**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 25 residents with three residents reviewed for quality of care. Based on record review, observation, and interview, the facility failed to ensure staff implemented care and treatment consistent with standards of care when staff failed to ensure Resident (R)1 received the antibiotic treatment as ordered by the infectious disease physician. On [DATE] R1 readmitted to the facility after an acute hospital stay related to empyema (collection of pus in the pleural cavity related to bacterial pneumonia). Upon readmission, facility staff noted R1's three antibiotic medications did not have a stop date noted. R1's admission paperwork noted multiple times the resident was to continue antibiotics for four weeks, but facility staff did not review the admission paperwork and health information sent by the hospital and failed to contact the ordering physician for clarification. Facility staff called the resident's primary care physician, relayed inaccurate and/or incomplete information, and received orders to continue the antibiotics for seven days and then discontinue. R1's antibiotic treatment stopped on [DATE]. On [DATE] the resident was noted to be pale with his eyes rolled back, he had abnormal vital signs with a blood pressure of 92/53 mmHg (millimeters of Mercury), pulse of 124 BPM (beats per minute), and oxygen saturation of 71-91% on room air. Staff notified the physician and received orders to send R1 to the hospital. R1 was sent to a higher level of care. R1 was admitted to the intensive care unit with respiratory failure due to empyema. R1 expired on [DATE]. The facility's failure to ensure staff provided nursing care and treatment consistent with standards of practice placed R1 in Immediate Jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), hypertension (high blood pressure), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The admission Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of four, which indicated severe cognitive impairment. The MDS further documented R1 required supervision of one staff for bed mobility, transfers, ambulation, locomotion, eating, and personal hygiene. The MDS documented R1 used oxygen as a resident in the facility. The Oxygen Therapy Care Plan, dated [DATE], directed staff to monitor R1 for signs and symptoms of respiratory distress, report to the doctor as needed, and to titrate oxygen settings to keep oxygen saturation above 90 percent (%). The Impaired Cognitive Function Care Plan, dated [DATE], directed staff to monitor/document/report as needed any changes in cognitive function. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated [DATE], documented R1 had a BIMS score of four and had documented physical, verbal, and other behaviors that included wandering and rejection of care during the look back period. The Health Status Note, dated [DATE], documented at 08:43 PM staff called the facility nurse to the bath house to assess R1. When the nurse entered R1 was slouched in the bath chair with drool running down the right side of his face and a slight facial droop. R1 was not responding to questions. R1's vital signs were assessed and measured at the following: blood pressure (BP) 54/34 mm/Hg, pulse 88 beats per minute and respirations 13 breaths per minute. Staff notified R1's representative and she wanted R1 to be seen in the emergency room. Staff notified R1's primary care physician and they ordered to send R1 to the emergency room. At 08:52 PM, R1's vital signs were BP 227/135 mm/Hg, oxygen saturation 77% on six liters of oxygen, pulse bouncing between 110 to 135 beats per minute, and respirations 24 per minute. At 09:04 PM emergency medical system in the building and transported R1 to the hospital. The Health Status Note, dated [DATE] at 03:05 AM, documented the local hospital was transferring R1 to a higher level of care and was waiting for a plane. The Health and Physical Document (H & P), dated [DATE], documented R1 had septic shock (a life-threatening condition caused by a severe localized or system-wide infection) suspected due to right-side empyema. R1's right sided weakness was due to sepsis (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infection which cause inflammation throughout the entire body instead) rather than acute ischemia (decreased supply of oxygenated blood to a body part). The H & P documented R1 was critically ill with accompanied acute impairment of one or more vital organ systems. The hospital Infectious Disease Consult Note, dated [DATE], documented R1 had an infectious process due to due to a right sided empyema and hydropneumothorax (abnormal presence of air and fluid in the pleural space) with a pleural (pertaining to the pleura the thin covering that protects the lungs) drainage catheter (a flexible tube inserted through a narrow opening into