**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, facility investigation file review, resident interview, staff interviews, and facility policy review the facility failed to ensure 4 of 6 residents (Resident #1, #2, #4, and #5) reviewed were free from abuse. Resident #1 stated Staff A crossed her arms and held them while doing something she did not want him doing and she told him to stop. Staff observed a bruise to her right outer forearm after the alleged incident. She indicated she would be frightened if she saw him again but if she does not see him she feels safe. Staff stated Resident #1 seemed really depressed about what happened and she could not understand why he would do that to her. Staff also reported Resident #1 indicated Staff A would pick on her, take her things, put them out of reach and was rough with her when he would change her brief. Staff reported Staff A would pick on Resident #2 to get a rise out of her. He would pick at her wig and annoy her, hide her cell phone, move her shoes and she did not like it. If she wanted to go to bed before 8:00 PM, he would push her in her wheelchair to the opposite hall and make her self-propel to her room so she couldn't go to bed right when she wanted to. Staff A will run with Resident #2 in her wheelchair down the hall but backwards. Resident #4 stated Staff A had scared the poop out of her one time. While sitting in her wheelchair by the nurse's station one night, Staff A came up from behind and tipped her wheelchair backwards all the way to the floor. He then raised it back up on all 4 wheels. Resident #4 stated she immediately went to her room after that because she was so scared. She stated what if he lost grip of the wheelchair and she fell to the ground. She indicated he gave her no warning just did it nor did he apologize for scaring her. Staff reported Staff A would hold Resident #5's arms down during cares to stop him from hitting staff members during cares. The facility reported a census of 44 residents. A determination was made that the facility's noncompliance placed residents in the facility in immediate jeopardy. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 11/28/23 at 3:00 PM. The facility staff removed the Immediate Jeopardy on 11/29/23 at 3:34 through the following actions: -On 11/28/2023, staff education was initiated to ensure staff are competent in the areas identified below. This education will be completed for all staff on 11/28/2023, or prior to their next shift: -Resident rights and facility responsibilities: -On 11/28/2023, all interviewable residents were interviewed by staff to ensure any abuse-related concerns have been addressed appropriately. No new concerns from residents were brought forward. -On 11/28/2023, all staff were interviewed to ensure any abuse related concerns have been properly addressed. An additional concern was brought forward during these interviews. The facility is following its process related to the allegation, including filing a new facility- initiated self-report. -On 11/29/2023, a resident council was completed by the Executive Director to ensure residents are aware of their options for reporting abuse and any other concerns to facility leadership and/or other available entities. -The facility initiated an ongoing audit on 11/29/2023 to include meeting with all interviewable residents once weekly for 16 weeks to ensure any concerns are addressed appropriately. -The facility initiated an ongoing audit on 11/29/2023 to assess staff understanding of the facility abuse policy, resident aggression, and resident rights. This audit will occur three times weekly for 16 weeks. -Any concerns will be reported to the administrator immediately and addressed in facility QA. -The facility has attempted to contact the alleged perpetrator since 11/22/23, with no response from the employee. His last date worked was 11/17/2023. He had been suspended since that last day worked on 11/17/2023. On 11/29/23, contact was again attempted to be made with the alleged perpetrator. A voicemail was left that his employment has ended with his last date worked of 11/17/2023. Findings include: 1. The annual Minimum Data Set (MDS) with a reference date of 7/18/23 documented Resident #1 required extensive assistance of two staff for bed mobility, transfers, dressing and toilet use. She also required extensive assistance of one staff for locomotion on and off the unit and personal hygiene and set up help only for eating. The quarterly MDS with a reference date of 10/27/23 documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 9 out of 15 indicating mild cognitive impairment. She reported feeling down, depressed, hopeless for 2-6 days during the review period. The MDS documented she exhibited physical and verbal behavioral symptoms directed towards others for 1-3 days during the review period. Resident #1 experienced rejection of care for 1-3 days during the review period. The resident was always incontinent of urine and continent of bowel. The following diagnoses were documented for Resident #1: major depressive disorder, dementia, psychotic disorder, personal history of a stroke, macular degeneration, and psychotic disorder with hallucination. The Care Plan focus area with an initiation date of 10/24/17 documented Resident #1 had limited mobility due to a stroke. Staff encouraged to be aware that she can experience dizziness when standing up. The care plan documented she required assistance of one staff while in her wheelchair. The wheelchair is her primary mode of locomotion but she rarely chose to get out of bed. A second care plan focus area with the same initiation date of 10/24/17 documented the resident had activities of daily living (ADL) self-care performance deficit due to her stroke, dementia, psychosis. The care plan documented she required assistance of two staff for bed mobility, assistance of one staff with stand-by assistance for dressing. The Care Plan focus area with an initiation date of 11/15/22 documented Resident #1 exhibited behaviors such as swearing at staff, screaming, throwing trash