**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 28 residents. The sample included three residents. Based on record review and interviews, the facility failed to ensure Resident (R) 1 received care consistent with the standards of practice when staff failed to report abnormal x-ray findings and obtain physician involvement for treatment. On 06/04/24, R1 had a fall in the facility's van. On 06/06/24, R1 complained of right shoulder pain and staff obtained an order for an x-ray. The x-ray showed a medial subluxation (dislocation) of R1's right glenohumeral joint (ball and socket joint at the shoulder). Staff failed to notify R1's physician of the results. On 06/27/24, after continued complaints of right shoulder pain affecting R1's activities of daily living (ADLs), staff obtained an order for a referral to an orthopedic (specializing in bones) doctor. Staff called to schedule an appointment but did not follow up or ensure an appointment was made for R1 until 07/18/24 when staff received a call from the orthopedic physician's office for a scheduled appointment on 07/31/24 at 09:45 AM. At the 07/31/24 appointment, the orthopedic physician noted R1 had an anterior (near the front of the body) subluxation of the humeral head with a probable impaction fracture (fracture that occurs when the broken ends of the bone are jammed together by the force of the injury) of the humeral head on the right side and would require surgical repair. The facility's failure to report abnormal X-ray findings to the physician and the delay in physician involvement in R1's injury placed R1 in immediate jeopardy. Findings included: - R1 admitted to the facility on [DATE] and transferred to the hospital on [DATE]. R1's EMR documented diagnoses of essential hypertension (high blood pressure) and other specified disorders of bone density and structure of the right shoulder. The admission Minimum Data Set (MDS) dated 04/17/24, documented R1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 had impairment on one side of her upper extremities and both sides of her lower extremities. R1 used a walker and a wheelchair. R1 required substantial/maximal assistance with showering, upper and lower body dressing, rolling left to right, sitting to lying, and lying to sitting on the side of the bed; partial/moderate assistance with toileting hygiene, sitting to standing, chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers; and was independent with personal hygiene, oral hygiene, and eating. The Quarterly MDS dated 06/28/24, documented R1 had a BIMS score of 15, which indicated intact cognition. R1 had no impairment and used a walker and wheelchair. R1 required substantial/maximal assistance with showering, rolling left to right, and tub/shower transfers; partial/moderate assistance with upper and lower body dressing, sitting to lying, lying to sitting on the side of the bed, sitting to standing, and chair/bed-to-chair transfers; supervision with toileting hygiene and toilet transfers, and was independent with eating, oral hygiene, and personal hygiene. The Functional Abilities Care Area Assessment (CAA) dated 04/24/24, documented R1 had a self-care deficit related to weakness and required assistance with ADLs. R1 had limitations with her right upper extremity and bilateral lower extremities. The Falls CAA dated 04/24/24, documented R1 had an increased risk for falls with injury due to impaired balance, limitations with range of motion, pain, and staff assistance with transfers. R1's Care Plan, initiated 05/13/24, documented R1 had a risk for falls with injury related to incontinence, impaired mobility with balance, and need for continuous oxygen. The care plan documented interventions, dated 05/28/24, that directed R1 needed a safe environment with even floors from spills and/or clutter and R1 used an electric wheelchair for independent mobility. R1's Care Plan, initiated 07/28/24, documented R1 had chronic pain in her shoulder and back related to arthritis and had a recent injury to her right shoulder from a fall. The care plan directed staff administered analgesia as per orders; staff evaluated the effectiveness of pain interventions; staff identified, recorded, and treated R1's existing conditions which increased pain; staff monitored/documented for probable cause of each pain episode and removed or limited the cause where possible; staff monitored/documented for side effects of pain medication and reported occurrences to the physician; staff monitored/recorded pain characteristics every shift and as needed (PRN); and staff notified the physician if interventions were unsuccessful or if current complaint was a significant change from R1's past experiences of pain. The Orders tab of R1's EMR documented an order with a start date of 04/10/24 for acetaminophen (pain medication) 650 milligrams (mg) every six hours as needed (PRN) for pain. R1's Medication Administration Record (MAR) for May 2024 revealed R1 received PRN acetaminophen for pain one time, on 05/31/24. R1's MAR for June 2024 revealed R1 did not receive any acetaminophen before 06/07/24. R1 received PRN acetaminophen for pain 14 times from 06/07/24 to 06/30/24. R1's MAR for July 2024 revealed R1 received PRN acetaminophen for pain 11 times. R1's MAR for 08/01/24 to 08/16/24 revealed R1 received PRN acetaminophen for pain 10 times. The facility's report on 08/15/24, documented on 06/04/24, Transportation Staff W transported R1 to a dental appointment, and during the ride, when the van took a turn, R1 heard a pop and the seatbelt came unbuckled. R1's electric wheelchair tipped sideways to the right. R1 stated the seat belt did not break but had come unlocked. R1 stated she stood up and held onto the seat and Transportation Staff W immediately pulled the van over to put R1's wheelchair back on all four wheels and helped R1 into her wheelchair. R1 had a skin tear on her right elbow which Transportation Staff W bandaged. Transportation Staff W and R1 continued to her appointment. On 06/06/24, R1 reported pain in her shoulder, which she stated was chronic. The provider ordered an x-ray, which showed a medial subluxation of the glenohumeral joint. R1's EMR revealed the following: A Skin/Wound Note on 06/04/24 at 02:28 PM documented R1 had a skin tear to her right elbow. R1 went to a dental appointment in the facility van and when the van made a turn, her wheelchair leaned, and her right elbow hit the van. A Health Status Note on 06/06/24 at 04:45 PM documented facility called Consultant GG regarding R1. R1 requested an x-ray of her right shoulder. Consultant GG ordered a portable two-view x-ray of R1's right shoulder. R1's medical record lacked evidence the facility notified R1's provider of the x-ray results on 06/06/24. R1's medical record lacked evidence the facility notified R1's provider of R1's continued right shoulder pain from 06/07/24 to 06/26/24. A Nurse Note on 06/27/24 at 01:38 PM documented R1 continued to complain of right shoulder pain affecting her ADL ability. The facility received an order for referral to orthopedics. The facility placed a call to orthopedics and waited for a return call for an appointment. R1's medical record lacked evidence the facility followed up with the orthopedic office to schedule an appointment for her referral from 06/28/24 to 07/17/24. A Nurse Note on 07/18/24 at 11:12 AM documented Administrative Nurse E and Social Services X made several calls over the past few