**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, facility policy review, and review of the facility's investigation, it was determined the facility failed to have an effective system to ensure residents were free from abuse for two (2) of three (3) sampled residents (Resident #1, Resident #2). Review of the facility investigations revealed on 04/03/2022, State Registered Nurse Aide (SRNA) #1 was observed by Housekeeper #1 placing her hands over the mouth of Resident #2 and told the resident to shut up. Additionally, on 04/03/2022, SRNA #1 was observed by SRNA #2 and SRNA #3 to roughly transfer Resident #1 from the bed to the wheelchair and stated, Why won't you fucking turn? Resident #1 also sustained a skin tear during the transfer. Though SRNA #1 was observed to be physically and verbally abusive to Resident #1 and Resident #2, staff failed to report the allegations of abuse and allowed SRNA #1 to continue to work her scheduled shift, which compromised the safety and well-being of all the facility's residents. The facility's failure to have an effective system in place to ensure residents were free from abuse, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 11/10/2022 and was determined to exist on 04/03/2022 in the areas 42 CFR 483.12 Freedom from Abuse (F600 and F609) at a S/S of J. The facility was notified of the IJ on 11/10/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan on 11/23/2022, alleging removal of the Immediate Jeopardy on 04/15/2022. The State Survey Agency (SSA) determined the IJ had been removed on 04/15/2022, as alleged, prior to exit on 11/23/2022. The facility implemented corrective action which was completed prior to the State Survey Agency's investigation. Based on validation of the facility's corrective actions it was determined to be Past Jeopardy. Refer to F609 The findings include: Review of the facility's policy, Abuse, Neglect, or Misappropriation of Resident Property Policy, revision date of 10/15/2022, revealed residents had the right to be free from abuse, neglect, involuntary seclusion, exploitation, or misappropriation of property. The facility would do whatever was in its control to prevent mistreatment, neglect, exploitation and abuse of residents or misappropriation of their property. Any employee who witnessed or suspected abuse, neglect, exploitation or misappropriation of property had occurred would immediately report the incident to the Administrator. Failure to report any concern related to neglect, exploitation, abuse, or misappropriation of property would result in disciplinary action and possible termination of employment. Additional review of the policy, revealed the definition of abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm or pain or mental anguish or deprivation by an individual, including a caretaker, or goods or services that were necessary to attain or maintain physical, mental and psychosocial well-being. This presumed that instances of abuse of residents, even those in a coma, could cause physical harm, pain, or mental anguish to the residents. Abuse included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facility or enabled through the use of technology. Continued review of the policy further revealed the definition of verbal abuse as any use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse included but were not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again; using derogatory language; or ignoring residents while care was being provided. Physical abuse included hitting, slapping, pinching, and kicking. 1. Closed clinical record review revealed the facility admitted Resident #2 on 08/27/2021 with diagnoses which included Cerebral Infarction, Major Depressive Disorder, Symptoms and Signs Involving Cognitive Functions and Awareness. The resident was discharged from the facility on 06/10/2022. Review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 02/14/2022, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15), indicating severely impaired cognition. Review of Resident #2's Comprehensive Care Plan, dated 04/11/2022, revealed the resident had ineffective coping which elicits behaviors of repetitive actions such as repeating words and counting over and over again. Further review of the care plan revealed an intervention to distract the resident to break the repetitive cycle. Review of State Registered Nurse Aide (SRNA) #1's personnel file revealed the employee was hired on 08/06/2020. A criminal background was completed and there was no evidence of disciplinary action noted in the employee's file. SRNA #1 was suspended on 04/04/2022 and resigned from her position on 04/08/2022. Review of the facility investigation, dated 04/08/2022, completed by the Nurse Consultant and the Administrator, related to Resident #2, revealed the investigation was initiated on 04/07/2022 after learning of the abuse allegation made by Housekeeper #1 to the Administrator. The investigation revealed on 04/03/2022 at 10:00 AM, SRNA #1 walked up behind Resident #2 and placed her hands over the resident's mouth and told the resident to shut up. At the conclusion of their investigation, the facility reported based on a thorough investigation including chart reviews, resident interviews, resident assessments, staff interviews and observation, the facility was unable to substantiate the allegation of abuse at that time. Review of the Witness Statement by Housekeeper #1, dated 04/07/2022 at 1:45 PM, revealed she witnessed SRNA #1 walk behind Resident #2, putting her hands over the resident's mouth and telling the resident to shut up. A couple of minutes later the housekeeper witnessed SRNA #1 push the resident's arm down and told the resident to shut up and stop yelling, it's annoying. Interview with SRNA #1, on 10/31/2022 at 1:37 PM, revealed it was reported she had been cursing at Resident #2. The SRNA reported she had asked the resident to be quiet but had not laid a hand on the resident. The incident was reported on 04/07/2022. She revealed she was suspended the morning of 04/04/2022. The SRNA revealed she had been educated on abuse in orientation and is aware abuse should be reported as soon as you see it. Interview with Housekeeper #1, on 11/01/2022 at 1:35 PM, revealed she witnessed SRNA #1 put her hands over Resident #2's mouth and told the resident to shut up on 04/03/2022 at 10:00 AM. The resident was sitting in the wheelchair in the common area. The Housekeeper revealed that she had received a little information on abuse prior to the incident when she was hired and reported she had since received in depth abuse education. The allegation of abuse was reported by Housekeeper #1, on 04/07/2022 to the Administrator. 