**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 27 residents, with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 2 and R1 remained free from verbal and mental abuse. This placed R2 and R1 at risk for continued abuse, embarrassment, humiliation, and decreased quality of life due to impaired psychosocial well-being. Findings included: - R2 ' s Electronic Medical Record (EMR) documented R2 had diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and pain. R2's Quarterly Minimum Data Set, (MDS) dated [DATE], documented R2 had a Brief Interview for Mental Status score of 15, which indicated intact cognition. The MDS documented R2 had an indwelling urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag) and was always incontinent of bowel. The MDS documented R2 as dependent on staff for all his activities of daily living (ADL) except for eating. The ADL Functional/Rehabilitation Potential Care Area Assessment, (CAA) dated 12/23/24, documented R2 as at risk for continued functional decline due to his diagnosis of MS and chronic pain. R2 was dependent on staff assistance for ADLs, including transfers and hygiene needs. R2 could feed himself finger foods but usually required staff assistance with his meals. R2 had severe contractures (abnormal fixation of the joints or muscles) of his hands and legs due to MS. R2 ' s Care Plan interventions dated 10/06/23 directed staff to know R2 was incontinent of bowel and staff were to check and change R2 every two to three hours. The plan directed staff to not rush R2, allow extra time to complete ADLs, and have a consistent approach among caregivers. The plan directed staff to allow R2 to have control over situations, establish a trusting relationship with R2, and encourage R2 to become involved in social interactions. The Facility Incident Report, dated 05/28/25, documented on 05/26/25, R2 was scheduled to have a bath. Certified Nurse Aide (CNA) O had two orientees, CNA P and CNA Q, go with her to R2 ' s room to train them on how to transfer and bathe R2. The report documented CNA P reported while they assisted R2 in his bed, R2 was incontinent of stool, which was normal for him. The report documented CNA O stated to R2, You are going to clean my shoes, you are going to buy me new shoes, you need to stop pooping so we can get you in the shower chair, and Oh, that ' s great. You ' re still pooping. The report documented R2 apologized repeatedly. The report noted after R2 ' s shower, the CNAs transferred R2 back to his room in the shower chair, CNA O stopped at the nurse ' s desk and told the staff present R2 pooped in the bathhouse, and it needed to be cleaned up. The report recorded R2 was interviewed and stated he felt embarrassed by what CNA O said to him. The report documented after questioning, CNA O admitted she said some of the things reported, but she was joking, and said she felt R2 knew she was joking. The report documented the facility terminated CNA O from employment. CNA P ' s Witness Statement, notarized on 05/27/25, documented at 03:00 PM, CNA O, CNA P, and CNA Q were getting R2 up for his shower. The statement noted when staff placed R2 in the lift sling, R2 began having bowel movements. CNA P stated CNA O started making remarks to R2 stating, You are going to clean my shoes, and You are going to buy me new shoes. CNA P stated CNA O kept repeating the comments and R2 kept saying, I ' m so sorry girls. CNA P documented CNA O glared at R2 whenever he looked at her. CNA P documented that CNA O then said, You need to stop pooping so we can get you in the shower, and Oh that ' s great. You are still pooping. CNA P noted the three CNA staff got R2 cleaned up and into the shower, R2 started to have incontinent stools again, and CNA O stated, You need to stop pooping. It ' s going all over the place,. CNA O kept giving R2 dirty looks. CNA P wrote when CNA O finished with R2 ' s shower, CNA O pushed R2 back to his room and then stopped at the nurse ' s desk and announced in front of everyone that R2 pooped again after the shower, and it needed to be cleaned up. CNA O ' s Witness Statement, notarized on 05/27/25, documented on 05/26/25 she assisted R2 to the shower. CNA O wrote she showed the other CNAs how to get R2 into the shower chair, R2 was incontinent of bowel movement at that time and asked if it got on their shoes. CNA O noted she jokingly replied, Yes, but they are washable and everyone laughed. CNA O documented that R2 kept apologizing, and CNA O reassured R2 that it was okay because her shoes and clothes were washable. On 06/02/25 at 11:30 AM, R2 sat up in bed with a neck pillow behind his neck and watched a program on his iPad. R2 had contractures to his bilateral hands but was able to use a stylus to run the iPad. R2 stated he had no control over his bowels and when staff assisted him up in the lift for transfers, he was always incontinent of stool. R2 confirmed the things CNA O said to him, and he stated she made him feel bad