a body cavity) in place that was actually a biliary (relating to the bile duct) drain that had migrated to R1's lung. On [DATE] the biliary tube was removed and replaced with an actual chest tube in radiology and the pleural fluid that returned was turbid (cloudy, opaque or thick with suspended matter) and had 30,000 white cells (blood cells that protect against illness and disease) of which 100% were neutrophils (a part of the white blood cell that is an innate part of the immune system). The gram stain (a method used to classify bacterial species) had many neutrophils and a rare gram-positive coccus (type of bacteria). Pleural fluid growth showed moderate growth of Raoultella (type of bacteria), moderate growth of Citrobacter (type of bacteria), and moderate growth of MRSA (methicillin resistant staphylococcus aureus - type of bacteria). R1 had been on vancomycin (antibiotic) and ceftriaxone (antibiotic). R1 also had a urine culture that had greater than 100,000 colonies of white cells of E. coli (type of bacteria). The infectious disease doctor recommended four weeks of antibiotic treatment with cefdinir, Flagyl, and linezolid. The Hospital Progress Note, scanned into R1's EMR under the Misc tab, dated [DATE], documented R1 was seen that morning with his son at his bedside. R1 complained of intermittent right abdominal pain, otherwise no complaints. R1 appeared to be resting comfortably. The report documented R1 was receiving cefdinir 300 milligrams (mg) by mouth twice a day, flagyl 500 mg by mouth every twelve hours, and linezolid 600 mg by mouth twice a day. Recommendations were to continue cefdinir, flagyl and linezolid for four weeks and if R1 did not tolerate them, then they would need to consider intravenous (IV - given through a vein) antibiotics. The Hospitalist Progress Note, under the Misc. tab dated [DATE], documented R1 was somewhat grumpy and wanting to leave the hospital. R1 denied chest pain or shortness of breath. R1's chest tube had been removed and R1 was afebrile. R1 transitioned to oral antibiotics. Tentative plans were for R1 to go to swing bed near his hometown. Antibiotics would be continued(cefdinir, flagyl, and linezolid) for four weeks. The Health Status Note, under Progress Notes tab dated [DATE], documented Administrative Nurse D received a nurse to nurse report regarding R1. The discharging facility nurse reported R1 was admitted for suspected stroke with negative CT (computed tomography) scan and MRI (magnetic resonance imaging). R1 actually had an infection, a urinary tract infection, and this was suspected to be the cause of R1's stroke like symptoms. R1's chest tube and biliary drain was also infected and tested positive for MRSA. R1 had the drain removed and a dressing was in place. The admission Summary Note, dated [DATE], documented R1 was readmitted to the facility at 05:04 PM. R1 returned to the facility via personal vehicle with his son driving. R1 was weak with transfer, but able to stand pivot with one person assist. R1 was alert and oriented to person only. R1's lung sounds were clear throughout all lobes. R1's bowel sounds were active to all quadrants. R1 had no complaints of pain or discomfort. The Discharge Instructions, under the Misc. tab dated [DATE], documented R1 was being discharged to the facility for skilled care with orders for physical therapy, occupational therapy, and speech therapy to see R1. The instructions documented R1 would be on a cardiac diet with no activity restrictions. The discharge instructions ordered the facility to obtain a comprehensive metabolic panel (CMP-lab text) and complete blood count (CBC-lab test) every Monday for three weeks and fax to the discharging physician. The medication orders in the discharge instructions documented R1 would be on cefdinir 300 mg twice a day, Flagyl 500 mg twice a day, and linezolid 600 mg twice a day for infection treatment and prevention. The medication orders did not have a stop date. Administrative Nurse D wrote in beside the orders Times 7 days per primary care physician. The discharge instructions documented R1 was to follow up with the discharging physician and cardiology in two to three weeks and was to follow up with his primary care physician in one to two weeks. R1's EMR documented R1 was given the antibiotics cefdinir, Flagyl, and linezolid twice a day for seven days with the last date administered on [DATE]. The Antibiotic Monitoring Note, dated [DATE], documented R1 was taking cefdinir, Flagyl, and linezolid related to the diagnosis of MRSA in right rib wound. The Antibiotic Monitoring Note, dated [DATE], documented R1 completed his antibiotics that day. A late entry Laboratory Note, dated [DATE], but entered on [DATE], documented a voicemail was left with R1's responsible party stating that lab results were sent to the discharging physician's office and R1's