2. Closed clinical record review revealed the facility admitted Resident #1 on 07/07/2021 with diagnoses which included Violent Behavior, Dementia with Behavioral Disturbance, and Disorientation. The resident was discharged from the facility on 06/05/2022. Review of Resident #1's Quarterly MDS, dated [DATE], revealed the facility assessed the resident as having a BIMS score of zero zero (00), indicating severe cognitive impairment. Review of the facility's Investigation dated 04/04/2022, and completed by the Nurse Consultant, revealed the Director of Nursing (DON) received an allegation of abuse, on 04/04/2022 at 7:00 AM, from State Registered Nurse Aide (SRNA) #2 regarding abuse of Resident #1 by SRNA #1, which occurred on 04/03/2022 at 3:30 PM. The investigation revealed SRNA #1 was rough with Resident #1 during a transfer. Further review of the investigation revealed the resident's responsible party and physician were notified of the incident. The resident had sustained a skin tear to the left arm after sitting on his/her own hand. Care was provided to Resident #1's skin tear by Licensed Practical Nurse (LPN) #1, who assessed the area and carried out the orders from the physician which included a dressing and geri sleeves. Involved staff were interviewed and statements were received. When SRNA #1 arrived to work on 04/04/2022 at 8:00 AM, she gave a statement and was suspended pending the outcome of the abuse investigation. After the facility finished its investigation, they concluded that based on the assessment of the resident, interviews with staff members, record review, employee file review, and a review of the timeline of events, the facility determined they were unable to substantiate an allegation of abuse. Review of State Registered Nurse Aide (SRNA) #2's witness statement provided on 04/04/2022 to the DON, revealed she was transferring Resident #1 to the wheelchair when the alarm sounded and SRNA #1 and SRNA #3 entered the room to assist. SRNA #2 alleged SRNA #1 went over to Resident #1 and pulled the resident away from SRNA #2 and sat the resident in the wheelchair roughly while making the statement, why won't you fucking turn? SRNA #2 revealed the resident sat on his/her own hand causing a skin tear. Review of the State Registered Nurse Aide (SRNA) #1's time sheet revealed the SRNA worked from 6:03 AM and clocked out at 5:56 PM on 04/03/2022, the date of the incident. Interview with SRNA #1, on 10/31/2022 at 1:37 PM, revealed on 04/03/2022 at 3:30 PM, SRNA #2 was getting Resident #1 up and she along with SRNA #3 entered the room to assist. She stated she was assisting SRNA #2 with the transfer of the resident from the bed to the wheelchair and during the transfer the resident sustained a skin tear to his/her left forearm arm after getting his/her hand caught under himself/herself. SRNA #1 stated she reported the skin tear immediately to Licensed Practical Nurse (LPN) #1. SRNA #1 denied being rough with the resident. Per the interview, SRNA #1 stated the resident did not yell out while being assisted into the wheelchair. SRNA #1 revealed she resigned on 04/08/2022. The State Survey Agency (SSA) Surveyor attempted telephone contact with SRNA #2 on 10/30/2022 at 2:04 PM, 10/31/2022 at 11:32 AM, 10/31/2022 at 2:14 PM, and 11/04/2022 at 11:37 AM; however, there was no response or a callback. Interview with SRNA #3, on 11/02/2022 at 1:22 PM, revealed she and SRNA #1 went to assist SRNA #2 with the transfer of Resident #1 after hearing the resident's bed alarm. She stated SRNA #1 took over the transfer, and independently transferred the resident from his/her bed to his/her wheelchair, when she entered the room. State Registered Nurse Aide (SRNA) #3 revealed the resident sustained a skin tear to the arm, during the transfer, and stated she heard SRNA #1 curse, but did not recall exactly what was stated. She revealed SRNA #1 had an attitude, at times. The SRNA revealed she reported the incident to Licensed Practical Nurse (LPN) #1. Interview with Licensed Practical Nurse (LPN) #1, on 11/01/2022 at 10:46 AM and on 11/04/2022 at 12:10 PM, revealed SRNA #1 had reported the skin tear to Resident #1's arm. She revealed she notified the resident's responsible party, and the physician of the skin tear and treatment orders were obtained. LPN #1 stated when she asked SRNA #2 and SRNA #3 if they felt like the incident was abuse, both SRNAs were unsure, but reported it had been a rough transfer. LPN #1 revealed SRNA #2 believed SRNA #1 abused Resident #1. Further, she stated it was abuse and SRNA #3 was not sure. LPN #1 stated she reported the incident to the Assistant Director of Nursing (ADON) on 04/03/2022 at 5:48 PM followed by the DON. Interview with the former Director of Nursing (DON), on 11/01/2022 at 10:07 AM, revealed she was called the evening of 04/03/2022 about the possible abuse by the Assistant Director of Nursing (ADON) about the rough transfer with a skin tear. On the morning of 04/04/2022, the DON revealed SRNA #2 reported to her that SRNA #1 was observed to be abusive towards Resident #1, the day before, on 04/03/2022. Continued interview with the DON revealed she realized SRNA #1 finished her shift. Per the interview with the DON, she began the investigation and suspended SRNA #1, to protect the residents from potential abuse, while conducting the investigation. Interview with the Director of Nursing (DON), on 11/01/2022 at 9:40 AM, revealed she had only worked at the facility for a few months and was not employed at the facility when the abuse allegations occurred. However, she revealed she would expect staff to ensure the safety of the resident and immediately notify their supervisor, and if the supervisor did not report, then staff were expected to go up the chain to report the incident Interview with the Interim Administrator, on 11/02/2022 at 2:48 PM, revealed he expected staff to keep the residents safe and if there was an abuse allegation that it would be reported to the DON/Administrator immediately. He further stated an investigation would be started and the allegation would be reported to the State Agency. The facility provided an acceptable Immediate Jeopardy Removal Plan on 11/23/2022, alleging removal of the Immediate Jeopardy on 04/15/2022. