**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident was free from mental and verbal abuse and intimidation, failed to ensure a staff member intervened while a resident was being mentally and verbally abused and intimidated, and failed to provide 72-hour psychosocial follow-up for 1 of 3 residents reviewed for abuse. (Resident B) Resident B indicated while being abused by the Executive Director, she thought she was going to be hit, her personal space was invaded, she was in fear for her life, and following the incident she thought the Executive Director (ED) sent an unidentified man hit man into the facility to harm her in retaliation for the ED being suspended. Finding includes: On 9/28/23 at 9:45 a.m., the Business Office Manager (BOM) indicated the previous ED was no longer the ED at the facility anymore. A document, titled Indiana State Department of Health Survey Report System, dated 9/28/23 at 12:39 p.m., indicated on 9/20/23 at 9:15 a.m., during a meeting between the previous ED and Resident B, Resident B indicated the previous ED took her walker out of her hands and was rude to her. After a thorough investigation, the five-day follow-up indicated the previous ED acted in an unprofessional manner leading Resident B to believe she had to discharge from the facility. When the Interim ED spoke to Resident B, he offered her to return to the facility. During an interview, on 9/28/23 at 11:00 a.m., the Interim ED indicated he had spoken (verbal counseling) to the previous ED within the past few weeks for how she was treating the managers and staff in general. She had treated some of the managers mean and staff members rudely and mean. She called out managers in the morning meeting instead of waiting to get them by themselves. She called out staff members in the hallways, instead of taking them into an unoccupied room. Many staff members were intimidated by her and afraid of losing their jobs if they reported her, so they would not report her to him when he came to visit the facility. He discovered the intimidation and fear of retaliation of staff members' jobs by the previous ED after he terminated her. During an interview, on 9/28/23 at 1:36 p.m., Resident B was observed sitting in her wheelchair, in her room, with her ex-husband sitting on her bed. She indicated, on 9/20/23, she was getting dressed to go home to see her dogs when the previous Executive Director busted in the door of her room. Breakfast had just been served onto her bedside table in front of her. She was sitting in her recliner with her bedside table across the front of her chair with her breakfast on it. She had just started eating her toast. Her ex-husband was sitting on her bed. The previous ED asked Resident B why her ex-husband was at the facility. The resident indicated he was at the facility because he took care of her and her animals. The previous ED indicated to the resident, he had to leave the facility. The resident indicated to the previous ED, if he had to leave, then she had to leave also, since he was her caregiver. The previous ED indicated she did not have to leave, but her ex-husband had to leave because he was not allowed to stay the night at the facility with her. Resident B indicated if he left, then she would leave also because he was her caregiver, since there was not enough staff at the facility to care for her in a timely manner. The previous ED indicated then the resident was to leave also. The previous ED jerked the bedside table out from in front of her and came at her like an angry bull. She invaded her personal space with her face up close to the resident's face and her arms pulled back and her chest puffed out indicating she was to leave the facility now. Resident B indicated to the previous ED, she was invading her personal space and told her to step back, which she did step back out of her face. The resident indicated at that time; she was scared to death of the previous ED. She thought the previous ED was going to hit her when she was invading her personal space. The previous ED left the room, but five minutes later, she came back to the room with three to four nurses and boxes to pack her belongings. Resident B had already begun to pack her belongings and the previous ED asked Resident B what she was doing, and the resident indicated she was leaving as the previous ED had told her to do. The previous ED indicated to her; she never told her to leave. She admitted on [DATE]. The Maintenance Director got her ex-husband a nice chair to sleep in, since he was with her every night providing care for her. He took care of her because there was not enough staff to care for her in a timely manner. She left with her belongings the day of the incident and went back home with her ex-husband. Resident B indicated after the previous ED was asked to leave the facility and she had returned as a resident, one evening she observed a tall African American male walking down the hallway towards her. She thought the previous ED hired this man as a hit man to come and kill me in retaliation for her being sent home. The Interim ED called and asked her to come back to the facility the next night (9/21/23) after she went home. The facility bus picked her up at her house and brought her back to the facility. She was anxious to come out of her room when the previous ED was in the facility, but after she was terminated, Resident B started going out to activities. She used to be very social when she lived at home. During an interview, on 9/28/23 at 2:00 p.m., Resident B's ex-husband indicated he stayed at the facility overnight each night from 6:00 p.m. until 10:00 a.m., the next day. His wife was incontinent, and it took the staff so long to answer her call light at times. If he did not stay and take care of her, she would wet on herself and he did not want that to