on the floor, self-isolation, rejection of cares, combative with cares. The care plan documented she had behaviors of making false accusations to staff. Staff were encouraged to approach her in a calm manner and explain what cares are going to be given; document behaviors such as yelling, swearing, combativeness, rejection of care; she moved to a private room with tile floor due to her throwing trash and food on the carpet; her family reported that she has always been a negative person this is not a new problem; she likes to joke around with people; please ensure that two staff go in to her room for all cares; and re-approach when agitated. The following Progress Notes were documented for Resident #1: -On 11/8/23 at 7:40 PM Staff B Certified Nursing Assistant (CNA) told nurse that Resident #1 had a bruise on her right arm and that the resident reported that it was from Staff A holding her down. A 4-centimeter (cm) x 4 cm dark purple bruise noted to resident's right arm. The nurse asked the resident what her bruise was from and she said Staff A had pinched her when he was putting her pants on. Resident #1 stated she was yelling at him and that she had been swinging her arms. The resident stated this happened last night, not this evening. -On 11/9/23 at 1:09 PM the Social Worker went into the resident's room at 11:00 AM on this day to do an interview with her about concerns with a staff member. Resident #1 stated he held both my arms down, squeezed her right arm harder than the left and that he comes in to torment her. The resident stated she was not sure what happened that night other than he came into change her and he's usually rough changing her so she told him no and that's when they started to fight. The Social Worker stated she does not feel safe when Staff A is working; he argues with her, takes her things, when he comes back everything starts up. The resident told the Social Worker that she told Staff A she does not want him in her room anymore. She added he takes her table away from her so she can't reach her water at night and has to go all night without a drink. During the altercation, Resident #1 indicated she told Staff A Ow you're hurting my arm, he wouldn't let go and believed he did it on purpose. Resident #1 stated she was sick it of and was not going to let him mess with her anymore. She reported being afraid to go to sleep because she does not feel safe. The facility investigation file included the following: -A document titled Abuse Investigation documented Resident #1 was able to identify Staff A by name on 11/8/23 when speaking with Certified Nursing Assistants (CNA) and the nurse regarding her bruise. Staff E CNA was caring for Resident #1, when the resident showed Staff E a bruise to her right arm. Resident #1 reported to Staff E, Staff A had taken care of her the night before, held her down on the bed during cares. Resident #1 also told Staff F CNA and the MDS Coordinator that Staff A held her arms down during cares. The Social Worker interviewed Resident #1 the next day and Resident #1 again indicated that Staff A held her arms down during cares and believed he hurt her on purpose. -The investigation documented the resident had a bruise to her right forearm that measured 4 centimeters (CM) x 4 cm. Resident #1 also told Staff B that Staff A held her arms down during cares, causing the bruise to her right forearm. -Staff A was immediately suspended pending investigation and Resident #1 will be care planned to have 2 staff assist her at all times. -Staff A reported while changing Resident #1, the resident was telling him that her brief was too tight so he let her do it herself. Staff A stated the resident started hitting him, screaming that the brief was too tight, so he left the room. Staff A denied grabbing Resident #1's arm or holding her down at any time. He stated that he might have put his arm up to block her form hitting him. -Timeline of Incident: On 11/8/23 at 7:40 PM the Administrator was notified by the MDS Coordinator that Resident #1 sustained a bruise to her right arm. Staff E was providing cares to Resident #1 at approximately 7:30 PM on 11/8/23 at which Resident #1 told her about and showed her a bruise she had on her right arm. The resident stated she told Staff A he was hurting her but he did not stop and later she noticed the bruise on her arm. Staff E asked Staff B to come in to Resident #1's room to look at her arm. The resident showed her the bruise. Staff B asked Resident #1 how she got that bruise and the resident stated Staff A held her arms down onto the bed. Staff B notified the nurse manager, the MDS Coordinator, who was working on the floor at that time of Resident #1's report. The MDS Coordinator spoke to Resident #1 and she again stated that Staff A pinched her as he was putting her pants on. She also stated she yelled at Staff A while swing her arms. No other injuries were found during the head to assessment completed. -Social Service Director interviewed Resident #1 the next day, 11/9/23 at approximately 11:00 A to get additional details of the incident. During this interview Resident #1 reported that Staff A held both her arms down, squeezing her right arm harder. Resident #1 stated he comes in and torments her. She was not sure what happened that night but he came in to change her. She told him no, since he was always rough with her when he changes her and that's when they started to fight. The resident reported that she does not feel safe when Staff A is working. He argues with her and takes her things. She stated when he comes back everything starts up. She also stated that she told him that she does not want him in her room anymore. Resident #1 stated that Staff A takes her table away from her to where she can't reach her water. She told Resident #1 that he was hurting her arm and he did not let go. She thinks he hurt her on purpose. The resident also stated we were both in the fight and that she was not going to let him mess with her anymore; she is sick of it. Resident #1 reported that she is afraid to go to sleep and does not feel safe. He