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. On 04/04/2022, Licensed nursing staff completed skin assessments of 100% of cognitively impaired resident with a Brief Interview for Mental Status (BIMS) of less than eight (8). 2. On 04/04/2022, the Social Service Director (SSD) completed resident interviews with 100% of alert and oriented residents with a BIMS above (8) eight. No residents voiced any concerns of abuse, and no areas of concern were identified. 3. On 04/05/2022, the Facility Consultant reviewed 100% of grievances for January, February, and March 2022, to ensure all reportable allegations were reported and investigated. 4. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and the Facility Consultant conducted 100% staff interviews regarding allegations of abuse to determine if any were not reported. This was completed by 04/05/2022. As of 04/08/2022, any staff member who had not been interviewed was not allowed to work until interviews were completed. On 04/07/2022 an issue was identified. This situation involved the same staff member who was already suspended based on the first investigation. The second incident was reported to the appropriate state agencies. 5. On 04/05/2022, the Facility Consultant did in-service with the Administrator, DON, ADON and Unit Manager (UM). The abuse policy was reviewed, reporting immediately, within two (2) hours and within twenty-four (24) hours was discussed. They also went over the types of abuse, The Elderly Justice Acts and required postings in the facility, protecting the residents immediately and the suspension of the alleged perpetrator. 6. Nursing management staff to include the UM, ADON, DON and Facility Consultant completed re-education with 100% of facility staff to include as needed staff. The facility did not use agency or temporary staff at the time of this re-education. All education was completed by 04/08/2022. Education was provided on the abuse policy, reporting all allegations of abuse immediately to the supervisor, the types of abuse, the Elderly Justice Act, protection of the residents and suspension of the alleged perpetrator. 7. The Facility Consultant, DON, ADON, UM and Administrator conducted quizzes with 100% of staff currently employed at the facility. This was completed 04/08/2022. 8. On 04/07/2022, the Administrator educated Housekeeper #1 regarding the abuse policy, types of abuse, timely reporting of abuse and immediate protection of the resident. Housekeeper #1 was no longer employed at the facility. 9. Any staff that could not be reached on scheduled workday or by phone was sent a certified letter explaining the expectation for reeducation. 10. All new staff since 04/08/2022 were educated upon hire on the abuse policy with a focus on timely reporting of abuse. 11. The Facility Consultant attempted to report on 04/11/2022 to the State Board of Nursing and Community College that SRNA #2 had been substantiated for abuse. 12. Starting 04/15/2022, the facility would interview five (5) staff members to determine if any new allegations of abuse were not reported, when it required reporting and to whom. This was conducted by the DON, ADON, UM and/or the Administrator. Staff were selected randomly, to account for different shifts and different units with the focus on direct care staff members. Audits of five (5) staff per week were completed for four (4) weeks, two (2) staff per week for two (2) weeks, one (1) staff per week for two (2) weeks and one (1) staff per month for two (2) months. 13. Starting 04/15/2022, the facility had five (5) staff members complete an Abuse Quiz which was administered by the DON, ADON, UM and/or Administrator for four (4) weeks. Then two (2) staff for two (2) weeks, one (1) staff for two (2) weeks and one (1) staff for two (2) months. This was used to ensure the staff were maintaining what they learned through the re-education. Any staff member who did not obtain 100% were retrained on the spot. 14. Starting 04/15/2022, five (5) residents per week for four (4) weeks with a BIMS greater than eight (8) were randomly selected for interviews by the SSD. She used the Safe Survey to identify if resident had any concerns about how they were treated by staff in the facility. The facility continued to do this assessment of two (2) residents for two (2) weeks, one (1) resident for two (2) weeks and then one (1) resident for two (2) months. No concerns were identified. 15. The Quality Assurance Performance Improvement (QAPI) team met on 04/04/2022 to put a plan of action together once concerns of abuse had been identified. Present at the initial meeting were the Administrator, the DON, Dietary Manager, Facility Consultant, Rehabilitation Director, Unit Manager, SSD, and the Minimum Data Set Nurse. The Medical Director was present on the phone but did not offer any new suggestions. The last QAPI meeting reviewing the performance improvement plan was held on 07/27/2022 with no new issues identified since the initiation of the improvement plan. Members present included the Administrator, DON, Medical Director via phone, Environmental Services Director, SSD, MDS Nurse, and the Quality Improvement Nurse. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Review of Skin Assessments as compared to the Brief Interview for Mental Status (BIMS) listing for the time of this event validated each resident with a BIMS less than (8) had a skin assessment. No signs or symptoms of abuse were identified by the facility and after review, none were identified by the surveyor. 2. Review of the interview questionnaire of residents with a BIMS of eight (8) or greater completed on 04/04/2022, revealed no residents voiced any concerns regarding abuse through the interviews conducted by the SSD. Interview with Resident #6 on 11/21/2022 at 9:35 AM, revealed the resident felt very safe at the facility, staff were kind and took good care of her/her. The resident also stated the staff never talked bad or mistreated him/her in any way. Resident #6 reported he/she would talk to the Director of Nursing (DON) or the SSD if there were any concerns and felt things would be taken care of. Interview with Resident #4, on 11/21/2022 at 10:00 AM, revealed staff treated him/her very well. The resident revealed he/she felt very safe at the facility and the staff were wonderful and kind. Interview with Resident #7, on 11/21/2022 at 10:35 AM, revealed staff were really good and provided great care. Resident #7 revealed staff were very busy but were still able to meet his/her needs. The resident stated he/she was very outspoken and had no problem reporting any concerns to the staff. 