antibiotics were finished. The Health Status Note, dated 08.08.23, documented R1 was pale with his eyes rolling back. His BP was 92/53 mm/Hg, oxygen saturation was 71-91% on room air, and pulse was 124 bpm. R1's primary care physician was notified of R1's status at 08:19 PM and he gave orders to send R1 to the emergency room. The Health Status Note, dated [DATE], documented R1 was transferred to a higher level of care. The Health Status Note, dated [DATE], documented R1's responsible party called to the facility asking questions about R1's antibiotic treatment from his previous hospital admission. The responsible party told the facility the family was under the impression that R1's antibiotics were to be given for four weeks after his discharge from the hospital and the nurse last night stated the antibiotics were only scheduled for seven days. Administrative Nurse D stated that there was no end date for the antibiotics upon R1's return to the facility so she consulted R1's primary care physician on how long R1 was to take the antibiotics and he made the order for seven days. The Hospital Heath and Physical, dated [DATE], documented R1 was transferred to a higher level of care related to acute respiratory failure. After CT results were obtained, it was noted R1 had an empyema to his right lung and recommendations were for a chest tube to be placed and IV fluid resuscitation. The Hospital Consultation Report, dated [DATE], documented R1 was admitted to the hospital with septic shock from empyema and cardiogenic shock (when the heart cannot pump enough blood and oxygen to the brain and other vital organs) from sepsis. The Hospital Progress Note, dated [DATE], documented R1 had septic shock due to empyema, which was improving. The empyema (MRSA, Raoultella and Citrobacter) was due to a mal-positioned cholecystostomy tube (tube to drain fluid from the gall bladder). The empyema was recently evaluated by infectious disease at another hospital and R1 was placed on a four-week regimen of antibiotics. R1 was only administered seven days of antibiotics at the long-term care facility. Once R1 was more stable, will plan on transitioning R1 back to oral antibiotics. The Hospital Discharge Summary, dated [DATE], documented R1 expired on [DATE] at 11:20 AM. On [DATE] at 10:00 AM, Administrative Nurse D stated she had not called the hospital and clarified the antibiotics duration because R1 got to the facility after 05:00 PM and she was the charge nurse that day. Administrative Nurse D stated the discharging physician was not going to follow R1 after his discharge. Administrative Nurse D stated all she was told in the nurse to nurse report was that R1 had MRSA in his biliary tube site and his nares. Administrative Nurse D stated that is what she reported to R1's primary care physician when she called him for an end date on the antibiotics. Administrative Nurse D stated R1's primary care physician stated R1 had probably been on antibiotics while at the hospital so stated to go ahead and continue the antibiotics for seven more days. Administrative Nurse D stated she never read through the other discharge documents the discharging facility had sent until after the family notified the facility R1 was supposed to have been on antibiotics for four weeks. Administrative Nurse D stated she then read the progress notes from the discharging hospital stating antibiotics were to continue for four weeks. On [DATE] at 01:20 PM, Administrative Staff A stated Administrative Nurse D had done nothing that any other nurse would not have done. Administrative Nurse A stated getting a new admission especially late in the day is overwhelming and that she probably would have done the exact same thing as Administrative Nurse D. The facility admission Criteria Policy, revised [DATE], documented the objectives of our admission policy are to provide uniform criteria for admitting residents to the facility, admit residents who can be cared for adequately by the facility, address concerns residents and family have during the admission process, assure that the facility receives appropriate medical and financial records prior to or upon the resident's admission. Prior to or prior to admission the resident's attending physician provides the facility with information needed for the immediate care of the resident including at least: type of diet, medication orders, including as necessary, a medical condition or problem associated with each medication and routine care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment. The facility failed to ensure staff provided nursing care and treatment consistent with standards of practice which placed R1 in Immediate Jeopardy. On [DATE] the facility completed the following corrective actions to address the immediacy for R1: On [DATE] the medical director, nurse consultant, and regional manager