crossed her arms which made it easier for him to squeeze her arm. -Plan of Action: after being notified of Resident #1's allegation, Staff A was immediately suspended pending investigation. The community will continue to follow the current care plan and add that the resident will require assistance of two staff members for cares at all times. On 11/17/23 at 10:58 AM observed Resident #1 lying in bed with her bedside table close by and her call light within reach. When asked if anyone had ever hurt her during cares, she indicated there was one guy. Then she crossed her arms in a bear hug way and pointed to a bruise on her right outer lower arm just above her wrist. It was circular, purple with different healing stages of yellow and light brown. She added it still hurt too. When asked what happened she stated that guy came in and did something she did not want him to do, so he held my arms down. She told him to stop. She added he liked to move her things like her TV and other things in her room. Why would he do that, he could break my things. Resident #1 was asked why that staff member did that to her arm she said because he was doing something she did not want him to do but could not recall what that was. When asked what the name of the guy she indicated she did not know his name but looks like Santa because he is fat. When asked if she had seen him recently she stated she has not seen him in a long time and would be frightened if she saw him again. She felt safer if she does not see him. 2. The quarterly MDS with a reference date of 8/28/23 documented Resident #2 had a BIMS score of 10 out of 15 indicating mild cognitive impairment. The MDS indicated she required extensive assistance of two staff for bed mobility; transfers; toilet use and extensive assistance of one staff for dressing and personal hygiene. The MDS documented she utilized a wheelchair for mobility. The following diagnoses were documented for Resident #2: anxiety, heart failure, dementia, depression and atrial fibrillation. The Care Plan focus area with an initiation date of 6/15/23 documented she had self-care deficit related to her restricted mobility, arthritis and anxiety. The care plan indicated she required assistance of one staff for bed mobility, transfers, toileting, dressing and ambulation in her room, wheelchair for mobility out of her room. While ambulating she required a gait belt and walker plus one staff member on stand by and one staff on stand by for transfers and toileting. On 11/28/23 at 10:30 AM Resident #2 sat in her wheelchair at the nurse's station, staff assisted her to her to her room so a private interview could be completed. Resident #2 was asked how staff were she stated good, they are good. Resident indicated she had no concerns with staff picking on her, touching her wig when they shouldn't, and denied ever being in her bed when it was raised up high. 3. The quarterly MDS with a reference date of 9/12/23 documented Resident #4 had a BIMS score of 11 out of 15 indicating mild cognitive impairment. The MDS documented she required supervision with setup help only for bed mobility, transfers, toilet use, and personal hygiene. Resident #4 utilized a wheelchair and walker. The following diagnoses were listed for Resident #4: acute and chronic respiratory failure with hypoxia, cancer, anemia, heart failure, renal failure, diabetes mellitus, stroke, anxiety, depression, atrial fibrillation, and chronic obstructive pulmonary disease (COPD). The Care Plan focus area with an initiation date of 7/7/21 documented Resident #4 had an activities of daily living (ADL) deficit due to having a stroke, COPD, chronic heart failure, chronic respiratory failure, and lower back pain. The care plan documented she was an assistance of one staff with a gait belt and forward wheeled walker for ambulation; assistance of one staff for bathing, bed mobility, and dressing. She could independently complete her personal hygiene, toileting, transfers, and eating. The Care Plan focus area with an initiation date of 7/14/21 documented Resident #4 had actual pain related to osteoarthritis and previous compression fracture to her lower back. Staff were encouraged to assess for signs and symptoms of pain, administer medications as ordered and to notify the physician of any uncontrolled pain. On 11/21/23 at 9:33 AM observed Resident #4 in her wheelchair in her room. When asked how she felt staff were she stated they are short, and that it just does not seem like a friendly atmosphere. She added the 2:00 PM-10:00 PM shift seemed short/pissed off at her but has had no issues with abuse. Resident #4 stated Staff A scared the poop out of her one time. She was sitting in her wheelchair at the nurse's station, one night when he walked up behind her and tipped her wheelchair backwards. He tipped it all the way down to the floor then raised her back up on all four wheels. After this happened she immediately went to her room because she was so scared. She questioned, what if he lost his grip and she fell on the ground? Staff A did not say anything, no warning, he just did it. He also did not apologize either for scaring the her. She did not tell anyone about this incident with Staff A. During a follow-up meeting on 11/29/23 at 1:17 PM she indicated she spoke to the Administrator about this incident with Staff A and felt very comfortable doing so. Resident #4 added she still has nightmares about what happened that night. She initially felt bad talking about it but now she does not because this is her home. She stated Staff A should feel bad for what he did, not her. She believes over time she will not have those nightmares. 