and humiliated in the shower room that day. R2 said everyone else at the facility treated him very well. On 06/02/25 at 11:45 AM, CNA P stated that R2 was such a sweet man, and he had no control over his bowels due to his diagnosis of MS. CNA P stated that making R2 feel bad for something he had no control over was wrong. CNA P stated she recently received education on ANE and reporting suspected abuse or neglect immediately. On 06/02/25 at 11:55 AM, Administrative Nurse D stated there were several times CNA O would say things to other staff, would have to be redirected not to say things like that, then she would say she was just joking. Administrative Nurse D stated at first, CNA O would not admit what she said to R2, but then CNA O did finally admit what she said after she already filled out her Witness Statement. Administrative Nurse D stated this kind of behavior of staff degrading residents would not be tolerated by any of the staff working at the facility, CNA O was terminated from employment, all staff were assigned ANE education in Relias (a training portal) and received the education verbally before working their next shift. The facility ' s Abuse, Neglect, and Exploitation Policy, revised 04/12/22, documented the facility had developed and implemented this policy and procedure to prohibit abuse, neglect, exploitation, or misappropriation of property by any perpetrator, including but not exclusive to any staff member or volunteer of the facility or any contracted agency staff, vendors, family member or visitors of the elder or other elders, or any other elders. Facility staff will not allow others to use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. - R1 ' s Electronic Medical Record (EMR) documented R1 had diagnoses of Alzheimer ' s disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, and confusion), major depressive disorder (major mood disorder which causes persistent feelings of sadness), psychosis (any major mental disorder characterized by a gross impairment in reality perception), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), restlessness, and agitation. R1's Significant Change Minimum Data Set (MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. The MDS documented R1 had physical behaviors directed toward others during the observation period. The MDS documented R1 required the use of a wheelchair pushed by staff for locomotion and required maximum staff assistance for all her activities of daily living (ADL). The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 03/24/25 documented R1 had a diagnosis of Alzheimer ' s disease and was alert and oriented to herself only. The CAA noted R1 was placed on hospice care due to Alzheimer ' s disease and was at risk for impaired cognition related to end-of-life care. The CAA documented R1 could become agitated with staff when she was in pain, she required substantial assistance due to total dependence with ADL care and was non-ambulatory. The Psychosocial Well-Being CAA, dated 03/24/25, documented R1 did not do well with groups of people or loud noises and would become agitated. The CAA documented R1 was offered one-on-one activities from staff as she would allow. The Communication CAA, dated 03/24/25, documented R1 ' s diagnoses of Alzheimer ' s disease and major depressive disorder increased R1 ' s risk for impaired communication. The CAA documented R1 was not always able to communicate her needs to staff. The CAA documented R1 typically showed agitation when she needed something. R1 ' s Care Plan documented R1 could have behaviors of cussing and hitting, which typically occurred during baths and bowel movements. The plan directed staff R1 liked to listen and sing to country music (03/27/25). The plan directed staff to explain to R1 step by step what staff were doing when providing care, as this helped calm R1 down to know what was going to happen (11/13/24). The plan directed staff to provide R1 with a calm environment when she was agitated (12/13/23). The plan directed staff to provide R1 maximum to total assistance for all her cares (12/13/23). The Facility Incident Report, dated 05/05/25, documented on 05/01/25 at approximately 07:00 PM, Certified Nurse Aide (CNA) M and CNA N provided peri-care and bedtime care for R1. The report noted R1 became agitated, and CNA N attempted to calm R1 by assuring her cares were almost done. The report documented that CNA M stated, No [R1], I ' m going to make this take longer just to [expletive] you off. The report documented CNA N reported the occurrence to LN G at 07:15 PM and Licensed Nurse (LN) G reported the incident to Administrative Nurse D. The facility told CNA M to immediately exit the facility. The report documented CNA M refused to write a statement and was terminated from employment on 05/02/25. CNA N ' s Witness Statement, notarized on 05/05/25, documented while providing care to R1, CNA M told R1 to shut up. CNA N stated she told R1 they were almost done, and