weeks to orthopedics regarding setting up an appointment for a new referral due to continued right shoulder pain. The facility received a return call from orthopedics with an appointment scheduled for 07/31/24 at 09:45 AM. A Nurse Note on 08/05/24 at 02:30 PM documented R1 had an initial consult at orthopedics regarding her right shoulder pain. R1 informed the facility she needed surgery and needed clearance from a pulmonologist (a doctor who specializes in diagnosing and treating diseases of the lungs). The facility obtained an order for a referral to a pulmonologist, faxed the referral order to the pulmonologist, and awaited a reply to schedule the consult. R1's medical record lacked evidence the facility followed up with the pulmonologist's office to schedule an appointment for her referral from 08/06/24 to 08/14/24. A Nurse Note on 08/15/24 at 03:28 PM documented the facility notified the pulmonologist's office regarding the new referral and requested an appointment to assess clearance for shoulder surgery. The pulmonologist's office nurse informed the facility that late October was the earliest available. Social Services X notified another pulmonology clinic of the referral and requested an appointment. A Transfer to Hospital Summary on 08/16/24 at 05:12 AM documented R1 voiced complaints of lower abdominal pain, dizziness, and altered mental status. R1 requested to be sent to the hospital for evaluation and treatment. Upon request, the facility was unable to provide progress notes from R1's provider from 06/04/24 to the present. Upon request, the facility supplied a fax confirmation that revealed the facility faxed R1's referral to the orthopedic office on 07/02/24 at 02:19 PM. Upon request, the facility provided Progress Notes from R1's orthopedic consultation on 07/31/24. The Progress Notes documented R1 fell out of her wheelchair due to the seatbelt breaking onto her right shoulder against a lift gate and had pain ever since the incident. R1 could not raise her arm above waist level and when she tried to move it, her shoulder popped. R1 had not seen anyone about her shoulder since the injury. R1's x-ray of her right shoulder from 07/31/24 revealed an anterior subluxation of the humeral head with probable impaction fracture of the humeral head and possibly a fracture extending up superiorly into the humeral head as well. The Impression/Plan for R1 documented R1 had right shoulder pain after a fall two months ago with what appeared to be an impacted head fracture anteriorly subluxated and she might have had a rotator cuff (a capsule of fused tendons that supports the arm at the shoulder joint) tear. The orthopedic provider gave R1 the option of therapy injection medications which he did not believe would do much for her or a shoulder replacement. He recommended R1 think about her options and if she wanted surgery, she would need medical clearance. On 08/19/24 at 12:57 PM, Certified Nurse Aide (CNA) N stated R1 complained of right shoulder pain that had worsened over the last couple of months and slowed down her ability to perform ADLs. On 08/19/24 at 01:09 PM, Licensed Nurse (LN) G stated R1 complained of right shoulder pain after the van incident, and it affected her ADLs. He stated after the facility received X-ray results, the nurse notified the provider and documented the notification in a note. LN G stated if a resident had continued pain for more than a couple of days, he notified the provider and documented it in a note. He stated generally, the provider saw residents following incidents or new pain. He stated the facility should have followed up with R1's provider about her right shoulder pain prior to 06/27/24. LN G stated he thought Social Services X set up any referral appointments. He stated if he received a referral, he sent it to Social Services X. He stated there should be a follow-up system for setting up a referral appointment. On 08/19/24 at 01:23 PM, Social Services X stated Administrative Nurse E sent the referrals to the provider the referral was for. She stated sometimes the facility received a call back from the referred provider to schedule the appointment. Social Services X stated the facility called the referred provider within a couple of days to make the appointment and sometimes the referred provider stated they did not receive the referral or they would have to call back. Social Services X stated she did not put a note in every time she tried to call the referred provider to set up an appointment and she only handled the referrals when Administrative Nurse E was gone. She stated the facility faxed the referral as soon as they received it and followed up within a couple of days. She stated the facility faxed R1's orthopedic referral on 06/27/24 but when she called to follow up, they said they did not get it, so she refaxed it on 07/02/24. On 08/19/24 at 01:34 PM, Administrative Nurse E stated she did not know R1 had right shoulder pain until a week after the van incident and an x-ray had been completed. She stated R1 reported to her on 06/27/24 that her right shoulder pain affected her ADL ability and Administrative Nurse E received an order for a referral to orthopedics. She stated she called the orthopedic office that day and received a number to fax the referral order. Administrative Nurse E stated she called the orthopedic office at least three times between 06/27/24 and 07/18/24 and the office told her she would receive a call back. She stated she did not know why she did not document the follow-up attempts. She stated any nurse handled the referrals and the Director of Nursing (DON) at the time should have followed up with the referral. Administrative Nurse E stated the nurse on the floor should handle the referrals and keep calling until they get a reply. On 08/19/24 at 01:53 PM, Administrative Nurse D stated if a resident had new or increased pain, she expected nursing to assess the resident and notify the physician then document it in a note. She stated she expected the nurse to notify the physician of the X-ray results and document the notification. Administrative Nurse D stated the charge nurse sent referrals and she expected nursing to follow up in a couple of days to make the appointment and then document. The facility's Acute Condition Changes- Clinical Protocol policy, revised 07/05/24, documented that staff contacted the physician based on the urgency of the situation and the attending physician responded in a timely manner to the notification of problems or changes in condition or status. The policy directed staff to monitor and document the resident's progress and responses to treatment. The policy directed the physician to review the status of the condition change and document their evaluation at the next visit. On 08/19/24 at 02:07 PM Administrative Staff A received a copy of the Immediate Jeopardy Template and was informed of the facility's failure to ensure R1 received care consistent with the standards of practice which placed R1 in immediate jeopardy. The facility completed the following corrective actions to remove the immediacy for R1: Licensed nurses were educated on physician recommendations and order follow-ups including appointments starting 08/19/24 and all licensed nurses were educated prior to their next shift. Licensed nurses were educated on post-incident follow-up starting on 08/19/24 and all licensed nurses were educated prior to their next shift. Licensed nurses