4. The quarterly MDS with a reference date of 10/16/23 documented Resident #5 had severely impaired cognitive skills for decision making skills. The MDS documented he exhibited physical behavioral symptoms directed towards others 4-6 days during the review period and verbal behavioral symptoms towards others 1-3 days during the review period. Resident #5 also rejected cares 1-3 days during the review period. The MDS documented he was frequently incontinent of urine and bowel. The following diagnoses were listed for Resident #5: Alzheimer's disease, coronary artery disease, hip fracture, anxiety, and depression. The annual MDS with a reference date of 7/18/23 documented Resident #5 required extensive assistance of two staff for bed mobility; transfers; dressing; toilet use and extensive assistance of one staff for personal hygiene. The MDS documented he utilized a wheelchair for mobility. The Care Plan focus area with an initiation date of 9/14/22 documented Resident #5 had ADL self-care performance deficit related to Alzheimer's disease, impaired balance, left femur fracture with partial replacement. The care plan documented he required assistance of 2 staff and a gait belt for ambulation, assistance of two staff for toileting, wears a disposable brief and assistance of 1 staff for hygiene. The following Progress Notes documented the following: -On 10/7/23 at 3:45 PM resident was combative with cares this morning, hitting and kicking. -On 10/9/23 at 12:00 AM some hitting at CNA while he was sitting in the wheelchair. -On 10/10/23 at 1:38 AM resident resistant with cares at bed time; hitting, kicking staff. -On 10/31/23 at 12:08 PM resident has been alert today and combative when being transferred or changed. Resident tried to spit on the CNA when transferring. -On 11/16/23 at 7:08 PM resident physically abusive to CNAs while assisting to bed; hitting, cursing and pulled CNA by the hair in to his bed. On 11/17/23 at 10:37 AM the Activity/Social Service Director stated Resident #1 told her she does not like Staff A in her room because he picks on her, takes things from her and puts them out of reach and is rough with her when he changes her brief. Resident #1 reported to her that Staff A crossed her arms with her right arm on top and squeezed her arms that way. Resident #1 said Ow that hurts but Staff A did not stop and did not say why he did that to her. When asked how Resident #1 was after this happened she stated the resident was scared if Staff A would be in the building because she could not sleep and was afraid he would come in to her room to torment her or sneak up on her. The Activity/Social Service Director stated she heard complaints from other CNAs that Staff A picked on residents, and did small things to get them going. She was asked to give examples of what she had heard: there is a resident that wears a wig and Staff A would pull it off as the resident would tell him to give it back. The same resident was lying in bed and Staff A would raise the bed higher than normal to scare her. With Resident #1 he would pick on her, take her stuff, take her glasses away from her just to get a rise out of her. She indicated she took her concern to the previous Director of Nursing (DON), current DON and Administer because these things should not be happening. It was reported that Staff A would sit on the floor in Resident #2's room and make her walk from the bathroom by herself with the gait belt on. Another CNA walked in to help Resident #2 before she fell to the ground because Staff A was not doing anything. On 11/17/23 at 12:45 PM Staff F CNA stated Staff A would go in to assist Resident #1 without telling her what he was doing, would just go in and do whatever. If Resident #1 would tell Staff A no or refuse the tasks he would continue on and not walk away which intensified her mood. She had thrown a tray at Staff A before and would yell at him. Resident #1 told her that Staff A pinned her down and continued to change her then pointed to a bruise on her arm. Staff F stated Resident #1 appeared kind of angry about the situation and did not want him back in her room. She has had other residents voice concerns about Staff A. Resident #4 told her Staff A would not give her snacks and had tipped her chair back with her in it which scared her. She had also witnessed Staff A mess with Resident #2; moved her wig, hides her cell phone, moved her shoes and she did not like that. He would also run with her in her wheelchair, down the hall but pushing the wheelchair backwards. Staff F stated that if Resident #2 wanted to go to bed before 8:00 PM, he would push her in her wheelchair down another hall away from her room. On 11/17/23 at 2:18 PM Staff E CNA stated Resident #1 reported to her that she was very sad and depressed. When asked why, Resident #1 stated because Staff A grabbed her arms to hold her down and squeezed hard. Resident #1 indicated she told him to stop because it hurt but he continued to squeeze her harder after that. Staff E stated Resident #1 seemed really depressed it happened and did not understand why Staff A would do that to her. Staff E had witnessed him pick on Resident #2 but taking her down the wrong hall to mess with her. Resident #2 wears a wig, is very protective of it and will not take it off. Staff E had witnessed him touching her wig to annoy and bother her. It really set her off when he took her down the wrong hall. When asked how often this happens she stated it happened quite a bit; Staff A thinks he is joking but that is not something to joke about especially if it is setting off the residents. On 11/17/23 at 2:47 PM Staff B CNA reported Resident #1 told her Staff A held her down on the bed but was unsure why he did that. Staff B stated she knows Staff A is rough with residents; he is stronger than he thinks. She had witnessed him being rough with Resident #5 while he was having behaviors. Staff A would hold on to him so he did not hit during cares. When asked what she meant by hold on to him she stated he would hold on to his arms way too hard and squeeze them so he does not hit during cares. At times Staff A would stand up while doing this and hold Resident #5's arms in the air or hold him in a bear hug like manner. Staff B reported Staff A also liked to pick on residents and if they asked him to stop he would not. He would pick on Resident #2 by pulling off her wig and would continue to do that even after she told him to stop. Staff A had a rule for Resident #2 that she could not go to bed before 8:00 