened from that, and V2 should have been made aware of the incident. V2 said regarding operationg a mechanical lift, it should be 2 people, staff need to make sure the pad is placed correctly under the resident, and all rings are secured on the mechanical lift, than once all is secure that the resident can be transfered. V2 said, the purpose of 2 person assist with mechanical lifts is to prevent injury. V2 again said, V13 and V14 both said the mechanical lift pad shifted and they could not explain how that happened. V2 said, after this incident, all cna's got mechanical lift hand on training and V13 and V14 also got a written test on mechanical lifts. V2 said, she has been working in the facility since March 2024 and she does not know what kind of mechanical lift training staff received prior to the incident. V2 said, regarding V13 and V14, they no longer work here and facility has not been able to get in touch with them, they do not answer their phone. V2 said, the root cause of R2's injury was improper transfer. On 6/8/24 at 11:30 am V2 (DON) said the facility schedule for 4/26/24 shows V16 (CNA) as assigned to R2 but it was V14 (CNA) and she was training V13. On 6/8/24 at 12:32 V2 said, she did not fill out risk management regarding R2 and root cause was shifting of the hoyer pad, however she would not explain how that happened. On 6/10/24 V2 provided document stating V13 (CNA) started working in the facility on 4/24/24 and her last day was 5/21/24. Facility's time care report affirms V13 and V14 were on duty on 4/26/24. V12's (LPN) statement regarding R2 dated 4/30/24 documents in part: I (V12) was the nurse on duty. I was called to the room to assess patient after being transfer to bed via mechanical lift. Per cna's pt's foot hit footboard upon transferring to bed. Noticed no signs of pain/bruising/redness. Pt was continue to monitor throughout shift. V13's (CNA) statement regarding R2 dated 5/2/24 documents in part: V13 was training with another cna and we were putting resident to bed with a mechanical lift and she hit her foot on the bed. Cna went to get the nurse and then I helped cna finish getting resident comfortable in bed. V14's (CNA) statement regarding R2 dated 4/30/24 documents in part: I (V14) worked with R2 on 4/26. As me and another cna were putting her back to bed with a mechanical lift. The mechanical pad shifted as we were lowering her down to bed and her foot hit the foot board. Resident did not show any signs of pain. I assisted her with ADL's (activity of daily living) and made her comfortable for the night. R2's care plan documents in part: R2 Requires use of full body lift for transfer. Diagnosis includes: impaired mobility, generalized weakness (Date Initiated: 08/27/2021, Revision on: 06/08/2024) Interventions: Full body lift with 2 person assist for all transfers (Date Initiated: 08/27/2021, Revision on: 06/08/2024). Ensure the full body lift legs are adequately spread for increased base of support (Date Initiated: 08/27/2021, Revision on: 06/08/2024), Ensure resident is in the center of the full body lift pad before beginning transfer (Date Initiated: 08/27/2021, Revision on: 06/08/2024), Staff to support [NAME] body and legs during full body lift transfer (Date Initiated: 08/27/2021, Revision on: 06/08/2024). Facility policy Transfers- Manual Gait Belt and Mechanical Lifts (Effective Date: 11-28-12, Revisions: 1-19-18) documents in part: Purpose: In order to protect the safety and well-being of the Staff and Residents, and to promote quality care, this facility will use Mechanical lifting devices for the lifting and movement of Residents. Guidelines: 1. Mechanical lifting devices shall be used for any resident needing a two person assist, or who cannot be transferred comfortably and/or safely by normal transfer technique. Except during emergency situations or unavoidable circumstances, manual lifting is not permitted. 2. Staff responsible for direct resident care will be trained in the use of mechanical lifting devices annually and as needed. Refer to Manufacturer ' s Guide for proper instructions for use of equipment for transfer and weighing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to protect a cognitively impaired resident from physical and emotional abuse by a staff member who forcefully pushed the resident in her wheelchair and shouted at the resident out of frustration which caused the resident to be fearful of the staff member, emotionally distraught and intimidated; and facility failed to follow their policy on abuse prevention. This failure affected one (R81) of 5 residents reviewed for abuse from a sample of 37 residents. Findings include: R81 is a [AGE] year-old female with birth date of [DATE]. She admitted to the facility on [DATE] and has a past medical history not limited to