were consulted. On [DATE] a report was made with state agency. On [DATE] an admission/readmission checklist was made to include a second nurse check of medication list. A nurse-to-nurse report template was created. On [DATE], added if order clarification is needed and discharge provider is unavailable a temporary order will be obtained from the primary care provider while awaiting clarification from discharge provider. Admission/readmission Audit, including review of hospital discharge paperwork will be completed within 72 hours of admission/readmission by DON and designee. On [DATE] all nurses were educated on a second nurse check of orders from any new admission or readmission. Administrative staff were educated on the admission audit. On [DATE] all nurses were educated on the additions made to the admission/readmission checklist. After the immediacy was removed the deficient practice remained at a scope and severity of G to represent the actual harm to R1.

The facility identified a census of 24 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure residents remained free from verbal and mental abuse and mistreatment. On 08/06/23 at approximately 02:00 AM, Certified Nurse Aide (CNA) M heard Licensed Nurse (LN) G holler at Resident (R)1 shut the [expletive] up or I swear I will kill you. CNA M asked CNA N who she should report the incident to, and CNA N told CNA M to talk to Administrative Nurse D next time CNA M saw her. Five days later, CNA M reported the incident to LN H. Upon receiving the allegation, the facility started an investigation which revealed another resident, R2, reported LN G had yelled and cussed at him. The investigation further revealed other staff heard LN G cussing in the hallways and telling residents to be quiet, then shutting the residents' doors so LN G would not have to hear them yelling, though the staff had not reported this to the facility administrator when it occurred. The facility failed to ensure R1 and R2 were free from staff abuse and mistreatment. This placed R1 and R2 in immediate jeopardy. Findings included: - The Electronic Medical Record (EMR) documented R1 had diagnoses of insomnia (inability to sleep), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), and age-related debility. The admission Minimum Data Set (MDS), dated 05/15/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS documented R1 required limited to extensive assistance with all activities of daily living (ADL) except for eating which was supervision/set-up help. The MDS documented R1 exhibited verbal behaviors directed towards others one to three days during the look back period. The MDS documented R1 had other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, or verbal/vocal symptoms like screaming/disruptive sounds) one to three days during the look back period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/15/23, documented R1 had severe cognitive impairment and required cues for recall. The Behavioral Symptom CAA, dated 05/15/23, documented R1 had behaviors of yelling/screaming and crying. The Behavioral Care Plan, dated 05/22/23, documented R1 had occasional episodes of yelling/screaming and directed staff to analyze key times, places, circumstances, triggers, and what de-escalated R1's behavior and document. The care plan directed staff to assess and anticipate R1's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. The Impaired Cognitive Function Care Plan, dated 05/09/23, directed staff to cue, reorient, and supervise R1 as needed. The care plan directed staff to monitor/document/report as needed any changes in cognitive function specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. The Nurse's Note, dated 06/22/23, documented R1 was in bed and yelling about wanting to get up. R1 stated, I wish I could just go to sleep but I can't. The Mood/Behavior Note, dated 08/06/23 at 01:00 AM, documented R1 yelled help me and please and woke up other residents. R1 exhibited this behavior from 08/05/23 at 07:00 PM to 08/06/23 at 01:00 AM. R1 was in her room, in her recliner watching television. When staff asked R1 what she needed or why she was hollering R1 stated, I don't know or I'm not hollering. Staff told R1 that she was disturbing other residents and R1 stated, No I'm not. Interventions that were tried: food, beverages, pain medication, repositioning, different setting, different staff approaching, and talking to R1. None of the interventions were effective. The Facility Incident Report, dated 08/14/23, documented on 08/10/23 at 07:48 PM Administrative Staff A called Administrative Nurse D to inform her a report was made to the night shift nurse LN H, by CNA M, that LN G yelled at R1 during the night on 08/06/23 at approximately 02:00 AM. CNA M reported she went to the nurses station to ask CNA N to help her with repositioning another resident. While