CNA M stated, No, R1. I ' m going to make this take longer just to [expletive] you off. CNA N stated she stayed quiet, she and CNA M exited R1 ' s room together, and CNA N reported the incident to LN G. On 06/02/25 at 10:00 AM, R1 sat in a recliner in the day room, watched a western on TV, and fidgeted in the recliner, restless. R1 would not answer questions or communicate. On 06/02/25 at 10:30 AM, CNA N stated that R1 was easy to take care of and was very sweet. CNA N stated that R1 did not like to be exposed for long periods of time when cares were provided, but if R1 started to get agitated, she was easily redirected. CNA N stated the facility provided education regarding ANE and knew if she saw or heard something, she would report it immediately. On 06/02/25 at 10:45 AM, LN H stated that R1 was easy to care for and easily redirectable. LN H stated she was educated regarding ANE and knew to report any possible instances of abuse immediately to administrative staff and to keep residents safe. On 06/02/25 at 11:30 AM, Administrative Nurse D stated the incident of verbal abuse by CNA M was unacceptable. Administrative Nurse D said CNA M refused to provide a witness statement regarding the incident and refused to talk to administrative personnel about the incident. Administrative Nurse D stated the facility assigned ANE training to all staff in Relias (a training portal), and the facility verbally educated staff on all shifts until all staff were trained. The facility ' s Abuse, Neglect, and Exploitation Policy, revised 04/12/22, documented the facility had developed and implemented this policy and procedure to prohibit abuse, neglect, exploitation, or misappropriation of property by any perpetrator, including but not exclusive to any staff member or volunteer of the facility or any contracted agency staff, vendors, family member or visitors of the elder or other elders, or any other elders. Facility staff will not allow others to use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility identified the above deficient practices and implemented immediate corrective actions, which were all completed on 05/31/25 and included: All nursing staff re-educated on recognizing and reporting abuse, neglect, and exploitation, and the CNA perpetrators were terminated from employment. Due to the corrective action completed before the onsite survey, the citation was deemed past noncompliance at a G scope and severity to represent R2's actual psychosocial harm evidenced by embarrassment and humiliation.

The facility identified a census of 30 residents with three residents reviewed for falls. Based on record review and interview, the facility failed to follow Resident (R) 1's care plan and provide her with the correct supervision resulting in a fall with injury. On 01/05/23 at approximately 07:50 AM, Certified Nurse Aide (CNA) M assisted R1 to the toilet and placed all of R1's clothing in the bathroom with her, and then shut the curtain to the bathroom. R1 reached down to pick up a sock on the floor, fell to her left side, sustained skin tears to her left hand and elbow, a minimally displaced zygomatic arch (the bone that forms the prominent part of the cheek and the outer side of the eye socket) fracture (broken bone), and soft tissue swelling overlying the left orbit (the socket of the skull in which the eye and its appendages are situated). The facility failed to follow R1's care plan which documented the staff were not to leave R1 unattended in the bathroom and R1 required limited to extensive staff assistance for dressing. This deficient practice placed R1 at risk for falls and pain. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of hypertension (high blood pressure), peripheral vascular disease (PVD, abnormal condition affecting the blood vessels), and anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues). The admission Minimal Data Set (MDS), dated 01/03/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS documented R1 required extensive assistance of one staff for toileting, dressing, hygiene, bathing, bed mobility, and transfers. The MDS further documented R1 was unsteady and required staff assistance for stability during transitions (moving from a seated to standing position, walking, turning around and facing the opposite direction, moving on and off the toilet, and surface-to-surface transfers). The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/03/23, documented R1 had forgetfulness and nursing staff were to cue and re-orientate R1 as needed. The Activities of Daily Living (ADL) CAA, dated 01/03/23, documented R1 required limited to extensive assistance with ADLs and was at risk for decline in ADL function, pain incontinence, and falls due to requiring assistance with function of daily cares. The Fall CAA, dated 01/03/23, documented R1 had impaired balance which put R1 at risk for falls. The Fall CAA also documented R1 could make unsafe decisions putting her at risk for falls. The