Weakness, Lack of Expected Normal Physiological Development in Childhood, Non-ST Elevation Myocardial Infarction, Syncope and Collapse, and Difficulty in Walking. On [DATE] at 11:54 AM while outside of R81's room, surveyor overheard V8 (Certified Nursing Assistant/CNA) being verbally abusive to R81 regarding a telephone cord being tangled up in her wheelchair. Surveyor then observed V8 (CNA) forcefully push R81, who was seated in her wheelchair, from next to her bed forward towards the room door. V8 (CNA) then said loudly and with continued frustration, I'm still trying to get the cord untangled, went behind R81's wheelchair, then proceeded to lift the wheelchair from behind and turned it so R81 was now facing the doorway. Surveyor observed R81 at this time while sitting near doorway and she appeared frightened. At 11:57 AM, V8 (CNA) then moved R81 from the area near the doorway back to the area next to her bed. Upon leaving R81's room, when asked if staff should talk to a resident in that manner with such frustration, V8 (CNA) said no and I'm sorry. V8 (CNA) was informed that she should apologize to the resident and not to the surveyor. V8 again apologized to surveyor but did not observe V8 (CNA) apologize to R81. At 11:58 AM, surveyor reported incident to V9 (Licensed Practical Nurse) who was working on the unit. At 12:15 PM, observed V8 (CNA) assisting other staff members pass lunch trays on this same unit. On [DATE] at 12:22 PM, V1 (Administrator) said abuse protocol is for the alleged perpetrator to be removed immediately. V1 then said regarding the alleged incident with V8 (CNA), that she was just told about it and V8 is now gone. At 1:21 PM, V1 (Administrator) provided R81's initial abuse report submitted to the department that indicated surveyor reported V8 seemed frustrated and was not speaking to R81 appropriately. Report stated that V8's (CNA) statement was taken but was not included within the report. Received V8's statement from V1 (Administrator) which indicated V8 was having a hard time getting cords loose from R81's wheelchair. Statement also indicated V8 could not recall speaking inappropriately to R81, but was probably speaking loudly because she could not hear R81. On [DATE] at 1:55 PM, interviewed R81 in her room. When asked if she had ever experienced poor staff treatment and/or abuse prior to today, R81 said I just wanted to get it done. Then added, I was scared of that one that was in here, there's one that always yells but so long as they help me, I'm not going to say anything. At 2:03 PM, R81 who appeared frustrated added if they want to yell, then I just let them go ahead and yell. On [DATE] at 2:15 PM, V1 (Administrator) said that she knows V8 (CNA) from a previous facility and V8 personally took care of her loved ones. V1 added that she knows V8 talks loudly because she is hard of hearing but has never know of V8 (CNA) to speak in this alleged manner. Reviewed V8's personal file which showed a physician assessment dated [DATE] that documented, patient denies any hearing loss. Reviewed V8's (CNA) training logs that showed she last completed abuse and neglect training on [DATE]. On [DATE], reviewed R81's MDS Section C - Cognitive Patterns dated [DATE] that showed her Brief Interview for Mental Status (BIMS) score was 11 out of 15 which indicated moderate cognitive impairment. Also reviewed R81's current plan of care which did not show an implemented care plan to prevent R81 from being abused. On [DATE] at 11:21 AM, when talking with R81 regarding the incident with V8 (CNA) from previous day, R81 said they come in and don't tell us who they are. They make me want to not care anymore. On [DATE] at 11:31 AM, V12 (Licensed Practical Nurse) said she started working at facility one month ago and completed abuse training during her orientation. When asked to name specific types of abuse, V12 said verbal, financial, and physical are the only ones I know of. On [DATE] at 01:39 PM, V19 (Certified Nursing Assistant) said she had just completed abuse training a week ago. When asked to name specific types of abuse, V19 said verbal, physical and that's all I know of. On [DATE] at 01:49 PM, V20 (Certified Nursing Assistant) who was assigned to the 400 unit said, her last abuse in-service was last night and types of abuse are verbal, sexual, physical, and abuse done to others. Reviewed Facility Reported Incident Final Abuse Reports for the last year until present and noted the following: On [DATE], a male (deceased ) resident complained of being physically abused by a certified nursing assistant. Report indicated the staff member was interviewed and denied physically abusing the resident. The allegation of physical abuse was not substantiated by V1 (Administrator). Reviewed resident's MDS Section C - Cognitive Patterns while