CNA M and CNA N were in the nurse's station, CNA M stated she heard R1 yelling out and LN G went to R1's room and told R1 to Shut the [expletive] up or I swear I am going to kill you. CNA M stated she asked CNA N what she should do since she didn't know who to call or where the information was so turn it in. CNA M stated she did not feel the interaction was appropriate. CNA M stated CNA N told her she should talk to Administrative Nurse D when she saw her next. Administrative Nurse D went to the facility to interview CNA M and educated CNA M on proper Abuse, Neglect, and Exploitation procedure and to call Administrative Nurse D any time with concerns. CNA M then filled out a witness statement. Administrative Nurse D called CNA N to ask what had occurred. CNA N stated she did not remember the statement that was made or the incident that was reported because the night was very busy, and the residents were restless, and she was running around helping a lot of people. Administrative Nurse D called LN G and spoke to her about the incident that occurred. LN G stated she never said anything like that. LN G stated she went to R1's room and told her to use her call light if she needed help because she knew how to use a call light. LN G stated R1 was sitting in her recliner and when LN G left the room, R1 used her call light, and CNA N went into her room to assist her. LN G was placed on suspension while the investigation was pending. LN G had worked one shift after the incident, the night shift of 08/06/23 06:00 PM to 06:00 AM. On 08/11/23 at 09:30 AM, Administrative Nurse D interviewed R1 about the incident that was reported. R1 stated, Yes the nurse yelled at me at supper and then again during the night. Administrative Nurse D asked R1 if she remembered what the nurse said and R1 stated, No I just remember her yelling at me and it making me feel worse. I don't know what I did wrong. Administrative Nurse D assured R1 she did not do anything wrong. When Administrative Nurse D interviewed R1, R1's arms and hands were shaking and Administrative Nurse D assured R1 the facility would protect her and do the right thing, and R1 thanked Administrative Nurse D. On 08/11/23, LN G came to the facility to speak with Administrative Nurse D and to fill out a Witness Statement. LN G told Administrative Nurse D she had a hard time when the residents were restless and when R1 yelled out a lot, LN G had to step away, but she had not yelled or said anything inappropriate to the residents. Administrative Nurse D spoke to three cognitively intact residents. Two of the residents had no problems with LN G. R2 stated LN G had yelled and cussed at him before and he did not like her. R2 denied LN G had been physically mean to him. Administrative Nurse D spoke to CNA N about LN G. CNA N stated LN G got overwhelmed when the residents were crazy and LN G would make comments about wanting to kill herself, but CNA N stated she had never heard LN G be mean to someone when CNA N had been in the room, but LN G would make comments about hating it at the facility and wanting to kill herself. Administrative Nurse D interviewed CMA R, who had recently switched to day shift from night shift. CMA R stated LN G was a very loud person with a horrible potty mouth. CMA R stated she had heard LN G yelling in the halls and cussing about residents. CMA R did not know if the residents heard or understood LN G. CMA R stated LN G would get frustrated and voice her feelings very loud in the hall and there were several nights when a resident was yelling out all night and LN G would go into their room and tell them to be quiet and shut their door so she could not hear them. CMA R stated she would go and open the resident's doors up and check on them or talk to them. CMA R stated there were times she would tell LN G a resident was anxious, and LN G would say she wasn't going to give the resident anything because she did not want them to make them sleep too much and LN G did not want to chemically restrain the residents. CMA R stated LN G did not want to do anything when she was at the facility and would complain all of her shift. On 08/14/23 the facility terminated the employment of LN G. On 08/15/23 at 10:00 AM, observation revealed R1 seated at the dining room table in the commons area coloring in a picture book. On 08/15/23 at 10:00 AM, R1 stated the nurse had yelled at her and growled at her and she was scared, but she was not scared anymore. On 08/15/23 at 11:30 AM, CNA M stated she had heard LN G yell at R1 stating Shut the [expletive] up or I am going to kill you! CNA M stated she did not know what to do about the situation but knew what LN G said was horribly inappropriate and something needed to be done. On 08/15/23 at 12:50 PM, Administrative Nurse D stated the results of the investigation she conducted showed LN G did not have a lot of