3. Interview with the Facility Consultant on 11/23/2022 at 6:00 PM, revealed she reviewed each entry into the grievance log for January, February, and March 2022 as alleged. She revealed however, a formal documented audit did not occur. She wrote a signed statement to show she reviewed the grievance log information and had not found any concerns. The State Survey Agency (SSA) Surveyor reviewed all the facility's grievance logs from April 2022 to the current date and discovered eight (8) areas the facility called care delivery concerns. Based on review of those eight (8) cases residents were interviewed and either could not recall the event, or no longer had any concerns regarding the issue. Interview on 11/21/2022 at 10:45 AM, with Resident #7 revealed he/she no longer had any care concerns. 4. Review of the facility's documentation of the abuse questions completed by staff compared to the staff roster revealed one hundred and one (101) staff's name present, which was 100% of the facility's staff at that time, documented as having completed the training as alleged. Additionally, interviews were 11/22/2022: with SRNA #6 at 1:45 PM; SRNA #7 at 1:30 PM; SRNA #8 at 2:35 PM; SRNA #12 at 12:40 PM; SRNA #13 at 1:50 PM; and SRNA #14 at 2:55 PM. All the SRNAs revealed they were interviewed about any allegations of abuse or concerns of abuse, how and when abuse was to be reported to the DON and/or the Facility Consultant. Interview on 11/22/2022: with Housekeeper #1 at 12:05 PM; Housekeeper #2 at 12:15 PM; and a laundry staff person at 12:30 PM revealed all had been interviewed by the DON and/or the Facility Consultant about when to report abuse, to whom to report abuse and the different kinds of abuse. All staff interviewed revealed it was not up to them to determine if a situation was abuse or not, they were just to report it immediately to management. 5. Interview with Licensed Practical Nurse (LPN) #7/Unit Manager on 11/22/2022 at 3:00 PM, revealed she had been provided education by the Facility Consultant on the abuse policy; reporting immediately, within two (2) hours and within twenty-four (24) hours; the types of abuse; the Elderly Justice Acts; required postings in the facility; protecting the residents immediately and suspension of the alleged perpetrator. LPN #7 stated she had to pass a quiz covering all those subjects. Interview with the ADON on 11/23/2022 at 5:45 PM, revealed she was provided education by the Facility Consultant on the abuse policy; reporting immediately, within two (2) hours and within twenty-four (24) hours; the types of abuse; the Elderly Justice Acts; required postings in the facility; protecting the residents immediately and suspension of the alleged perpetrator. The ADON stated she was required to take a quiz and pass it with 100%. Interview with the DON on 11/23/2022 at 6:00 PM, revealed the Facility Consultant provided in-services on the abuse policy; reporting immediately, within two (2) hours and within twenty-four (24) hours; the types of abuse; the Elderly Justice Acts; required postings in the facility; protecting the residents immediately and suspension of the alleged perpetrator. Interview with the Administrator on 11/23/2022 at 6:15 PM, revealed the Facility Consultant covered the abuse policy; reporting immediately, within two (2) hours and within twenty-four (24) hours; the types of abuse; the Elderly Justice Acts; required postings in the facility; protecting the residents immediately and suspension of the alleged perpetrator with him. 6. Review of the facility's sign in sheets for the in-services provided for staff revealed one hundred and one (101) staff's names, which represented 100 % of the facility's staff employed at that time. Per review, all education was completed by 04/08/2022. Interviews conducted with thirty-four (34) facility staff on 11/22/2022 through 11/23/2022, revealed very staff member interviewed was able to name the seven (7) types of abuse, when to report incidents (immediately), who to report to incidents to (their direct supervisor), the DON, and the Administrator. In addition, all staff interviewed were able to identify that resident safety was the number one (1) priority, and the alleged perpetrator would be suspended pending investigation. Further interview revealed staff also expressed understanding that it was not up to them to decide if a situation was abuse or not, it had to be reported so management could investigate. Interview with the Facility Consultant, on 11/23/2022 at 6:00 PM, revealed she provided reeducation to the Administrator and all staff were provided education on 04/04/2022. Interview revealed she immediately activated the Performance Improvement Plan (PIP) and started doing quizzes with staff. According to the Facility Consultant, all staff were present and took the quiz and were required to get 100%. She stated if the staff member did not get 100% score, reeducation was conducted on the spot and the quiz was taken again until 100% was achieved. 7. Interview with the Facility Consultant on 11/23/2022 at 6:20 PM, revealed she was present for the quizzes for the majority of staff members. She revealed she was at the door where the quiz was given and graded it on the spot. Continued interview revealed any missed items were immediately reviewed with the staff member and then the staff member had to take the quiz again until 100% was achieved. She further stated staff were not scheduled to work again until the task was completed. 8. Review of the facility's signed document revealed the Administrator completed the alleged education for Housekeeper #1 regarding the abuse policy, types of abuse, timely reporting of abuse and immediate protection of the resident listed on 04/07/2022. Per review, Housekeeper #1 was disciplined, and warning disciplinary action was validated by the SSA Surveyor. Interview with the Administrator on 11/23/2022 at 4:30 PM, revealed he provided the re-education for Housekeeper #1 back in April 2022, when the incidents arose. He revealed he went over the F600 regulation with the staff member and a warning disciplinary action was given to the Housekeeper #1. 