were educated on pain management and observation starting on 08/19/24 and all licensed nurses were educated prior to their next shift. Licensed nurses were educated on physician notifications to include abnormal diagnostic testing starting 08/19/24 and all licensed nurses were educated prior to their next shift. All current staff were educated on abuse, neglect, and exploitation on 08/16/24. Staff notified R1's physician of abnormal x-ray findings and requested the physician to review pain medications to ensure pain control for R1 on 08/19/24. An ad-hoc Quality Assurance and Performance Improvement (QAPI) meeting with the facility's medical director occurred on 08/19/24. The onsite surveyor verified the implementation of the above corrective actions and removal of the immediacy on 08/19/24. The scope and severity of the deficient practice remained at a G to reflect the actual injury to R1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 18 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to provide trauma-informed care for Resident (R) 17 who had an extensive history of trauma. On 05/11/23, the facility performed a social services assessment on R17 which revealed an extensive history of traumatic relationships, experience with disaster, profound feelings of helplessness, history of serious accidents and/or injuries and a history of abuse and sexual harassment. Despite this information, the facility did not develop a plan of care which identified and addressed triggers in order to prevent recurring traumatization. On 11/01/23 R17 told Activity Staff Z about her history of traumatization, previous suicide attempts, and her feelings of wanting to shoot herself. R17 cried and stated she felt sad and suicidal. The facility's failure to identify and implement person-centered interventions to address the psychosocial well-being for R17, who had an extensive history of trauma, placed R17 in immediate jeopardy. The facility further failed to ensure trauma informed care was developed an implemented for R14 and R4. Findings included: - R17's Electronic Medical Record (EMR) recorded diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (swallowing difficulty), need for assistance with personal care, heart failure, pain, disease of the spinal cord, Parkinsonism (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), insomnia (inability to sleep), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder. R17's Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had intact cognition and no signs or symptoms of delirium (sudden severe confusion, disorientation, and restlessness) or psychosis (any major mental disorder characterized by a gross impairment in reality perception). The MDS documented R17 had no behavioral symptoms and further documented R17 denied thoughts of being better off dead or hurting herself in some way. The Psychosocial Well-Being Care Area Assessment (CAA), dated 12/20/23, documented risk factors to include decreased socialization, worsening depression, and anxiety. R17's Care Plan, documented interventions dated 01/30/23 that noted R17 used antianxiety and antidepressant medications that had a black box warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration). R17's Care Plan directed staff to administer medications as ordered. R17's Care Plan dated 12/06/23 noted R17 had mood, behavior, and psychosocial problems. The plan noted R17 could be manipulative, and attention-seeking at times, and was known to fabricate stories. The plan directed staff to administer medications as ordered and allow R17 to voice concerns regarding life and physical and emotional challenges. The plan documented R17 received mental health counseling and directed staff to praise any indication of progress and improvements in behaviors. The Social Service Assessment, dated 05/11/23, documented R17's significant life events including her parents' home burned down. R17 had a traumatic birth experience and a history of unsettled relationships. The assessment documented R17 had a close family member sent to jail, had serious financial problems, a serious physical or mental illness. The assessment documented R17 had been emotionally abused, neglected, had an abortion or miscarriage at age [AGE], had seen violence between family members, been robbed, mugged, or physically attacked. The assessment further documented R17 had been abused and physically attacked and had touched or was made to touch someone else in a sexual way because she forced her in some way or threatened to harm her or someone else if did not before and after age [AGE]. The resident reported the specific time of year which made it more difficult was Christmas, and the scent of pine trees, and Christmas cookies. R17 informed the assessor that talking with her granddaughter helped and the granddaughter could be contacted when anxious. R17 said listening to music was calming. R17's clinical record lacked evidence the assessment was used to develop interventions that addressed the identified areas of past trauma, potential triggers, and interventions to mitigate ongoing or recurring traumatization. A Progress Note dated 11/01/23 at 02:50 PM documented Administrative Staff A spoke with R17 after Activity Staff Z reported R17 was giving away her belongings and felt taken advantage of. The note documented R17 had been crying and reported being raped throughout her life and by a family member; R17 reported she had a baby at age [AGE] and was ready to snap. The note documented R17 further reported she did not feel secure in her head, and she reported trying to kill herself while she was in jail by hanging a sheet from a pipe. R17 said she was sad and if she had a pistol or a shotgun, she would shoot herself. The note documented R17 stated she woke up that morning feeling suicidal, sad and that she was not the same person she was a few days before. the note documented R17 told Administrative Staff A that R17 stated she would throw herself off the biggest building in Topeka. R17 told Administrative Staff A that R17's best friend had killed herself. The note documented R17 was difficult to follow, changed topics quickly, and avoided attempts to redirect back to current feelings and thoughts. A Progress Note, dated 11/01/23 at 08:11 PM documented Administrative Staff A and Administrative Nurse D met with R17 at 02:50 PM about R17's statements made earlier to Administrative Staff A. R17 was much calmer and was able to carry on an appropriate conversation. The note documented R17 reverted to things that happened in her past. The staff allowed R17 to revisit her thoughts and feelings and then redirected her to the present and how she felt at that time. Staff assured R17 the nurse practitioner would be in the facility that day and would visit R17. A Progress Note, dated 11/01/23 at 10:23 PM, documented Consultant Nurse Practitioner (NP) JJ arrived at the facility at approximately 06:00 PM and visited extensively with R17. Consultant NP JJ prescribed Ativan (antianxiety medication) 0.5 milligrams (mg) to 1 mg every eight hours as needed for anxiety. A Progress Note, dated 11/03/23, documented R17 could change counseling providers and the intake was scheduled for Tuesday at 08:00 AM. R17's clinical record lacked the provider notes from Consultant NP JJ for the visit on 11/01/23. R17's clinical record lacked evidence the facility did anything in response to R17's expressions of suicidal intent and/or