patience, could be loud and inappropriate in the halls, and LN G did not need to be working with the elderly. Administrative Nurse D stated she expected staff to know the reporting procedure for any alleged abuse and neglect allegations, so the facility could provide safety for the residents. On 08/15/23 at 03:30 PM, Administrative Staff A expressed regret the facility hired LN G and said she expected all staff to know and adhere to the abuse and neglect policy of the facility. The facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating Policy, dated September 2022, documented all reports of resident abuse including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property are reported to the local, state, and federal agencies as required by current regulations and thoroughly investigated by facility management. If resident abuse, neglect, exploitation, misappropriation of resident property must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as within two hours of an allegation involving abuse or results in bodily harm or within 24 hours of an allegation that does not involve abuse or result in bodily harm. The facility failed to ensure R1 and R2 were free from staff abuse and mistreatment. This placed R1 and R2 in immediate jeopardy. On 08/15/23, the onsite surveyor verified the following corrective actions to remove the immediacy for R1 and R2: On 08/10/23 the facility immediately educated CNA M, CNA N, LN H on the process of how to report abuse, neglect, and exploitation. The facility immediately suspended LN G pending the investigation. On 08/10/23 the facility submitted the incident to the State Agency. On 08/11/23 Administrative Nurse D filed a police report. On 08/15/23 Administrative Nurse D reported LN G to Kansas State Board of Nursing Licensing Department. On 08/15/23 the facility emailed all agency staff schedulers the abuse, neglect, and exploitation (ANE) information and what the facility expected of their staff upon entering the facility. On 08/15/23 Administrative Nurse D and Administrative Staff A educated all staff either in person or via phone call about the facility expectations regarding ANE. The facility also gave written warnings to the staff who heard LN G act inappropriately during her shift and failed to report to Administrative Nurse D or Administrative Staff A. On 08/15/23 the facility hung posters in staff areas regarding the proper way to report any suspicion of ANE, provided all residents the same information for self-reporting, and called resident representatives regarding the provided information as well. After the immediacy was removed, the deficient practice remained at the scope and severity of G to represent the isolated, actual harm to R1 as evidence by R1's verbalizations of fear.

The facility identified a census of 24 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview the facility failed to ensure staff identified a situation of verbal and mental abuse and mistreatment as an allegation of abuse and failed to immediately report to the facility administrator (LNHA). On 08/06/23 at approximately 02:00 AM, Certified Nurse Aide (CNA) M heard Licensed Nurse (LN) G holler at Resident (R)1 shut the [expletive] up or I swear I will kill you. CNA M asked CNA N who she should report the incident to, and CNA N told CNA M to talk to Administrative Nurse D next time CNA M saw her. Five days later, CNA M reported the incident to LN H. Upon receiving the allegation, the facility started an investigation which revealed another resident, R2, reported LN G had yelled and cussed at him. The investigation further revealed other staff heard LN G cussing in the hallways and telling residents to be quiet, then shutting the residents' doors so LN G would not have to hear them yelling, though the staff had not reported this to the facility administrator when it occurred. The facility failed to ensure staff identified a situation of verbal and mental abuse and mistreatment as an allegation of abuse and failed to immediately report to the LNHA. This placed R1 and R2 in immediate jeopardy. Findings included: - The Electronic Medical Record (EMR) documented R1 had diagnoses of insomnia (inability to sleep), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), and age-related debility. The admission Minimum Data Set (MDS), dated 05/15/23, documented R1 had a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. The MDS documented R1 required limited to extensive assistance with all activities of daily living (ADL) except for eating which was supervision/set-up help. The MDS documented R1 exhibited verbal behaviors directed towards others one to three days during the look back period. The MDS documented R1 had other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, or verbal/vocal symptoms like screaming/disruptive sounds) one to three days during the