9. Review of the facility's certified mail receipts revealed letters were sent as alleged, and the card received back prior to 04/15/2022. The review revealed no concerns were noted. 10. Review of the last five (5) staff hired revealed the abuse packet in orientation and review of the policy to ensure new staff were educated and understood the expectation. Interview on 11/22/2022, with Housekeeper #2 and Housekeeper #3, Laundry Staff #1, Cook, and Nurse Aide Student revealed all the staff each knew the seven (7) types of abuse; knew to make sure the resident was safe; to report to management immediately; and that they did not determine what was or was not abuse. Interview with the Staff Development Coordinator on 11/23/2022 at 1:25 PM, revealed she had helped with ongoing training for new staff in orientation. She revealed all staff were trained on abuse before they access the floor, and this had included her. Per the SDC, the Facility Consultant did the orientation with her and went over the facility policies and procedures since she was new to this agency. She revealed she had been doing on going education with staff on abuse. Interview with the DON on 11/23/2022 at 1:40 PM revealed she was provided education when she came on board with the facility. 11. Interview with the Facility Consultant on 11/23/2022 at 6:00 PM, revealed she called the State Board of Nursing and was informed they were not where that information needed to be reported to. She stated she was told to contact the State Community College to make the report. Per interview she called the State Community College and was informed they did not take that type of report either. She called back to the Board of Nursing, and they did not have a different answer. Further interview revealed the Facility Consultant had a signed form to account for the phone calls she had made regarding determining the correct reporting path, which she had been unable to do. 12. Starting 04/15/2022, the facility will interview five (5) staff members to determine if any new allegations of abuse were not reported, when it required reporting and to whom. This was conducted by the DON, ADON, UM and/or the Administrator. Staff were selected randomly, to account for different shifts and different units with the focus on direct care staff members. Audits of five (5) staff per week were completed for four (4) weeks, two (2) staff per week for two (2) weeks, one (1) staff per week for two (2) weeks and one (1) staff per month for two (2) months. Review of the facility's audits revealed the facility interviewed staff members as alleged in the IJ Removal Plan within the specified timeframes and no concerns were noted. Interviews with staff conducted between 11/22/2022 and 11/23/2022 revealed thirty-four (34) staff plus management staff, to include housekeepers, laundry, maintenance, dietary staff, nurse aides and licensed nurses were able to account for each subject they received education on. Each staff member could report the seven (7) types of abuse, identify they were to keep the resident safe, and report immediately to management. Also, staff reported it was not up to them to decide if something was abuse or not, just report anything that was a concern. It was determined through these interviews, two (2) staff members could use a bit more education on the exact requirements, but they knew the basics. The facility was made aware of the concerns. This does not put them to a later compliance date because of the special needs of those two (2) staff members. Interview with the MDS Coordinator on 11/23/2022 at 1:00 PM, revealed she helped with in-services and did pop up interviews on staff randomly and ask them abuse questions. Further interview revealed she felt the facility had done a great job making sure everyone knew the expectation on abuse and what had to happen. 13. Review of the facility's documentation of staff audits revealed the number of staff audits was provided and noted to be accounted for each timeframe represented above. Per review, the staff interviewed were able to verbalize the seven (7) types of abuse, state they were to report incidents immediately and to keep the residents safe. Further review revealed as of 11/22/2022, the facility had provided much abuse training for many staff regarding the ongoing education over the months by all management staff, with no concerns found. 14. Interview with Resident #4 on 11/22/2022 at 10:00 AM, revealed the facility had interviewed him/her, and he/she felt safe in the facility. Resident #4 stated staff treated him/her well and if there were any concerns, he/she knew to report to the charge nurse or the DON. Interview with Resident #7 on 11/22/2022 at 10:35 AM, revealed the facility had interviewed him/her and he/she felt safe in the facility. The resident revealed staff were kind and provided good care and if there were any concerns, he/she would report it to the DON and/or Administrator. Interview with the Social Services Director (SSD) on 11/23/2022 at 12:40 PM, revealed she helped with the facility's removal plan and completed the Safe Surveys with residents and no concerns were found. 