ideation other than talking to her and setting up counseling sessions for the following week. The record lacked documentation of any safety or protective interventions initiated. The record lacked evidence of person-centered interventions to address the suicidal ideation or the history of traumatic experiences. The facility was unable to provide any evidence of the above upon request. A Progress Note, dated 11/05/23 at 02:08 PM documented R17 texted her texted her representative and said she was having min-strokes and would not make it through the day. The note documented that R17 felt her Parkinson's was progressing and R17 was seeing her dead mother at night and during the day for the last week and continued to talk to other staff about her paranoid ideations. A 'Progress Note, dated 12/08/23 at 11:12 AM documented R17 stated she felt as if her heart were going to explode. R17's vital signs were withing normal limits, and R17 said she believed the cause was stress. She stated she was stressed about her money situation and asked for her as needed antianxiety medication. A Progress Note, dated 12/18/23 at 07:02 PM documented R17 remained in isolation in her room. She was tearful and stated she was lonely. She complained of feeling fatigued but denied any other symptoms. She rested in bed and was up in a chair and listened to music. On 01/23/24 at 10:01 AM observation revealed R17 walked with assistance to the bathing room. R17 had a soft voice and movement consistent with Parkinsonism. On 01/24/24 at 01:33 PM, Certified Nurse Aide (CNA) M reported R17 was anxious and cried a lot. CNA M stated R17 was difficult to understand which made it difficult to figure out what was upsetting her. CNA M stated R17 had not been sleeping well. CNA M stated he tried to be a good listener and spend time with R17 which was helpful per CNA M. CNA M stated he did not know where to find information regarding specifics about R17's past or what triggers might upset her. On 01/25/24 at 12:11 PM, Certified Medication Aide (CMA) R reported R17 got anxious or agitated at times and when that happened, staff just gave R17 some space. CMA R reported the only thing she knew about R17's past was that R17 may have had a granddaughter who died. CMA R stated she had never heard R17 talk about self-harm. CMA R said she felt that knowing R17's history of trauma and specific triggers would help staff provide R17 care and help staff know what to do when R17 was upset. On 01/24/24 at 01:55 PM, Licensed Nurse (LN) G reported R17 presented with anxiety and behaviors. LN G reported R17 had been extremely anxious and requested as-needed antianxiety medication as soon as she could have it. LN G stated she did not know if R17's Care Plan included matters related to her R17's history of trauma or if it included any triggers and interventions for staff to know how to provide care to R17. LN G stated she had only worked in the facility for a few months and had not yet had time to read R17's Care Plan. On 01/24/24 at 04:40 PM, Administrative Nurse D stated she was not aware of R17's Social Service Assessment done in May 2023. Administrative Nurse D reported R17 had shared her history of substance abuse and that she had to steal food and sell her body for drugs. Administrative Nurse D stated R17 attempted to manipulate situations for whatever she was seeking, like the use of as-needed medications. Administrative Nurse D verified information from the assessment would help staff provide care to R17. Administrative Nurse D stated that knowing R17's triggers now explained why R17 had increased her use of as-needed antianxiety medications to almost daily in December 2023. On 01/25/24 at 12:16 PM, Administrative Staff A reported that as soon as she learned R17 had voiced thoughts of self-harm, Administrative Staff A and Administrative Nurse D went and talked to the resident and stayed with R17. Administrative Staff A stated she removed a pair of scissors from R17's room but nothing else. Administrative Staff D stated Consultant NP JJ came to the facility right away and spent a significant amount of time with R17. Administrative Staff A stated Consultant NP JJ told facility staff that she felt R17 was not going to harm herself and that R17 was just upset and made a mistake when she stated she was going to harm herself. Administrative Staff A verified the facility lacked documentation to support the conclusion that R17 would not harm herself. Upon request, the facility did not provide a policy related to trauma informed care. The facility's failure to identify and implement person-centered interventions to address the psychosocial well-being for R17, who had an extensive history of trauma, placed R17 in immediate jeopardy. The facility implemented the following actions to address the immediacy: R17 was interviewed on 01 /25/24 for current thoughts of harmful self and plan to execute. R17 denied any thoughts of self-harm or a plan to execute. R17 had a trauma-informed care assessment completed on 01/26/24 to identify experiences, triggers, stressors, and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. On 01/26/24 the facility scheduled the mental health counseling service provider to visit with R17. R17 was placed on 30-minute checks on 01/25/24 to be monitored by nursing staff for statements of self-harm or usual behaviors with immediate escalation to the licensed staff. Staff received education on 01/25/24 on monitoring for self-harm statements and usual behaviors with physician notification if indicated. Nursing initiated monitoring of R17 for mood and behavior changes, statements of self-harm, and usual behaviors each shift beginning 01/25/24 with physician notification of any changes. The resident would be placed on one on one if self-harm is identified. R17's Care Plan was revised to reflect traumatic experiences, triggers, de-escalation, and interventions on 01/26/24 based on the current assessment to minimize triggers and/or re-traumatization. On 01/29/24, an onsite inspection verified the removal of the immediacy for R17 on 01/26/24. The deficient practice remained at a scope and severity of a G. -The Electronic Medical Record (EMR) documented R14 had diagnoses that included malignant neoplasm (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) of the bladder, foot drop of the right and left foot, other symptoms and signs involving the nervous system and other symptoms and signs involving cognitive functions and awareness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R14 had intact cognition, and no delirium (sudden severe confusion, disorientation, and restlessness) or psychosis (any major mental disorder characterized by gross impairment in reality perception). R14 had verbal behavioral symptoms directed toward others and rejection of care for one to three days during the observation period. R14 was independent with most activities of daily living, had no pain, and received no high-risk medications. The admission Care Area Assessment did not trigger cognitive loss, psychosocial well-being, communication, behavioral symptoms, psychotropic (alters mood or thought) drug use, or functional activities of daily living. R14's Care Plan, dated 01/14/24, documented that R14 was an elopement risk/wanderer, was disoriented to place, attempted to leave the facility unattended, and had impaired safety awareness. The plan documented R14 wandered aimlessly and significantly intruded