PM, but this is not care planned. If she wanted to go to bed before 8:00 PM, he would put her on a different hall and make her wheel herself back to her room. She was on B hall and he would put her on A hall that is directly in front of the nurse's station. He would do this almost every single night he worked if she asked to go to bed. Staff B reported to her that Staff A had tipped Resident #4's wheelchair back while she was in it. This scared her but he kept doing it. She indicated they have reported their concerns to nurses but not sure if anything had been done about it. On 11/21/23 at 12:09 PM the MDS Coordinator was not aware of any staff members picking on residents as well as no complaints of Staff A. She denied hearing residents and resident voice concerns about Staff A. On 11/21/23 at 12:22 PM the DON indicated she was unaware of any resident concerns with Staff A. She added she was not aware of any staff members teasing or taking things away from residents. During a follow-up interview on 12/5/23 at 3:30 PM she stated all staff are to complete the mandatory reporting training upon hire, complete the refresher course every three years and complete regular training for competencies. The DON was asked to describe what abuse is and she indicated physical, verbal, financial, sexual, inappropriate touching, teasing, taunting, making residents feel scared. Abuse can be from residents, family members and other visitors. She added residents should be treated with respect, kindness, while respecting their rights. The DON stated this is their resident's homes and they should feel comfortable and safe. On 11/22/23 at 12:49 PM Staff G CNA was asked how Staff A was as a co-worker and she began to laugh. She indicated she had issues with him all the time. He has told one resident that she can't go to bed at a certain time, Resident #2. One-night Staff G put Resident #2 to bed because she was ready for bed but Staff A went back in and took her out of bed, placed her in her wheelchair by the nurse's station. She indicated this happened a couple of months ago and when she called him out on it he does not say or do anything. She would take her concerns to the nurses, which was usually the night nurses and had talked to the Activity/Social Service Director about it too. Staff had told her that one day Staff A was in assisting Resident #2 but he sat on the floor and watched the resident walk to her bed by herself. Staff G indicated Resident #2 used a gait belt to walk. The other staff member had to help Resident #2 so she would not fall. This happened not too long ago. Staff G had witnessed Staff A take Resident #2 to the oppose hall when she wanted to go to bed. She again called him out on this and he just ignored her. Staff G stated this is their home and they can go to bed when they want to. Staff G also reported Staff A put Resident #2 to bed and raised the bed as high as it would go; there is no reason for that. Staff A would not answer Staff G when she questioned him about it. She reported Staff A would hover over Resident #5 while he had behaviors and that is not a good way to calm him down. They are to leave him alone to calm him down. On 11/28/23 at 11:34 AM Staff A stated his job duties at the facility included cleaning up residents, providing hygiene, make sure residents are emotionally ok, their meal trays are being passed, they are eating if they chose to do so, check and change them at night, and make sure they are not abused or anything, no bruises or anything. Staff A acknowledged this was his first CNA job. Staff A stated the facility has residents that hit but he himself is a big [NAME] and can take it. When asked what residents had those types of behaviors he stated Resident #1 and #5, along with two other residents. When asked what kind of abuse training he had he indicated just the standard pamphlet the facility gave out to staff and residents, and the facility has signs everywhere. He stated the facility has online courses, nothing more than the monthly online courses. Staff A was asked what he would do if a resident he was caring for would have behaviors he indicated he would come back later and try to provide cares again. He had heard of redirection as a way to handle the behavior but his instincts are to block and he put his arms up in the air. Staff A denied knowing of residents being teased at the facility by any staff members and acknowledged it was unacceptable to tease anyone. When asked if he heard of staff picking on residents he stated there's no point in that, why would you irritate residents, it would just make your job harder. Staff A was asked to talk about the night Resident #1 made the allegation he stated he went into her room to ask if she wanted changed and she told him he should have been in there forever ago. As he was providing cares, she swatted at him and he walked away. He added she can do things on her own but he tried to be extra helpful and make sure her brief was on right. He went back, looked in to see if she was ok. Resident #1 told the nurse she had hit him because her brief was tight. He said he instinctively put his arm up when she swatted at him and walked away to get her to calm down faster. He denied holding her arms down, squeezing her arms. He did state she told him to stop as he assisted with her brief, he walked away after she was hitting him. Staff A denied pushing Resident #1's arms during cares. Staff A stated Resident #1 called him Santa Claus because he has a big belly like him. He also denied removing Resident #2's wig to pick on her, he likes her. He would let her self-propel to her room when she is ready for bed. He denied pushing her down the opposite hall, she liked to be at the nurse's station because she is a fall risk. When asked if he ever sat back and watched Resident #2 walk from the bathroom without assistance, he stated when he first started she was a lot more independent, he would hold on to her and corrected her posture if needed. He added she is to always have two people in with her now. Staff A indicated there was no point in