happen. Depending on how well she was doing each day determined whether he spent the night to provide care for her or not. One of the nurses told him to park out back and gave him the code to the back door to the facility, so he could leave and come back into the facility as he pleased. He was present when the previous ED came down to the resident's room, on 9/20/23. She got right up into her face, invading her personal space and was yelling at her indicating he had to get out of the facility because he could not stay there. He was taken back while the yelling was going on and was in shock. He did not even know what to do because he was not believing what he was witnessing. During an interview, on 9/28/23 at 2:25 p.m., Qualified Medication Aide (QMA 6) indicated the previous ED and Housekeeping delivered boxes to Resident B's room for her to pack her belongings. The day before (9/19/23) the previous ED was standing in the hallway yelling at CNAs 7 and 8, but she did not know why she was yelling at them. During an interview, on 9/28/23 at 2:20 p.m., LPN 9 indicated the previous ED was in the hallway on the day before the incident with Resident B (9/19/23) being very loud and angry indicating I need all the CNAs in room [ROOM NUMBER] now. She was upset because a housekeeper had told her a CNA refused to pack the resident's belongings up in room [ROOM NUMBER] after the CNA was told the resident was being discharged . The record for Resident B was reviewed on 9/28/23 at 3:10 p.m. Diagnoses included, but were not limited to, diabetes mellitus type II, need for assistance with personal care, depression, generalized anxiety disorder, weakness, and chronic kidney disease stage 3. An admission Minimum Data Set (MDS) assessment, dated 8/24/23, indicated the resident's Brief Interview for Mental Status was coded at an 11, which indicated the resident had mild cognitive impairment. A psychiatry progress note, dated 9/15/23 at 1:00 a.m., indicated the visit was for her initial psych evaluation and medication management and to address an increase in her anxiety symptoms. She was started on Buspirone (an anti-anxiety medication) 5 mg (milligrams) by mouth three times a day that visit. She had no history of psychotropic medication use prior to her facility admission. She had generalized weakness. She had a changed sleep pattern. Her appearance/behavior was calm and cooperative. Her mood was depressed. She had mild judgement impairment and mild insight impairment. Her attention/concentration was good. Diagnoses for this visit was moderate major depressive disorder, and generalized anxiety disorder. A psychiatry progress note, dated 9/18/23 at 1:00 a.m., indicated the visit was to complete the Mini Mental State Examination (MMSE), which the resident scored a 28/30, which indicated no cognitive impairment. Her Preadmission Screening and Resident Review (PASRR) indicated she had not had previous psychiatric admissions or outpatient mental health services prior to being admitted to the facility. She was dependent for all Activities of Daily Living (ADL) except for feeding herself and she was incontinent. She had no use of psychotropic medication use prior to being admitted to the facility. Her cognition function was intact. Her appearance/behavior was calm and cooperative. Her mood was depressed. She had a fair short-term memory. She had mild impairment of her judgement and insight. Her depression screening test completed on 8/30/23, indicated she was positive for depression. The dementia assessment completed on 8/25/23, indicated she scored 3/6, which indicated she was somewhat dependent with a moderate functional impairment. A progress note, dated 9/20/23 at 9:16 a.m., indicated Resident B's discharge paperwork was explained to her and she refused to sign the Against Medial Advice (AMA) paperwork. The AMA paperwork was signed by two nurses. The resident was provided with medications as approved by the facility corporate office. She was transported from the facility to home by her husband's vehicle. She took her personal walker with her. There was a lack of 72-hour follow-up in the resident's record for psychosocial monitoring following mental and verbal abuse and intimidation by the previous ED. A care plan for Resident B indicated she had a history of being a social person and enjoying people. During an interview, on 9/28/23 at 4:03 p.m., CNA 7 indicated she came around the Harmony nurses' desk when she heard a loud commotion from down the hall. She heard yelling as she picked up room trays from breakfast. The previous ED was yelling at Resident B and Resident B was telling the previous ED she was not staying at this facility if her ex-husband could not stay with her. She walked up to Resident B's room and observed the previous ED to be standing in front of the resident who was sitting in her recliner. The previous ED was pointing her finger at the resident standing above her as the resident was sitting in her recliner. The previous ED was towering over the resident because she was a tall and larger lady. When asked if 0 was quiet and 10 was extremely loud, CNA 7 indicated the previous ED was yelling at a level 10 at the resident. When asked why she did not intervene when the previous ED was yelling at the resident, CNA 7 indicated she was intimated by the previous ED and now afraid of her due to a situation she and CNA 10 experienced the day before (9/19/23). She was told to go to another resident's room with the previous ED, on 9/19/23, where she waited for CNA 10 to arrive. When CNA 10 arrived at the resident's room, the previous ED along with the Housekeeping Supervisor in attendance in the room, the previous ED started screaming at a level 10 with aggressive screaming because she and the Housekeeping Supervisor thought CNAs 7 and 10 refused to pack the discharged