on the privacy of others. The plan directed staff to distract R14 from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book. The care plan further documented R14 would pack up his belongings, give them to his spouse, and report the items as stolen. The plan directed staff to call R14's spouse when this happened. The plan lacked trauma-informed care interventions. R14's EMR lacked a Social Service Assessment (SAA) on admission and lacked evidence a trauma-informed care assessment was completed. The Progress Note dated 10/20/23 at 03:12 PM, documented R14 approached the nursing home administrator and talked about being upset because he was hard of hearing and had to speak loudly so others thought he was mean, and staff did not like him. R14 was allowed to vent frustrations and staff were available whenever he had concerns and would like to talk. The Progress Note dated 11/24/23 at 04:23 PM, documented R14 was very agitated and confused. R14's spouse was on the phone and R14's conversation and thought process was irrational. R14's spouse instructed staff to walk away and not argue with him. R14 approached a staff member who informed R14 that the staff would not argue with him. Staff told R14 that when he calmed down, the charge nurse would be glad to have a conversation with him. R14 was angry, however, and walked to the dining room for supper. The on-call physician ordered to monitor R14 for changes in mental status changes and if needed, send him to the emergency room to be evaluated. The Progress Note dated 11/27/23 at 02:10 PM followed up on emails received from Veteran Affairs regarding concerns with the resident's behaviors. R14 had not displayed behaviors that were unmanageable by staff. Referral to other facilities made for the possibility of transfer. The Progress Note dated 12/06/23 at 03:13 AM, documented R14 had agitation over medication that had already been administered. The staff attempted to re-orient R14 to the time and situation multiple times and contacted Administrative Nurse D for direction. R14 repeatedly approached the nurse station to ask about his medications. The Progress Note dated 01/07/24 at 10:40 PM, documented R14 was confused thinking he was commanding a warship, giving orders out to troops (staff). R14 had not had any aggravation or aggressive behavior thus far, just expected a response when he gave the orders. Staff tried to redirect, change the conversation, offer a book, drink, and snacks, and call his wife. R14 refused and he went back to commanding the ship, staff continued to have one-on-one staff nearby for observation due to several recent falls. The Progress Note dated 01/12/24 at 12:09 PM, documented R14 was confused, did not know his room, and was door-seeking. Staff offered R14 lunch which he refused and stated food killed him. Staff were unable to redirect. The Progress Note dated 01/15/24 at 12:41 AM, documented R14 wandered to rooms during the shift, and appeared verbally and physically aggressive, but was redirected and interventions became effective. The Progress Note dated 01/15/24 at 05:32 PM, documented R14 was found lying cross-legged in a female resident's bed. Staff attempted to get R14 out of the room without success. R14 stated he was going to stay there, and no one was going to tell him to leave. Staff offered chocolate milk and he agreed to come out. The Progress Note dated 01/18/24 at 04:25 PM, documented R14 had been wandering the facility, was found lying in empty rooms covered up several times that day, and in the employee breakroom. Staff attempted to redirect the resident from rooms marked as under construction and the resident told staff they were in the wrong business. The Progress Note date 01/23/24 at 03:10 AM documented R14 was observed with anxiety and wandering on the unit. R14 heard voices and refused to go back to his room. R14 was redirected when he wandered and calmed. R14 was able to take his medications at bedtime. On 01/23/24 at 09:44 AM observations revealed R14 sat at the commons area next to the dining room looking through a book. On 01/23/24 at 12:21 PM, ongoing observation revealed R14 left the dining room heading down the hall to an unoccupied room where he then laid in the bed and, covered himself up with a blanket. Shortly thereafter he exited that room and went to the hall in which his room was located. R14 went to the end of the hallway, stopped briefly to rest against the wall, opened the clean linen closet door, and then proceeded to the exit door. At the exit, he pushed the exit door until it sounded, then walked away to an empty room next to his room and proceeded to lay in the unmade bed which also had a chair placed on the foot of the mattress/bed. R14 then stretched his legs and pushed the chair to try to make room for his legs. Staff approached R14 and inquired about needing care in his room and he cooperated with the request and returned to his room with staff. On 01/24/24 at 08:32 AM observation revealed R14 had been in the dining room eating breakfast but was not in his room, activity room, or therapy room. Upon inquiring from staff, the staff reported R14 was probably in a bed down the other hall and staff reported this happened all the time. Upon looking surveyor found R14 in an unoccupied room (room [ROOM NUMBER]) lying in a bed covered with blankets. R14 then got out of bed and was asking the staff where the bank was located. Staff reminded the resident his spouse was coming to the facility for a care plan meeting and R14 inquired what happened at the meeting. Staff informed him the meeting was to talk about whether he liked staying in the facility, to which he replied, Well that's a stupid question. On 01/23/24 at 12:21 PM Administrative Nurse E stated R14 wandered, and the facility tried to get a consult for a diagnosis of dementia (progressive mental disorder characterized by failing memory, and confusion) dementia to be able to place the resident for possible placement in a dementia unit. On 01/23/24 at 12:51 PM, Certified Nurse Aide (CNA) P reported R14 wandered and constantly went into other residents' rooms and had to be redirected, which sometimes made the resident frustrated. CNA P stated staff had been directed to call his wife if he was looking for her or his wallet. CNA P stated to address the resident as Sir as he served in the military. On 01/24/24 at 01:31 PM, Licensed Nurse (LN) G stated R14 had behaviors that varied from day to day. LN G verified R14 wandered into other resident rooms and empty rooms. LN G stated staff tried to keep an eye on him for his safety. LN G also stated he was easily agitated, had a long history in the military and his family had reported increased confusion at night. LN G stated R14 had an increase in an antidepressant and the primary physician was to set an appointment for a psych consult and would call the facility when this was arranged. LN G reported R14 liked to sit by the dining room and look at books, she was not aware of a trauma-informed care assessment or care plan problem which addressed this. On 01/24/24 at 04:27 PM, Administrative Nurse D stated R14 lacked a dementia diagnosis upon admission. The resident's wife could no longer take care of him due to her medical needs. Administrative Nurse D was not aware if a trauma assessment had been completed but said she knew R14 had a military history. Upon request, the facility did not provide a trauma-informed care policy. The facility failed to ensure R14 received trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident which placed the resident at risk for unmet behavioral health care needs.