at facility dated [DATE] that showed his Brief Interview for Mental Status (BIMS) score was 11 out of 15 which indicated moderate cognitive impairment. On [DATE], a surveyor reported an allegation of verbal abuse made by R75's spouse. Report indicates the residents involved were not interviewed due to cognition and the staff member involved denied verbally abusing any resident during her interview. The allegation of verbal abuse was not substantiated by V1 (Administrator). On [DATE], when interviewed by a surveyor about an incident that occurred on [DATE], R37 said she was verbally and physically abused by V28 (Certified Nursing Assistant). R37 then stated that she was informed V28 was no longer employed at the facility. Report indicated the facility attempted to contact V28 for an interview but was unable to reach her. The allegation of verbal and physical abuse was not substantiated by V1 (Administrator). R37's Brief Interview for Mental Status (BIMS) score dated [DATE] showed 14 out of 15 which indicated no cognitive impairment. On [DATE], R37 complained of being physically abused by a certified nursing assistant. Report indicated the staff member was interviewed and denied physically abusing R37. The allegation of physical abuse was not substantiated by V1 (Administrator). On [DATE], R29 (hospitalized since [DATE]) complained of being verbally abused by a certified nursing assistant. R29's Brief Interview for Mental Status (BIMS) score dated [DATE] showed 15 out of 15 which indicated no cognitive impairment. Report indicated the staff member was interviewed and denied verbally abusing R29. The allegation of verbal abuse was not substantiated by V1 (Administrator). On [DATE] at 09:50 AM, V1 (Administrator) was interviewed by the survey team regarding the outcome of her abuse investigations reviewed during survey. When asked how V1 concluded the allegations were all unsubstantiated, including those allegations made by residents who were cognitively intact, V1 (Administrator) said it's their word versus the staff because that's how I was trained. On [DATE], V1 provided final investigation report for R81 that did not indicate the result of investigation findings, whether abuse was substantiated or not. Report indicated surveyor reported to V9 (LPN) that V8 (CNA) was speaking loudly to R81 and indicated that V8 did not mean to sound frustrated she was trying to get her wheelchair untangled. Report also indicated V8 (CNA) was not frustrated with the resident but only with the cords restricting the wheelchairs mobility and that V8 did not intend to show any willful frustration towards R81. Report concluded with, the facility will do one on one abuse and customer service training with V8 prior to her return to work, will closely monitor V8 upon return by conducting random checks on residents she cares for. On [DATE] at 1:35 PM, requested R81's initial and most recent abuse/neglect screen and abuse care plan from V7 (Social Services Director) who said screenings should be completed upon admission, quarterly and with any allegations. At 2:39 PM V7 said the facility began screening residents for abuse or neglect and implementing abuse care plans as of [DATE]. At 2:44 PM, V7 (Social Services Director) said R81 was not screened for, or care planned for abuse upon her admission on [DATE]. V7 then provided R81's abuse/neglect screen dated [DATE] and abuse care plan with revision date or [DATE]. On [DATE] at 1:48 PM, when asked if there is required training to be the abuse coordinator, V1 (Administrator) said no, but I do yearly abuse training courses on-line. When asked when she last completed abuse training, V1 said I'll have to get back to you with the date. At 2:00 PM, V1 indicated her last abuse prevention and reporting training was completed on [DATE]. Reviewed Abuse Policy last revised [DATE] that showed the facility prohibits abuse and neglect by staff done by orientating and training employees on how to deal with stress and difficult situations. Policy defines abuse as any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means and provides examples of mental and verbal abuse include but not limited to yelling or hovering over a resident, with the intent to intimidate. Policy indicated under establishing a resident sensitive environment will be accomplished through: Resident Assessment: as part of the resident's life history on the admission statement, comprehensive care plan, and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, history of trauma or misappropriation of resident property, who have needs, triggers and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment, or misappropriation of resident property for these residents. Staff will continue to monitor the goals and approaches on a regular basis and update as necessary.