resident's belongings. CNA 7 indicated they both wanted to wait to pack her belongings until closer to her being discharged because she had dementia and they did not want her to have any behaviors when she seen them packing her belongings up. If the previous ED was mad at a resident for something, she was fiery mad and aggressive with the resident. The ADON (Assistant Director of Nursing) and the Wound Doctor had to have heard the screaming across the hallway because they were over there working on a resident's wounds. She felt she was bullied by the previous ED and was scared to break up the interaction between the previous ED and Resident B because of her being screamed at the day before. During an interview, on 9/28/23 at 4:31 p.m., the ADON indicated the day prior to the incident with Resident B (9/19/23), she and the Wound Physician was in the room across the hallway from the resident who was to be discharged later that day. They both overheard the previous ED yelling at two CNAs while in the resident's room. When asked how loud she was yelling if 0 was quiet and 10 was extremely loud, she indicated she was yelling at a level 9. The Wound Physician made the statement Someone's in trouble. The ADON indicated she could hear anger in the previous ED's voice while yelling at the CNAs. On the day of the incident, (9/20/23), between the previous ED and Resident B, the previous ED told the ADON and the DON (Director of Nursing) to go down to Resident B's room with her to be her witness when she talked to her. Both the ADON and DON went to the resident's room with the previous ED. The previous ED clarified with Resident B why she was not staying at the facility. Resident B indicated because the previous ED kicked her out of the facility. The previous ED indicated she had not kicked her out and Resident B indicated when she kicked her ex-husband out of the facility, she kicked her out also. The previous ED was re-clarifying and backsliding to cover herself on kicking the resident out of the facility because after she left the resident's room, she came from the Redbud hallway to her office talking angrily on her cell phone in the hallway, saying I want her out of here now today repeatedly. In staff meetings, she called managers out and was passive-aggressive with them. She picked on staff and made it difficult on staff if she did not like you. The previous ED ran the facility like a Tyrant ruler by staff working under fear and intimidation. During an interview, on 9/29/23 at 11:26 a.m., CNA 8 indicated Resident B was her resident the day of the incident between her and the previous ED (9/20/23). The incident happened around breakfast time. Her ex-husband had been in her room staying with her every night to help provide care for her, which all the CNAs where so glad he was there because she did require a lot of care at times and required a lot of emotional care and attention. CNA 8 had been in her room at least twice that day already. The previous ED walked into the room as CNA 8 was walking to the resident's room, so she stayed outside the room, because she did not go in resident's rooms when management or nurses were in their rooms out of respect for the resident's privacy. The previous ED was fussing at Resident B, but she did not know why she was fussing at her. The resident was sitting in her recliner with her walker in front of her and the previous ED was standing in front of her walker. Her bedside table was at the side of her recliner. The previous ED was screaming at the resident at a level 10 if 0 was quiet and 10 was extremely loud. After she was finished fussing at the resident, the previous ED stormed out of the resident's room and she pointed to CNA 8 and instructed her to get the resident and her husband some boxes. She pointed to the floor tech girl and instructed her to get the resident and her husband some boxes. The floor tech girl got the boxes for the resident and her husband and CNA 8 got a cart for them, so they were able to wheel their belongings out of the facility to their car. CNA 8 indicated when the previous ED stormed out of the resident's room and pointed at her, instructing her to get the boxes, she felt like a child and her mom was scolding her. She did not intervene during the screaming at the resident because she was shocked it was happening and she was intimidated by the previous ED. A document, titled Human Resources Notice of Corrective Action, dated 9/25/23 and provided by the Interim ED on 9/29/23 at 12:29 p.m., indicated the Previous ED was terminated on 9/25/23, after an allegation of verbal and mental abuse was brought forward about her. After an investigation was complete, it was found that her actions were in violation of Center for Medicare and Medicaid Services (CMS) and the Indiana Department of Health's abuse regulations and the facility's policy on abuse and the companies code of conduct. During a phone interview, on 9/29/23 at 12:19 p.m., the previous ED indicated the Business Office Manager (BOM) told her Resident B's husband was living there at the facility. She went to the resident's room and found her and her husband in the room. She asked the resident if he was spending the night in her room and the resident indicated she had permission for her husband to sleep at the facility with her. She indicated she spoke to them and told them on the day she admitted he was only allowed to spend one night. The previous ED told them both he was not allowed to sleep at the facility at night, that's when the resident began to escalate and raise her voice toward the previous ED and indicated if the previous ED was kicking out her husband, she would be living also. The previous ED told her that was fine if that was the way it had to be and the resident then escalated more, saying the previous ED was kicking her out of the