15. Review of the facility's QAPI minutes documentation and sign in sheet for 04/04/2022 revealed the Facility Consultant, Dietary Manager, Unit Manager, Social Service Direct[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and a review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure allegations of abuse were reported immediately to state agencies for two (2) of three (3) residents (Residents #1 and #2). Review of the facility's abuse investigations, dated 04/04/2022 and 04/07/2022 revealed the facility failed to report allegations of abuse in a timely manner, less than two (2) hours. Staff's failure to report two (2) allegations of abuse in a timely manner, presented a delay in the onset of the abuse investigations, which allowed State Registered Nurse Aide (SRNA) #1 to abuse Resident #1 the same afternoon as the abuse of Resident #2. Staff witnessed SRNA #1 cover the mouth of Resident #2 and told the resident to shut up and later in the day two (2) other staff witnessed SRNA #1 roughly transfer Resident #1 from the bed to the chair, and stated, Why won't you fucking turn?. Resident #1 sustained a skin tear to the left arm during the transfer after the resident's arm was caught under him/her. Review of the facility's investigations, dated 04/03/2022 at 10:00 AM, revealed Resident #2 was in the common area and was repetitively counting when Housekeeper #1 witnessed SRNA #1 place her hands over the resident's mouth and stated, shut up. The abuse allegation was not reported until 04/07/2022 at 1:45 PM by SRNA Housekeeper #1 to the Administrator. Review of the facility's investigation, on 04/03/2022 at 3:30 PM, SRNA #2 and SRNA #3 witnessed SRNA #1 roughly transfer Resident #1 from the bed to the chair. The resident sustained a skin tear to the left arm during the transfer after his/her hand was caught under the resident. The abuse allegation was not reported until 04/04/2022 at 7:00 AM to the Director of Nursing (DON) by State Registered Nurse Aide (SRNA) #2. The facility's failure to have an effective system in place to ensure the reporting of abuse allegations to the state agency in a timely manner, less than two (2) hours, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 11/10/2022, and was determined to exist on 04/03/2022, at CFR 483.12 Freedom from abuse (F600, F609). The facility was notified of Immediate Jeopardy on 11/10/2022. The State Survey Agency validated the removal of the Immediate Jeopardy, as alleged, on 04/15/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan on 11/23/2022, alleging removal of the Immediate Jeopardy on 04/15/2022. The State Survey Agency (SSA) determined the IJ had been removed on 04/15/2022, as alleged, prior to exit on 11/23/2022. The facility implemented corrective action which was completed prior to the State Survey Agency's investigation. Based on validation of the facility's corrective actions it was determined to be Past Jeopardy. The findings include: Review of facility policy, titled Abuse, Neglect, or Misappropriation of Resident Property Policy, revision date of 10/15/2022, revealed any employee who witnessed or suspected that abuse, neglect, exploitation, or misappropriation of property had occurred would immediately report the alleged incident to their supervisor, who would immediately report the incident to the Administrator. Further review of the policy revealed the Administrator was responsible for ensuring that complaints of abuse, neglect, exploitation, or misappropriation of property and injuries of unknown origin were investigated. Measures would be initiated to prevent any further potential abuse while the investigation was in progress. The Administrator was responsible to review the results of the investigation and report the alleged incident to the appropriate agencies in accordance with state and federal regulations. Further, the Administrator would ensure the Division of Licensure and Regulation would be notified immediately of all complaints of abuse, and neglect, including injuries of unknown origin, misappropriation of resident property. Employees would immediately report such allegations to the Administrator who would ensure the Cabinet was notified in accordance with KRS 209.030, as amended. All such allegations would be investigated and action taken as necessary to prevent further potential abuse while the investigation was in progress. 1. Closed clinical record review revealed the facility admitted Resident #2 on 08/27/2021 with diagnoses which included Major Depressive Disorder, Cerebrovascular Disease (CVD), Disorientation and Other Symptoms and Signs Involving Cognitive Functions and Awareness. The resident was discharged from the facility on 06/10/2022. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6), indicating severe cognitive impairment. Review of the facility investigation completed by the Nurse Consultant and the Administrator, revealed the incident occurred on 04/03/2022 at 10:00 AM. SRNA #1 placed her hands over Resident #2's mouth and told the resident to shut up while the resident was sitting in the common area. The incident was not reported to the Administrator until 04/07/2022 at 1:45 PM. The State Agency was notified on 04/08/2022 at 2:58 PM, over 24 hours after the allegation was received by the Administrator. Review of the witness statement for Housekeeper #1, on 04/03/2022 at 10:00 AM, revealed she witnessed SRNA #1 walk up behind Resident #2, putting her hands over the resident's mouth and said to the resident to shut up. The resident had been counting repetitively. A couple of minutes later the housekeeper witnessed SRNA #1 push the resident's arm down and told the resident to shut up and stop yelling, it's annoying. The resident was sitting in the common area. The Housekeeper reported the abuse allegation on 04/07/2022 at 1:45 PM to the Administrator. Interview with the State Registered Nurse Aide (SRNA) #1, on 10/31/2022 at 1:37 PM, revealed someone had reported she had cursed at Resident #2. The SRNA reported she simply asked the resident to be quiet and never touched the resident. Interview with Housekeeper #1, on 11/01/2022 at 1:35 PM, revealed she witnessed SRNA #1 put her hands over Resident #2's mouth and told the resident to shut up while the resident was sitting in the common area. The Housekeeper stated she was not sure if what she saw was abuse until she was in an abuse training being done by the facility. She revealed that she had received a little information on abuse when she was hired and reported she had since received in-depth abuse education. She did not report the allegation immediately. The abuse allegation was reported to the Administrator on 04/07/2022 at 1:45 PM, four (4) days after SRNA #1 was witnessed being abusive to Resident #2. 