look back period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/15/23, documented R1 had severe cognitive impairment and required cues for recall. The Behavioral Symptom CAA, dated 05/15/23, documented R1 had behaviors of yelling/screaming and crying. The Behavioral Care Plan, dated 05/22/23, documented R1 had occasional episodes of yelling/screaming and directed staff to analyze key times, places, circumstances, triggers, and what de-escalated R1's behavior and document. The care plan directed staff to assess and anticipate R1's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. The Impaired Cognitive Function Care Plan, dated 05/09/23, directed staff to cue, reorient, and supervise R1 as needed. The care plan directed staff to monitor/document/report as needed any changes in cognitive function specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. The Nurse's Note, dated 06/22/23, documented R1 was in bed and yelling about wanting to get up. R1 stated, I wish I could just go to sleep but I can't. The Mood/Behavior Note, dated 08/06/23 at 01:00 AM, documented R1 yelled help me and please and woke up other residents. R1 exhibited this behavior from 08/05/23 at 07:00 PM to 08/06/23 at 01:00 AM. R1 was in her room, in her recliner watching television. When staff asked R1 what she needed or why she was hollering R1 stated, I don't know or I'm not hollering. Staff told R1 that she was disturbing other residents and R1 stated, No I'm not. Interventions that were tried: food, beverages, pain medication, repositioning, different setting, different staff approaching, and talking to R1. None of the interventions were effective. The Facility Incident Report, dated 08/14/23, documented on 08/10/23 at 07:48 PM Administrative Staff A called Administrative Nurse D to inform her a report was made to the night shift nurse LN H, by CNA M, that LN G yelled at R1 during the night on 08/06/23 at approximately 02:00 AM. CNA M reported she went to the nurses station to ask CNA N to help her with repositioning another resident. While CNA M and CNA N were in the nurse's station, CNA M stated she heard R1 yelling out and LN G went to R1's room and told R1 to Shut the [expletive] up or I swear I am going to kill you. CNA M stated she asked CNA N what she should do since she didn't know who to call or where the information was so turn it in. CNA M stated she did not feel the interaction was appropriate. CNA M stated CNA N told her she should talk to Administrative Nurse D when she saw her next. Administrative Nurse D went to the facility to interview CNA M and educated CNA M on proper Abuse, Neglect, and Exploitation procedure and to call Administrative Nurse D any time with concerns. CNA M then filled out a witness statement. Administrative Nurse D called CNA N to ask what had occurred. CNA N stated she did not remember the statement that was made or the incident that was reported because the night was very busy, and the residents were restless, and she was running around helping a lot of people. Administrative Nurse D called LN G and spoke to her about the incident that occurred. LN G stated she never said anything like that. LN G stated she went to R1's room and told her to use her call light if she needed help because she knew how to use a call light. LN G stated R1 was sitting in her recliner and when LN G left the room, R1 used her call light, and CNA N went into her room to assist her. LN G was placed on suspension while the investigation was pending. LN G had worked one shift after the incident, the night shift of 08/06/23 06:00 PM to 06:00 AM. On 08/11/23 at 09:30 AM, Administrative Nurse D interviewed R1 about the incident that was reported. R1 stated, Yes the nurse yelled at me at supper and then again during the night. Administrative Nurse D asked R1 if she remembered what the nurse said and R1 stated, No I just remember her yelling at me and it making me feel worse. I don't know what I did wrong. Administrative Nurse D assured R1 she did not do anything wrong. When Administrative Nurse D interviewed R1, R1's arms and hands were shaking and Administrative Nurse D assured R1 the facility would protect her and do the right thing, and R1 thanked Administrative Nurse D. On 08/11/23, LN G came to the facility to speak with Administrative Nurse D and to fill out a Witness Statement. LN G told Administrative Nurse D she had a hard time when the residents were restless and when R1 yelled out a lot, LN G had to step away, but she had not yelled or said anything inappropriate to the residents. Administrative Nurse D spoke to three cognitively intact residents. Two of the residents had no problems with LN G. R2 stated LN G had yelled and cussed at him before and he did not like her. R2 denied LN G had been physically mean to him. Administrative Nurse D spoke to CNA N about LN G. CNA N stated LN G got