facility. She tried to tell the resident again she was able to stay, but her husband was not able to sleep in her room anymore. At some point during the conversation, the walker got moved from out in front of the resident and the previous ED did not know how it got moved. The resident accused the previous ED of abusing her and threatening her. She indicated the Regional [NAME] President terminated her on Monday (9/25/23) for causing psychosocial harm to Resident B. During a phone interview, on 9/29/23 at 12:43 p.m., CNA 10 indicated the previous ED indicated she needed to talk to her on the day before the incident between her and Resident B (9/19/23). A CNA was busy and was not packing up a resident's belongings, who had been discharged . She was not going to pack up the belongings at that time, because that resident would have behaviors. CNAs 7 and 10 were in the room along with the Housekeeping Supervisor when the previous ED was screaming at CNAs 7 and 10. When asked what the level of loudness was of the previous ED's voice if 0 was quiet and 10 was extremely loud, she indicated a level 8. The Wound Nurse from the facility and the Wound Physician was in the room across the hall working on a resident's wounds and they heard the previous ED screaming at the CNAs. She was being aggressive with the CNAs for no reason. CNA 10 was confused as to why the previous ED was coming at her like that. There was a monthly in-service that day and the previous ED brought up packing up resident's belongings. CNA 7 made a comment and the previous ED got very aggressive with her during the meeting raising her voice at CNA 7 and cut her off, so she was not able to speak. During an interview, on 9/29/23 at 1:51 p.m., Floor Tech 12 indicated she was cleaning the floors on the 300 Hallway when the incident occurred between the previous ED and Resident B. When the previous ED came out of room [ROOM NUMBER], she pointed her finger at her and CNA 8 instructing them to get boxes for the resident in room [ROOM NUMBER]. She had never seen the previous ED get upset like that before with a resident. She got three big sized boxes and took them and sat them at the side of Resident B's door in the hallway, since there were management staff in her room talking with her. 30-45 minutes after the incident with the previous ED, Resident B and her husband packed their belongings and left the facility. During an interview, on 9/29/23 at 2:20 p.m., the Interim DON with the Social Service Director in attendance, indicated she and the ADON witnessed the previous ED being angry and aggressive while walking down the Redbud hallway carrying on a conversation regarding Resident B needing to leave the facility today. She told her and the ADON to go to Resident B's room with her to be her witness as to what was being said because she did not want her saying she had been inappropriate with her or threatened her. After she, the ADON, and the previous ED left Resident B's room, she, and the Social Service Director (SSD) went to Resident B's room to talk to her privately. Resident B and her husband indicated she was being thrown out of the facility by the previous ED. The DON indicated after the previous ED was terminated, Resident B started coming out of her room more and socializing with other residents. She would do activities now, where she mainly stayed in room before the previous ED was terminated. The SSD indicated she did not perform a psychosocial assessment on her as required following the abuse allegation. A current policy, titled Abuse Prevention and Reporting-Indiana, dated with a revision date of 10/28/22 and provided by the Interim ED on 9/28/23 at 3:15 p.m., indicated The facility affirms the right of our residents to be free from abuse .This facility therefore prohibits abuse. 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 occurrences of abuse .This will be done by .Immediately protecting residents involved in identified reports of possible abuse .Definitions: Abuse: 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. This also includes the deprivation by an individual, including a caretaker .mental and psychosocial well-being. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Mental and Verbal Abuse: Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend or disability. Examples of mental and verbal abuse include, but are not limited to .Yelling or hovering over a resident with the intent to intimate; threatening residents, including but limited to depriving a resident of care of withholding a resident from contact with family and friends .Orientation and Training of Employees: During orientation of new employees, the facility will cover at least the following topics .What constitutes abuse .The facility may not discharge, demote, suspend, threaten, harass or deny a promotion or other employment-related benefit to an employee, or in any other manner discriminate against an employee in the terms and conditions of employment because of lawful acts done by the employee; or file a complaint or a report against a nurse or other employee with the appropriate State professional disciplinary agency because of lawful acts done by the nurse or employee A current policy, titled Verbal/Mental Abuse Allegation Staff to Resident Quality Assurance Checklist, undated and provided by the Interim ED on 9/29/23 at 3:46 p.m., indicated Immediate: Alleged staff member removed from all resident contact. Alleged staff member escorted from the facility. Alleged staff member placed on suspension pending investigation .Resident assessed for psychological injury & documented .Resident placed on report for 72 hour follow up documentation on incident .INVESTIGATION/PREVENTATIVE MEASURES .SS (Social Services) Psychosocial Assessment This Federal tag relates to Complaint IN00418301. 3.1-27(a)(1) 3.1-27(b)