- The Electronic Medical Record (EMR) for R4 documented diagnoses of PTSD, Alzheimer's disease (a progressive mental disorder characterized by failing memory, confusion), and dementia (progressive mental disorder characterized by failing memory, confusion.) The Quarterly Minimum Data Set, dated 11/17/23, documented R4 had severely impaired cognition and required extensive assistance from two staff for activities of daily living (ADLs). The MDS further documented R4 had no physical behaviors and received antianxiety (class of medications that calm and relax people) medication. R4's EMR documented a Social Service Life Stressor Assessment completed for R4 on admission on [DATE]. The assessment documented the resident had witnessed violence, experienced inappropriate sexual experiences, and had been divorced. R4's Care Plan, dated 11/23/23, documented R4 had current and/or historical psychosocial events that affected his mood and behavior due to his time in the military. The plan directed staff to assist the resident from the room should there be a movie on the TV about the war. The care plan lacked any further interventions related to the Life Stressor Assessment triggers. The Physician's Order, dated 10/23/23, directed staff to administer lorazepam (antianxiety medication) oral concentrate 2 milligrams (mg) per milliliter (ml), administer 0.5 ml every two hours as needed for restlessness or anxiousness. A Nurse's Notes, dated 01/25/24 at 06:10 PM, documented R4 had no thoughts of self-harm. He was in a pleasant mood and felt safe. On 01/24/24 at 11:10 AM, Administrative Nurse D verified a care plan had not been developed to address R4's PTSD despite the trauma-informed care assessment completed on admission showed a history of trauma. Upon request, a policy for PTSD/Trauma Informed Care was not provided by the facility. The facility failed to ensure R4, who was diagnosed with PTSD, received trauma-informed care and services for his behavioral health needs This placed the resident at risk for unmet behavioral health care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 18 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to implement immediate protective measures when Resident (R) 17 verbalized suicidal intent and/or ideations. The facility further failed to assess R17's underlying causes of distress and failed to implement person-centered interventions to address the distress and prevent recurring or ongoing distress. On 11/01/23 R17 told Activity Staff Z about her history of traumatization, previous suicide attempts, and her feelings of wanting to shoot herself or jump to her death. R17 cried and shared the reasons she felt this way with Activity Staff Z. Activity Staff Z told Administrative Staff A. At 02:45 PM Administrative Staff A and Administrative Nurse D spoke with R17 who confirmed the information. Staff then alerted R17's physician and removed some scissors from R17's room but did not remove all potentially harmful items or place R17 under enhanced monitoring despite her statements of suicidal intent. After visiting with her provider on 11/01/23 at 06:00 PM, R17 received new orders for psychotropic medications but no nonpharmacological interventions were identified or developed to address R17's source of distress or suicidal ideation. This failure placed R17 in immediate jeopardy. Findings included: - R17's Electronic Medical Record (EMR) recorded diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), dysphagia (swallowing difficulty), need for assistance with personal care, heart failure, pain, disease of the spinal cord, Parkinsonism (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), insomnia (inability to sleep), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder. R17's Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had intact cognition and no signs or symptoms of delirium (sudden severe confusion, disorientation, and restlessness) or psychosis (any major mental disorder characterized by a gross impairment in reality perception). The MDS documented R17 had no behavioral symptoms and further documented R17 denied thoughts of being better off dead or hurting herself in some way. The Psychosocial Well-Being Care Area Assessment (CAA), dated 12/20/23, documented risk factors to include decreased socialization, worsening depression, and anxiety. R17's Care Plan, documented interventions dated 01/30/23 that noted R17 used antianxiety and antidepressant medications that had a black box warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration). R17's Care Plan directed staff to administer medications as ordered. R17's Care Plan' dated 12/06/23 noted R17 had mood, behavior, and psychosocial problems. The plan noted R17 could be manipulative, and attention-seeking at times and was known to fabricate stories. The plan directed staff to administer medications as ordered and allow R17 to voice concerns regarding life and physical and emotional challenges. The plan documented R17 received mental health counseling and directed staff to praise any indication of progress and improvements in behaviors. The Social Service Assessment, dated 05/11/23, documented R17's significant life events including her parents' home burned down. R17 had a traumatic birth experience and a history of unsettled relationships. The assessment documented R17 had a close family member sent to jail, had serious financial problems, a serious physical or mental illness. The assessment documented R17 had been emotionally abused, neglected, had an abortion or miscarriage at age [AGE], had seen violence between family members, been robbed, mugged, or physically attacked. The assessment further documented R17 had been abused and physically attacked and had touched or was made to touch someone else in a sexual way because she forced her in some way or threatened to harm her or someone else if did not before and after age [AGE]. The resident reported the specific time of year which made it more difficult was Christmas, and the scent of pine trees, and Christmas cookies. R17 informed the assessor that talking with her granddaughter helped and the granddaughter could be contacted when anxious. R17 said listening to music was calming. A Progress Note dated 11/01/23 at 02:50 PM documented that Administrative Staff A spoke with R17 after Activity Staff Z reported R17 was giving away her belongings and felt taken advantage of. The note documented R17 had been crying and reported being raped throughout her life; R17 reported she had a baby at age [AGE] and was ready to snap. The note documented R17 further reported she did not feel secure in her head, and she reported trying to kill herself while she was in jail by hanging a sheet from a pipe. R17 said she was sad and if she had a pistol or a shotgun, she would shoot herself. The note documented R17 stated she woke up that morning feeling suicidal. A Progress Note, dated 11/01/23 at 08:11 PM documented Administrative Staff A and Administrative Nurse D met with R17 about her statements made earlier to Administrative Staff A. R17 was much calmer and was able to carry on an appropriate conversation. The note documented R17 reverted to things that happened in her past. The staff allowed R17 to revisit her thoughts and feelings and then