sitting back and allow her to walk alone, she would not make it. He would only raise her bed up to adjust her in bed and put it back to the lowest position how she likes it. Staff A was asked if he tipped Resident #4's wheelchair back as she sat in it, he denied this and stated he walked up behind her pretending to scare her but that was it. He stated one time he walked up behind her, tapped on her shoulder and that scared her. Staff A acknowledged Resident #5 would hit a lot and he would just let him do it. He denied using his body to block Resident #5 from hitting staff during cares such as lying on him. Staff A was asked to describe what abuse is to him: either being negligent, physical or emotional abuse, preventing them from going to their rooms and not allowing them to do what they want. When asked if teasing and picking on residents is considered abuse he indicated he would say so. Staff A said it would be considered abuse to hold someone's arms down to the point that it caused pain and left a bruise. When asked if any of the cares he provided to the residents at the facility would be considered abuse he stated he did not think so. Review of a documented titled Freedom from Abuse Notice to Employees Resident/Patient Abuse, Neglect and Mistreatment of Belongings documented among the rights specified in the federal and state laws, each resident and patient has a right to a dignified existence and to be free from verbal, sexual, physical or mental abuse: corporal punishment and involuntary seclusion. Abuse includes, but not limited to: -Verbal Abuse: oral, written, or gestured language, including sarcastic remarks and derogatory statements, directed to residents, family members or significant others. -Physical Abuse: hitting, slapping, pinching, scratching, spitting, holding [NAME][TRUNCATED]

Based on observations, record review, facility investigation file review, resident interview, staff interviews, and facility policy review the facility failed to report abuse concerns involving 3 of 6 residents (Resident #2, #4, and #5) reviewed for potential abuse. Staff reported Staff A would pick on Resident #2 to get a rise out of her. He would pick at her wig and annoy her, would hide her cell phone, move her shoes and she did not like it. If she wanted to go to bed before 8:00 PM, he would push her in her wheelchair to the opposite hall and make her self-propel to her room so she couldn't go to bed right when she wanted to. Staff A would run with Resident #2 in her wheelchair down the hall but backwards. Resident #4 stated Staff A had scared the poop out of her one time. While sitting in her wheelchair up by the nurse's station one night, Staff A came up from behind her and tipped her wheelchair backwards all the way to the floor and then raised it back up on all 4 wheels. Resident #4 stated she immediately went to her room after that because she was so scared. She said what if he had lost grip of the wheelchair and she fell to the ground. She indicated he gave her no warning just did it nor did he apologize for scaring her. Staff reported Staff A would hold Resident #5's arms down during cares to stop him from hitting staff members during cares. The facility reported a census of 44 residents. A determination was made that the facility's noncompliance placed residents in the facility in immediate jeopardy. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 11/28/23 at 3:00 PM. The facility staff removed the Immediate Jeopardy on 11/29/23 at 3:34 PM through the following actions: -On 11/28/2023, staff education was initiated to ensure staff are competent in the areas identified below. This education will be completed for all staff on 11/28/2023, or prior to their next shift: Resident rights and facility responsibilities -On 11/28/2023, all interview-able residents were interviewed by staff to ensure any abuse-related concerns have been addressed appropriately. No new concerns from residents were brought forward. -On 11/28/2023, all staff were interviewed to ensure any abuse related concerns have been properly addressed. An additional concern was brought forward during these interviews. The facility is following its process related to the allegation, including filing a new facility-initiated self-report. -On 11/29/2023, a resident council was completed by the Executive Director to ensure residents are aware of their options for reporting abuse and any other concerns to facility leadership and/or other available entities. -The facility initiated an ongoing audit on 11/29/2023 to include meeting with all interview-able residents once weekly for 16 weeks to ensure any concerns are addressed appropriately. -The facility initiated an ongoing audit on 11/29/2023 to assess staff understanding of the facility abuse policy, resident aggression, and resident rights. This audit will occur three times weekly for 16 weeks. -Any concerns will be reported to the Administrator immediately and addressed in facility QA. -The facility had attempted to contact the alleged perpetrator since 11/22/23, with no response from the employee. His last date worked was 11/17/2023. He had been suspended since that last day worked on 11/17/2023. On 11/29/23, contact was again attempted to be made with the alleged perpetrator. A voicemail was left that his employment had ended with his last date worked of 11/17/2023. Findings include: 1. The quarterly Minimum Data Set (MDS) with a reference date of 8/28/23 documented Resident #2 had a Brief Interview of Mental Status (BIMS) score of 10 out of 15 indicating mild cognitive impairment. The MDS indicated she required extensive assistance of two staff for bed mobility; transfers; toilet use and extensive assistance of one staff for dressing and personal hygiene. The MDS documented she utilized a wheelchair for mobility. The following diagnoses were documented for Resident #2: anxiety, heart failure, dementia, depression and atrial fibrillation. The Care Plan focus area with an initiation date of 6/15/23 documented she had self-care deficit related to her restricted mobility, arthritis and anxiety. The Care Plan indicated she required assistance of one staff for bed mobility, transfers, toileting, dressing and ambulation in her room, wheelchair for mobility out of her room. While ambulating she required a gait belt and walker plus one staff member on stand by and one staff on stand by for transfers and toileting. 