2. Closed clinical record review revealed the facility admitted Resident #1 on 07/07/2021 with diagnoses which included Violent Behavior, Dementia with Behavioral Disturbance and Disorientation. The resident was discharged from the facility on 06/05/2022. Review of Resident #1's Quarterly MDS, dated [DATE], revealed the facility assessed the resident as having a BIMS score of zero zero (00), indicating severe cognitive impairment. Review of the investigation, dated 04/04/2022, revealed the allegation of abuse for Resident #1 was formally made to the former DON on 04/04/2022 at 7:00 AM, at which time the abuse investigation was initiated. The staff had reported a rough transfer with a skin tear by SRNA #1. The resident's hand became caught underneath him/her during the transfer. The State Agency was notified on 04/04/2022 at 9:18 AM. The alleged abuse occurred on 04/03/2022 at 3:30 PM. SRNA #1 arrived to work on 04/04/2022 at 8:00 AM, gave a statement of the events and she was then suspended pending the outcome of the investigation. The SRNA resigned her position on 04/08/2022. The State Survey Agency (SSA) Surveyor, attempted to telephone contact with State Registered Nurse Aide (SRNA) #2; on 10/30/2022 at 2:04 PM, 10/31/2022 at 11:32 AM, 10/31/2022 at 2:14 PM, and 11/04/2022 at 11:37 AM; however, was unsuccessful. Interview with SRNA #1, on 10/31/2022 at 1:37 PM, revealed she was assisting SRNA #2 to transfer Resident #1 from the bed to the wheelchair. The resident sustained a skin tear to the left arm when the resident's arm was caught under the resident while he/she was being transferred. SRNA #1 denied being rough with the resident. After the transfer, SRNA #1 took Resident #1 to be seen by LPN #1 for treatment of the skin tear. Interview with State Registered Nurse Aide (SRNA) #3, on 11/02/2022 at 1:22 PM, revealed she and SRNA #1 had heard Resident #1's alarm sound so they went into the room to assist. SRNA #1 went to the side of the bed where SRNA #2 was to assist. The resident was transferred from the bed to the chair. SRNA #3 described the transfer as being rough. She also overheard SRNA #1 curse at the resident but could not remember exactly what she said. The resident sustained a skin tear to the arm during the transfer when the resident's arm got under him/her. She revealed that she did not report the incident immediately, but then talked with Licensed Practical Nurse (LPN) #1 about the incident and was unsure if the incident was abuse. Interview with Licensed Practical Nurse (LPN) #1, on 11/04/2022 at 12:10 PM, revealed she spoke with SRNA #2 and SRNA #3 regarding the incident as they reported it was a rough transfer. The LPN revealed she asked the SRNAs if they felt what had happened was abuse. Per the LPN, SRNA #2 felt like it was abuse and SRNA #3 wasn't sure and thought it was a rough transfer. The LPN stated SRNA #2 and SRNA #3 did not want SRNA #1 to get into trouble. LPN #1 reported the possible allegation of abuse to the Assistant Director of Nursing (ADON) who notified the DON. Interview with the Director of Nursing (DON), on 11/01/2022 at 9:40 AM, revealed she had only been in her role for a few months and she was not working in the facility at the time of either of the abuse allegations but that it was her expectation that the regulations and policies be followed. Interview with the former Director of Nursing (DON), on 11/01/2022 at 10:07 AM, revealed she was called the evening of 04/03/2022 about the possible abuse of Resident #1 and it was described as a rough transfer to her. However, per the interview, on the morning of 04/04/2022, SRNA #2 reported to her that Resident #1 was observed to be verbally and physically abused by SRNA #1. The former DON revealed she did not begin investigating the abuse until SRNA #2's report. The former DON revealed she suspended SRNA #1, pending the outcome of the abuse investigation. Interview with the Interim Administrator, on 11/02/2022 at 2:48 PM, revealed he was not working in the facility at the time of the allegations. He stated his expectations regarding abuse, were to keep the resident safe and if abuse was suspected, the resident's safety would be ensured and the allegations of abuse should be reported immediately to the DON and Administrator. Interview with the Administrator, on 11/18/2022 at 12:04 PM, revealed it was his expectation that allegations of abuse would be reported to state agencies, as per the facility's policy. He further stated, the facility had not followed the regulation as written, but should have. The facility provided an acceptable Immediate Jeopardy Removal Plan on 11/23/2022, alleging removal of the Immediate Jeopardy on 04/15/2022. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. On 04/04/2022, Licensed nursing staff completed skin assessments of 100% of cognitively impaired resident with a Brief Interview for Mental Status (BIMS) of less than eight (8). 2. On 04/04/2022, the Social Service Director (SSD) completed resident interviews with 100% of alert and oriented residents with a BIMS above (8) eight. No residents voiced any concerns of abuse, and no areas of concern were identified. 3. On 04/05/2022, the Facility Consultant reviewed 100% of grievances for January, February, and March 2022, to ensure all reportable allegations were reported and investigated. 4. The Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and the Facility Consultant conducted 100% staff interviews regarding allegations of abuse to determine if any were not reported. This was completed by 04/05/2022. As of 04/08/2022, any staff member who had not been interviewed was not allowed to work until interviews were completed. On 04/07/2022 an issue was identified. This situation involved the same staff member who was already suspended based on the first investigation. The second incident was reported to the appropriate state agencies. 5. On 04/05/2022, the Facility Consultant did in-service with the Administrator, DON, ADON and Unit Manager (UM). The abuse policy was reviewed, reporting immediately, within two (2) hours and within twenty-four (24) hours was discussed. They also went over the types of abuse, The Elderly Justice Acts and required postings in the facility, protecting the residents immediately and the suspension of the alleged perpetrator. 6. Nursing management staff to include the UM, ADON, DON and Facility Consultant completed re-education with 100% of facility staff to include as needed staff. The facility did not use agency or temporary staff at the time of this re-education. All education was completed by 04/08/2022. Education was provided on the abuse policy, reporting all allegations of abuse immediately to the supervisor, the types of abuse, the Elderly Justice Act, protection of the residents and suspension of the alleged perpetrator. 