redirected her to the present and how she felt at that time. Staff assured R17 that the nurse practitioner would be in the facility that day and would visit R17. A Progress Note, dated 11/01/23 at 10:23 PM, documented Consultant Nurse Practitioner (NP) JJ arrived at the facility at approximately 06:00 PM and visited extensively with R17. Consultant NP JJ prescribed Ativan (antianxiety medication) 0.5 milligrams (mg) to 1 mg every eight hours as needed for anxiety. A Progress Note, dated 11/03/23, documented R17 could change counseling providers and the intake was scheduled for Tuesday at 08:00 AM. R17's clinical record lacked the provider notes from Consultant NP JJ for the visit on 11/01/23. R17's clinical record lacked evidence the facility did anything in response to R17's expressions of suicidal intent and/or ideation other than talking to her and setting up counseling sessions for the following week. The record lacked documentation of any safety or protective interventions initiated. The record lacked evidence of person-centered interventions to address the suicidal ideation or the history of traumatic experiences. The facility was unable to provide any evidence of the above upon request. On 01/23/24 at 10:01 AM observation revealed R17 walked with assistance to the bathing room. R17 had a soft voice and movement consistent with Parkinsonism. On 01/24/24 at 01:33 PM, Certified Nurse Aide (CNA) M reported R17 was anxious and cried a lot. CNA M stated R17 was difficult to understand which made it difficult to figure out what was upsetting her. CNA M stated R17 had not been sleeping well. CNA M stated he tried to be a good listener and spend time with R17 which was helpful per CNA M. CNA M stated he did not know where to find information regarding specifics about R17's past or what triggers might upset her. On 01/25/24 at 12:11 PM Certified Medication Aide (CMA) R reported R17 got anxious or agitated at times and when that happened, staff just gave R17 some space. CMA R reported the only thing she knew about R17's past was that R17 may have had a granddaughter who died. CMA R stated she had never heard R17 talk about self-harm. CMA R said she felt that knowing R17's history of trauma and specific triggers would help staff provide R17 care and help staff know what to do when R17 was upset. On 01/24/24 at 01:55 PM, Licensed Nurse (LN) G reported R17 presented with anxiety and behaviors. LN G reported R17 had been extremely anxious and requested as-needed antianxiety medication as soon as she could have it. LN G stated she did not know if R17's Care Plan included matters related to her R17's history of trauma or if it included any triggers and interventions for staff to know how to provide care to R17. LN G stated she had only worked in the facility for a few months and had not yet had time to read R17's Care Plan. On 01/24/24 at 04:40 PM, Administrative Nurse D stated she was not aware of R17's Social Service Assessment done in May 2023. Administrative Nurse D reported R17 had shared her history of substance abuse and that she had to steal food and sell her body for drugs. Administrative Nurse D stated R17 attempted to manipulate situations for whatever she was seeking, like the use of as-needed medications. Administrative Nurse D verified information from the assessment would help staff provide care to R17. Administrative Nurse D stated that knowing R17's triggers now explained why R17 had increased her use of as-needed antianxiety medications to almost daily in December 2023. On 01/25/24 at 12:16 PM, Administrative Staff A reported that as soon as she learned that R17 had voiced thoughts of self-harm, Administrative Staff A and Administrative Nurse D went and talked to the resident and stayed with R17. Administrative Staff A stated she removed a pair of scissors from R17's room but nothing else. Administrative Staff D stated Consultant NP JJ came to the facility right away and spent a significant amount of time with R17. Administrative Staff A stated Consultant NP JJ told facility staff that she felt R17 was not going to harm herself and that R17 was just upset and made a mistake when she stated she was going to harm herself. Administrative Staff A verified the facility lacked documentation to support the conclusion that R17 would not harm herself. Upon request, the facility did not provide a policy related to responding to acute behavioral crises or suicidal ideation and/or attempts. The facility failed to implement immediate protective measures when R17 verbalized suicidal intent and/or ideations. The facility further failed to assess R17's underlying causes of distress and failed to implement person-centered interventions to address the distress and prevent recurring or ongoing distress. This failure placed R17 in immediate jeopardy. The facility implemented the following actions to address the immediacy: R17 was interviewed on 01 /25/24 for current thoughts of harmful self and plan to execute. R17 denied any thoughts of self-harm or a plan to execute. R17 had a trauma-informed care assessment completed on 01/26/24 to identify experiences, triggers, stressors, and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident. On 01/26/24 the facility scheduled the mental health counseling service provider to visit with R17. R17 was placed on 30-minute checks on 01/25/24 to be monitored by nursing staff for statements of self-harm or usual behaviors with immediate escalation to the licensed staff. Staff received education on 01/25/24 on monitoring for self-harm statements and usual behaviors with physician notification if indicated. Nursing initiated monitoring of R17 for mood and behavior changes, statements of self-harm, and usual behaviors each shift beginning 01/25/24 with physician notification of any changes. The resident would be placed on one on one if self-harm is identified. R17's Care Plan was revised to reflect traumatic experiences, triggers, de-escalation, and interventions on 01/26/24 based on the current assessment to minimize triggers and/or re-traumatization. On 01/29/24, an onsite inspection verified the removal of the immediacy for R17 no 01/26/24. The deficient practice remained at a scope and severity of a D.

The facility identified a census of 25 residents. The sample included three residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure staff immediately reported allegations of abuse to the facility administrator. On 10/07/23 at approximately 04:45 PM Dietary Staff (DS) CC heard a loud verbal interaction between Administrative Nurse D and Resident (R)1 which DS CC perceived as verbal abuse. DS CC reported the alleged verbal abuse to DS BB on the evening of 10/08/23 and DS BB reported the event to Administrative Staff A on 10/09/23 at approximately 06:10 AM, almost two days later. Certified Nurse Aide (CNA) M also perceived the interaction as alleged abuse but did not report to the facility administrator because CNA M did not know who to report to, in Administrative Staff A's absence. On 10/08/23 at approximately 06:00 PM Activity Staff Z noted R3 was upset by an interaction which alleged verbal abuse or mistreatment by Administrative Nurse D to R3 earlier that day,10/08/23, though Activity Staff Z did not alert the facility administrator until 10/09/23 at approximately 10:10 AM, more than 16 hours later. The facility staff failed to identify potential abuse and report immediately to the facility administrator. This