overwhelmed when the residents were crazy and LN G would make comments about wanting to kill herself, but CNA N stated she had never heard LN G be mean to someone when CNA N had been in the room, but LN G would make comments about hating it at the facility and wanting to kill herself. Administrative Nurse D interviewed CMA R, who had recently switched to day shift from night shift. CMA R stated LN G was a very loud person with a horrible potty mouth. CMA R stated she had heard LN G yelling in the halls and cussing about residents. CMA R did not know if the residents heard or understood LN G. CMA R stated LN G would get frustrated and voice her feelings very loud in the hall and there were several nights when a resident was yelling out all night and LN G would go into their room and tell them to be quiet and shut their door so she could not hear them. CMA R stated she would go and open the resident's doors up and check on them or talk to them. CMA R stated there were times she would tell LN G a resident was anxious, and LN G would say she wasn't going to give the resident anything because she did not want them to make them sleep too much and LN G did not want to chemically restrain the residents. CMA R stated LN G did not want to do anything when she was at the facility and would complain all of her shift. On 08/14/23 the facility terminated the employment of LN G. On 08/15/23 at 10:00 AM, observation revealed R1 seated at the dining room table in the commons area coloring in a picture book. On 08/15/23 at 10:00 AM, R1 stated the nurse had yelled at her and growled at her and she was scared, but she was not scared anymore. On 08/15/23 at 11:30 AM, CNA M stated she had heard LN G yell at R1 stating Shut the [expletive] up or I am going to kill you! CNA M stated she did not know what to do about the situation but knew what LN G said was horribly inappropriate and something needed to be done. On 08/15/23 at 12:50 PM, Administrative Nurse D stated the results of the investigation she conducted showed LN G did not have a lot of patience, could be loud and inappropriate in the halls, and LN G did not need to be working with the elderly. Administrative Nurse D stated she expected staff to know the reporting procedure for any alleged abuse and neglect allegations, so the facility could provide safety for the residents. On 08/15/23 at 03:30 PM, Administrative Staff A expressed regret the facility hired LN G and said she expected all staff to know and adhere to the abuse and neglect policy of the facility. The facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating Policy, dated September 2022, documented all reports of resident abuse including injuries of unknown origin, neglect, exploitation, or theft/misappropriation of resident property are reported to the local, state, and federal agencies as required by current regulations and thoroughly investigated by facility management. If resident abuse, neglect, exploitation, misappropriation of resident property must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as within two hours of an allegation involving abuse or results in bodily harm or within 24 hours of an allegation that does not involve abuse or result in bodily harm. The facility failed to ensure staff identified a situation of verbal and mental abuse and mistreatment as an allegation of abuse and failed to immediately report to the LNHA. This placed R1 and R2 in immediate jeopardy. On 08/15/23, the onsite surveyor verified the following corrective actions to remove the immediacy for R1 and R2: On 08/10/23 the facility immediately educated CNA M, CNA N, LN H on the process of how to report abuse, neglect, and exploitation. The facility immediately suspended LN G pending the investigation. On 08/10/23 the facility submitted the incident to the State Agency. On 08/11/23 Administrative Nurse D filed a police report. On 08/15/23 Administrative Nurse D reported LN G to Kansas State Board of Nursing Licensing Department. On 08/15/23 the facility emailed all agency staff schedulers the abuse, neglect, and exploitation (ANE) information and what the facility expected of their staff upon entering the facility. On 08/15/23 Administrative Nurse D and Administrative Staff A educated all staff either in person or via phone call about the facility expectations regarding ANE. The facility also gave written warnings to the staff who heard LN G act inappropriately during her shift and failed to report to Administrative Nurse D or Administrative Staff A. On 08/15/23 the facility hung posters in staff areas regarding the proper way to report any suspicion of ANE, provided all residents the same information for self-reporting, and called resident representatives regarding the provided information as well. After the immediacy was removed, the deficient practice remained at the scope and severity of D