2. The quarterly MDS with a reference date of 9/12/23 documented Resident #4 had a BIMS score of 11 out of 15 indicating mild cognitive impairment. The MDS documented she required supervision with setup help only for bed mobility, transfers, toilet use, and personal hygiene. Resident #4 utilized a wheelchair and walker. The following diagnoses were listed for Resident #4: acute and chronic respiratory failure with hypoxia, cancer, anemia, heart failure, renal failure, diabetes mellitus, stroke, anxiety, depression, atrial fibrillation, and chronic obstructive pulmonary disease (COPD). The Care Plan focus area with an initiation date of 7/7/21 documented Resident #4 had an activities of daily living (ADL) deficit due to having a stroke, COPD, chronic heart failure, chronic respiratory failure, and lower back pain. The Care Plan documented she was an assistance of one staff with a gait belt and forward wheeled walker for ambulation; assistance of one staff for bathing, bed mobility, and dressing. She could independently complete her personal hygiene, toileting, transfers, and eating. The Care Plan focus area with an initiation date of 7/14/21 documented Resident #4 had actual pain related to osteoarthritis and previous compression fracture to her lower back. Staff were encouraged to assess for signs and symptoms of pain, administer medications as ordered and to notify the physician of any uncontrolled pain. On 11/21/23 at 9:33 AM observed Resident #4 in her wheelchair in her room. When asked how she felt staff were, she stated they are short and it doesn't seem like a friendly atmosphere. She added the 2:00 PM-10:00 PM shift seemed short/pissed off at her but has had no issues with abuse. Resident #4 stated Staff A scared the poop out of her one time. She was sitting in her wheelchair at the nurse's station, one night when he walked up behind her and tipped her wheelchair backwards. He tipped it all the way down to the floor then raised her back up on all four wheels. After this happened she immediately went to her room because she was so scared. She questioned, what if he lost his grip and she fell on the ground. Staff A did not say anything, no warning, he just did it. He also did not apologize either for scaring the her. She did not tell anyone about this incident with Staff A. During a follow-up meeting on 11/29/23 at 1:17 PM she indicated she spoke to the Administrator about this incident with Staff A and felt very comfortable doing so. Resident #4 added she still has nightmares about what happened that night. She initially felt bad talking about it but now she does not because this is her home. She stated Staff A should feel bad for what he did, not her. She believes over time she will not have those nightmares. 3. The quarterly MDS with a reference date of 10/16/23 documented Resident #5 had severely impaired cognitive skills for decision making skills. The MDS documented he exhibited physical behavioral symptoms directed towards others 4-6 days during the review period and verbal behavioral symptoms towards others 1-3 days during the review period. Resident #5 also rejected cares 1-3 days during the review period. The MDS documented he was frequently incontinent of urine and bowel. The following diagnoses were listed for Resident #5: Alzheimer's disease, coronary artery disease, hip fracture, anxiety, and depression. The annual MDS with a reference date of 7/18/23 documented Resident #5 required extensive assistance of two staff for bed mobility; transfers; dressing; toilet use and extensive assistance of one staff for personal hygiene. The MDS documented he utilized a wheelchair for mobility. The Care Plan focus area with an initiation date of 9/14/22 documented Resident #5 had ADL self-care performance deficit related to Alzheimer's disease, impaired balance, left femur fracture with partial replacement. The Care Plan documented he required assistance of 2 staff and a gait belt for ambulation, assistance of two staff for toileting, wears a disposable brief and assistance of 1 staff for hygiene. The following Progress Notes documented the following: -On 10/7/23 at 3:45 PM resident was combative with cares this morning, hitting and kicking. -On 10/9/23 at 12:00 AM some hitting at CNA while he was sitting in the wheelchair. -On 10/10/23 at 1:38 AM resident resistant with cares at bed time; hitting, kicking staff. -On 10/31/23 at 12:08 PM resident has been alert today and combative when being transferred or changed. Resident tried to spit on the CNA when transferring. -On 11/16/23 at 7:08 PM resident physically abusive to CNAs while assisting to bed; hitting, cursing and pulled CNA by the hair in to his bed. On 11/17/23 at 10:37 AM the Activity/Social Service Director stated she heard complaints from other CNAs that Staff A picked on residents, and did small things to get them going. She was asked to give examples of what she has heard and she stated there is a resident that wears a wig and Staff A would pull it off as the resident would tell him to give it back. The same resident was lying in bed and Staff A would raise the bed higher than normal to scare her. With Resident #1 he would pick on her, take her stuff, take her glasses away from her just to get a rise out of her. She indicated she took her concern to the previous Director of Nursing (DON), current DON and Administer because these things should not be happening. It was reported that Staff A would sit on the floor in Resident #2's room and make her walk from the bathroom by herself with gait belt on. Another CNA walked in to help Resident #2 before she fell to the ground because Staff A was not doing anything. On 11/17/23 at 12:45 PM Staff F CNA stated she has had other residents voice concerns about Staff