deficient practice placed R1 and R3 in immediate jeopardy. Findings included: - The facility reported incident on 10/09/23 documented incidents occurring on 10/07/23 and 10/08/23. The report alleged on 10/07/23 DS CC heard R1 yelling. DS CC looked up and saw Administrative Nurse D yelling at R1 to stop reading his book. Administrative Nurse D grabbed for R1's book and R1 yelled Don't touch my books. The incident report noted DS CC also heard Administrative Nurse D say that R1 did not know what he was talking about and told R1 that his spouse was not present. The report documented DS CC did not intervene at that time but the next day, on 10/08/23, DS CC told DS BB about the incident. The report noted that on 10/09/23 at 06:00 AM DS BB told Administrative Staff B of the alleged verbal abuse and Administrative Staff B instructed DS BB to inform Administrative Staff A of the allegation. The report further documented that on 10/08/23 at the noon meal, Administrative Nurse D raised her voice to R3. Administrative Nurse D was suspended, and an investigation was started. R1's Electronic Medical Record (EMR) documented a Nurse's Note dated 10/11/23 at 12:18 PM, late entry, which recorded that staff reported to Administrative Staff A an allegation of abuse perpetrated by a staff member. R3's EMR documented a Nurse's Note dated 10/09/23 at 03:22 PM which recorded staff talked with R3 about an incident from the weekend. R3 stated she was all right now. The note indicated R3 notified her family about the allegation and staff asked R3 if she wanted her physician to be notified about the incident and R3 stated No. Review of CNA M's notarized Witness Statement dated 10/16/23 documented on 10/08/23 Administrative Nurse D screamed at R1, because R1 was interrogating R2. Review of DS CC's undated, unnotarized Witness Statement, revealed DS CC worked on 10/07/23 at 04:45 PM. DS CC noted she heard R1 yelling and looked up to see what was going on. DS Cc noted Administrative Nurse D yelled at R1 about his spouse and his book and tried to grab R1's book. R1 told Administrative Nurse D to not touch his book and Administrative Nurse D told R1 he did not know what he was talking about, and his spouse was not present. DS CC recorded that R1, and Administrative Nurse D had several loud interactions, but she could not hear what it was all about. Review of DS BB's undated, unnotarized Witness Statement, revealed DS BB noted that DS CC told him on 10/08/23 that Administrative Nurse D yelled at R1, and that DS CC heard it all the way into the kitchen. Review of Administrative Staff B's undated, unnotarized Witness Statement, revealed that on 10/09/23 Administrative Staff B was informed by DS BB that DS CC heard Administrative Nurse D yelling at R1 on 10/07/23. Review of Administrative Nurse D's unnotarized Witness Statement, dated 10/09/23 documented R1 and R2 sat at a dining room table in a loud argument over who had served the most years in the service. Administrative Nurse D documented she approached the table and attempted to explain that the residents could sit anywhere. Administrative Nurse D reached out and touched R1's book. R1 stated Administrative Nurse D could not take his book. Review of another unnotarized Witness Statement, dated 10/09/23 by Administrative Nurse D documented that Administrative Nurse D heard R3 talking with an unknown visitor about the staff working that day. R3 told the unknown visitor there was only one CNA that came to work and R3 held up one finger repeating just one CNA to take care of all of the residents. At this point, Administrative Nurse D approached R3 and the unknown visitor and explained to both that there were enough staff to take care of the residents in the building. Administrative Nurse D stated there were six nursing staff in the building to assist with the 24 residents including licensed nurses and Administrative Nurse D acknowledged there was only one CNA. Review of Activity Staff Z's unnotarized Witness Statement, which lacked a date, documented on 10/08/23 at approximately 06:00 PM, R3 seemed upset. R3 explained to Activity Staff Z that Administrative Nurse D told both R3 and her visitor that there was enough coverage for the residents. R3 stated she was very embarrassed when Administrative Nurse D told her and her visitor that information. Activity Staff Z further documented on 10/09/23, the following day, at approximately 09:15 AM she went to R3's room and noted R3 was almost in tears and stated R3 was fearful that Administrative Nurse D might make living there uncomfortable with a retaliation. On 10/16/23 at 11:03 AM R1 sat on his bed reading a book. R1 appeared well groomed. R1 was hard of hearing, but when the speaker raised her voice R1 could hear what was being said. R1 could not recall anything that happened with a female staff member, but if it had happened it was taken care of now. R1 further stated he no longer saw that female staff member and that was ok by R1. On 10/16/23 at 01:20 PM R3 sat in her wheelchair. She appeared well groomed and was in good spirits. R3 stated that she was humiliated and did not like getting yelled at in the dining room by Administrative Nurse D. R3 further stated she wanted to know why Administrative Nurse D was eavesdropping on R3's conversation with her visitor. On 10/16/23 at 01:25 PM CNA M stated she was told to report concerns about abuse to Administrative Nurse D or Administrative Staff A. CNA M said since the concern was with Administrative Nurse D, she would have called Administrative Staff A, but Administrative Staff A was out of town. CNA M did not have Administrative Staff A's phone number and she did not know where to find it. CNA M further revealed she was taught to go up the ladder with any concerns but she did not have the contact numbers for Administrative Staff A or any above Administrative Staff A. On 10/16/23 at 03:40 PM Administrative Staff A stated she knew what happened was not good, but Administrative Nurse D claimed she did not yell at the residents. The facility's Abuse, Neglect, and Exploitation policy, lacking a date, documented the resident has a right to be free from verbal, sexual, physical, and mental abuse, and involuntary seclusion. It is the policy of Medicalodges, Inc., to treat each resident with respect, kindness, dignity, and care, to keep them free from abuse and neglect and to take swift action to investigate and adjudicate alleged resident abuse and neglect. Mental abuse includes, but is not limited to, verbal or non-verbal conduct which causes or has the potential to cause humiliation, intimidation, fear, shame, agitation, degradation, harassment or threats of punishment or deprivation. The facility failed to identify, and report alleged abuse which delayed investigation, protective measures, and increased the potential of impaired psychosocial well-being due to potential prolonged abuse, or mistreatment for the affected residents. The facility implemented the following corrective actions on 10/09/23: All staff were educated on Abuse, Neglect, and Exploitation including identifying and reporting to Administrative Staff any allegations of abuse. Administrative Nurse D was suspended and upon completion of Abuse, Neglect, and Exploitation education prior to working. Due to the fact all corrective actions were completed prior to the onsite investigation, the deficient practice was deemed past non-compliance at a J scope and severity.