Activities of Daily Living Care Plan, dated 09/26/22, directed staff that R1 required limited to extensive assistance of one to two staff for bed mobility, transfers, ambulation, locomotion, dressing, toileting, hygiene, and bathing. The Decision-Making Care Plan, dated 09/26/23, directed staff to provide R1 supervision with decision making to allow her to be safe and to function at the highest level possible. The Fall Care Plan, dated 12/05/22, directed staff to not leave R1 unattended in the bathroom while she used the toilet. The John Hopkins Fall Risk Scale, dated 01/03/23 documented R1 had a fall risk score of 19 which indicated R1 was a high risk for falls. The Witness Report, dated 01/05/23, documented CNA M stated he was picking up clothes while R1 got dressed in the bathroom. While hanging the clothes up, CNA M heard a crash. CNA M stated he turned around and saw R1 on the floor. CNA M turned on the bathroom call light and asked R1 what had happened. R1 told CNA M that she was reaching for her sock and leaned too far and fell. CNA M noted R1 had newly opened skin tear on the back of her hand. CNA M stated he ran to get the licensed nurse and when they got back to the room blood was pooling under R1's left elbow. CNA M stated that staff took R1's vital signs and sat her in a wheelchair. The Hospital Radiology Report, dated 01/05/23, documented R1 had sustained a minimally displaced left zygomatic arch fracture with soft tissue swelling overlying her left orbit. The Facility Incident Report, dated 01/06/23, documented R1 had a history of falls and was on the shooting star program and staff were to check on R1 frequently. On the morning of 01/05/23, CNA M reported that he was in R1's bedroom and had assisted R1 to the bathroom and onto the toilet. CNA M stated he had placed R1's clothing in the bathroom and closed R1's bathroom curtain for privacy. CNA M reported while R1 was in the bathroom he was hanging up R1's clothing and heard a noise coming from the bathroom. CNA M then observed R1 on the bathroom floor. CNA M notified licensed nursing staff. Licensed nursing staff observed R1 on the bathroom floor on her left side. Licensed nursing staff observed red drainage from R1's left hand and elbow. R1 had range of motion within normal limits and staff assisted R1 to a standing position and was full weight bearing without pain. Staff provided treatment to R1's left arm and elbow and licensed nursing staff noted R1's left eyebrow had bruising and swelling. R1 stated that she was reaching for her sock and leaned forward too far and fell. Neurological checks were initiated, and staff transferred R1 to the local hospital for evaluation. The Nursing Department Communication Form, dated 02/13/23, documented all care plans must be followed as the care plan interventions are stated. If a resident is care planned not to be left unattended whether that be in the bathroom, wheelchair, dining room etc. not leaving unattended entails the following: the nursing staff member must be present at all times. Nursing staff member must always have visualization on the resident. If a resident is not to be left unattended in the bathroom, and the resident requests the bathroom curtain be closed for privacy, and that the staff member resides on the other side of the curtain, nursing staff needs to immediately notify licensed staff by way of activating the call light system and not leaving the resident so that licensed staff can intervene at that time. Licensed staff need to educate and encourage residents that a staff member needs to be present at all times on any item that is mentioned in the care plan that is not to be left unattended. Failure to follow the plan of care can be considered abuse and/or neglect and have disciplinary action. The communication form/education was only signed by CNA M on 02/13/23. On 02/14/23 R1 was unavailable for observation or interview. On 02/14/23, CNA M was unavailable for interview. On 02/14/23 at 11:30 AM, Administrative Staff A reviewed R1's care plan directive which indicated not to leave R1 unattended and said CMA M was still in R1's attendance as he never left her room. Administrative Staff A stated it depended on what definition was used for unattended. On 02/14/23 at 11:35 AM, Administrative Nurse D stated that she expected all of the staff at the facility to follow the residents care plan. Administrative Nurse D verified that education regarding following care plans had only been given to CNA M. The facility's Fall and Fall Risk Policy, revised April 2018, documented staff will identify pertinent interventions to try and prevent falls and to address the risks of significant consequences of falling. Staff will try various relevant interventions until falling reduces or stops or until a reason is identified for fall continuation. The facility failed to provide adequate supervision, ADL assistance, and follow R1's care plan, to prevent a fall with a facial fracture for R1.