A. Resident #4 stated Staff A will not give her snacks and had tipped her chair back with her in it which scared her. She has also witnessed Staff A mess with Resident #2; moved her wig, hide her cell phone, moved her shoes and she did not like that. He would also run with her in her wheelchair, down the hall but pushing the wheelchair backwards. Staff F stated that if Resident #2 wanted to go to bed before 8:00 PM, he would push her in her wheelchair down another hall. Staff F stated the Social Worker/Activity Director asked her how Staff A had been and she told her he seemed rough. On 11/17/23 at 2:18 PM Staff E CNA stated she had witnessed Staff A pick on Resident #2 by taking her down the wrong hall to mess with her. Resident #2 wears a wig, is very protective of it and will not take it off. Staff E had witnessed him touching her wig to annoy and bother her. It really set her off when he took her down the wrong hall. When asked how often this happens she stated it happened quite a bit; Staff A things he is joking but that is not something to joke about especially if it is setting off the residents. Staff E reported she did not witness Staff A holding Resident #5 down but had heard of him doing this. Since she had not witnessed this she just watched to make sure nothing like that is being done. On 11/17/23 at 2:47 PM Staff B CNA stated had witnessed him being rough with Resident #5 while he was having behaviors. Staff A would hold on to him so he does not hit during cares. When asked what she meant by hold on to him she stated he would hold on to his arms way too hard and squeeze them so he does not hit during cares. At times Staff A would stand up while doing this and hold Resident #5's arms in the air or hold him in a bear hug like manner. Staff B reported Staff A also liked to pick on residents and if they asked him to stop he would not. He would pick on Resident #2 by pulling off her wig and would continue to do that even after she told him to stop. Staff A had a rule for Resident #2 that she should could not go to bed before 8:00 PM, but this is not care planned. If she wanted to go to bed before 8:00 PM, he would put her on a different hall and make her wheel herself back to her room. She was on B hall and he would put her on A hall that is directly in front of the nurse's station. He would do this almost every single night he worked if she asked to go to bed. Staff B reported Staff A had tipped Resident #4's wheelchair back while she was in it. This scared her but he kept doing it. She indicated they have reported their concerns to nurses, could not remember their names, but not sure if anything had been done about it. On 11/21/23 at 12:09 PM the MDS Coordinator stated she was not aware of any staff members picking on residents as well as no complaints of Staff A. She denied hearing residents and resident voicing concerns about Staff A. On 11/21/23 at 12:22 PM the DON indicated she was unaware of any resident concerns with Staff A. She added she was not aware of any staff members teasing or taking things away from residents. During a follow-up interview on 12/5/23 at 3:30 PM the DON acknowledged staff should report abuse concerns immediately. Staff should notify the charge nurse and the charge nurse will then notify someone in leadership. Most concerns have to be reported within two hours so if the charge nurse is the issue they must notify the DON or Administrator. There is also a reporting hotline if the staff member is not comfortable reporting to their supervisor. On 11/21/23 at 2:55 PM the MDS Coordinator, Administrator, DON, Office Manager, and Infection Control nurse were made aware of the concerns with Staff A and his treatment towards Resident #2, #4 and #5. They were all taken back by the information that was shared with them and indicated they had never heard of these concerns before. On 11/22/23 at 12:49 PM Staff G CNA was asked how Staff A was as a co-worker and she began to laugh. She indicated she has had issues with him all the time. He had told Resident #2 that she couldn't go to bed at a certain time. One-night Staff G put Resident #2 to bed because she was ready for bed but Staff A went back in and took her out of bed, and placed her in her wheelchair by the nurse's station. She indicated this happened a couple of months ago and when she called him out on it he did not say or do anything. She would take her concerns to the nurses, which was usually the night nurses and had talked to the Activity/Social Service Director about it too. Staff had told her that Staff A was in assisting Resident #2 but he sat on the floor and watched the resident walk to her bed by herself. Staff G indicated Resident #2 used a gait belt to walk. The other staff member had to help Resident #2 so she would not fall. This happened not too long ago. Staff G had witnessed Staff A take Resident #2 to the opposite hall when she wanted to go to bed. She again called him out on this and he just ignored her. Staff G stated this is their home and they can go to bed when they want to. Staff G also reported Staff A put Resident #2 to bed and raised the bed as high as it would go; there is no reason for that. Staff A would not answer Staff G when she questioned him about it. She reported Staff A would hover over Resident #5 while he had behaviors and that is not a good way to calm him down. They are to leave him alone to calm him down. She had taken her concerns to the nurses and it goes nowhere so she had gone to the Social Service Director/Activity Director. The nurses she reported this to, work nights and was usually Staff J Licensed Practical Nurse (LPN). Staff G stated she worked weekends so she does not work with management to report her concerns to. The facility's Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy updated on 10/19/22 indicated all allegations of resident abuse and neglect should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator or designated representative. All allegations of resident abuse shall be reported to the State Agency no later than two hours after the allegation is made.