7. The Facility Consultant, DON, ADON, UM and Administrator conducted quizzes with 100% of staff currently employed at the facility. This was completed 04/08/2022. 8. On 04/07/2022, the Administrator educated Housekeeper #1 regarding the abuse policy, types of abuse, timely reporting of abuse and immediate protection of the resident. Housekeeper #1 was no longer employed at the facility. 9. Any staff that could not be reached on scheduled workday or by phone was sent a certified letter explaining the expectation for reeducation. 10. All new staff since 04/08/2022 were educated upon hire on the abuse policy with a focus on timely reporting of abuse. 11. The Facility Consultant attempted to report on 04/11/2022 to the State Board of Nursing and Community College that SRNA #2 had been substantiated for abuse. 12. Starting 04/15/2022, the facility will interview five (5) staff members to determine if any new allegations of abuse were not reported, when it required reporting and to whom. This was conducted by the DON, ADON, UM and/or the Administrator. Staff were selected randomly, to account for different shifts and different units with the focus on direct care staff members. Audits of five (5) staff per week were completed for four (4) weeks, two (2) staff per week for two (2) weeks, one (1) staff per week for two (2) weeks and one (1) staff per month for two (2) months. 13. Starting 04/15/2022, the facility had five (5) staff members complete an Abuse Quiz which was administered by the DON, ADON, UM and/or Administrator for four (4) weeks. Then two (2) staff for two (2) weeks, one (1) staff for two (2) weeks and one (1) staff for two (2) months. This was used to ensure the staff were maintaining what they learned through the re-education. Any staff member who did not obtain 100% were retrained on the spot. 14. Starting 04/15/2022, five (5) residents per week for four (4) weeks with a BIMS greater than eight (8) were randomly selected for interviews by the SSD. She used the Safe Survey to identify if resident had any concerns about how they were treated by staff in the facility. The facility continued to do this assessment of two (2) residents for two (2) weeks, one (1) resident for two (2) weeks and then one (1) resident for two (2) months. No concerns were identified. 15. The Quality Assurance Performance Improvement (QAPI) team met on 04/04/2022 to put a plan of action together once concerns of abuse had been identified. Present at the initial meeting were the Administrator, the DON, Dietary Manager, Facility Consultant, Rehabilitation Director, Unit Manager, SSD, and the Minimum Data Set Nurse. The Medical Director was present on the phone but did not offer any new suggestions. The last QAPI meeting reviewing the performance improvement plan was held on 07/27/2022 with no new issues identified since the initiation of the improvement plan. Members present included the Administrator, DON, Medical Director via phone, Environmental Services Director, SSD, MDS Nurse, and the Quality Improvement Nurse. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Review of Skin Assessments as compared to the Brief Interview for Mental Status (BIMS) listing for the time of this event validated each resident with a BIMS less than (8) had a skin assessment. No signs or symptoms of abuse were identified by the facility and after review, none were identified by the surveyor. 2. Review of the interview questionnaire of residents with a BIMS of eight (8) or greater completed on 04/04/2022, revealed no residents voiced any concerns regarding abuse through the interviews conducted by the SSD. Interview with Resident #6 on 11/21/2022 at 9:35 AM, revealed the resident felt very safe at the facility, staff were kind and took good care of her/her. The resident also stated the staff never talked bad or mistreated him/her in any way. Resident #6 reported he/she would talk to the Director of Nursing (DON) or the SSD if there were any concerns and felt things would be taken care of. Interview with Resident #4, on 11/21/2022 at 10:00 AM, revealed staff treated him/her very well. The resident revealed he/she felt very safe at the facility and the staff were wonderful and kind. Interview with Resident #7, on 11/21/2022 at 10:35 AM, revealed staff were really good and provided great care. Resident #7 revealed staff were very busy but were still able to meet his/her needs. The resident stated he/she was very outspoken and had no problem reporting any concerns to the staff. 3. Interview with the Facility Consultant on 11/23/2022 at 6:00 PM, revealed she reviewed each entry into the grievance log for January, February, and March 2022 as alleged. She revealed however, a formal documented audit did not occur. She wrote a signed statement to show she reviewed the grievance log information and had not found any concerns. The State Survey Agency (SSA) Surveyor reviewed all the facility's grievance logs from April 2022 to the current date and discovered eight (8) areas the facility called care delivery concerns. Based on review of those eight (8) cases residents were interviewed and either could not recall the event, or no longer had any concerns regarding the issue. Interview on 11/21/2022 at 10:45 AM, with Resident #7 revealed he/she no longer had any care concerns. 4. Review of the facility's documentation of the abuse questions completed by staff compared to the staff roster revealed one hundred and one (101) staff's name present, which was 100% of the facility's staff at that time, documented as having completed the training as alleged. Additionally, interviews were 11/22/2022: with SRNA #6 at 1:45 PM; SRNA #7 at 1:30 PM; SRNA #8 at 2:35 PM; SRNA #12 at 12:40 PM; SRNA #13 at 1:50 PM; and SRNA #14 at 2:55 PM. All the SRNAs revealed they were interviewed about any allegations of abuse or concerns of abuse, how and when abuse was to be reported to the DON and/or the Facility Consultant. Interview on 11/22/2022: with Housekeeper #1 at 12:05 PM; Housekeeper #2 at 12:15 PM; and a laundry staff person at 12:30 PM revealed all had been interviewed by the DON and/or the Facility Consultant about when to report abuse, to whom to report abuse and the different kinds of abuse. All staff interviewed revealed it was not up to them to determine if a situation was abuse or not, they were just to report it immediately to management. 5. Interview with Licensed Practical Nurse (LPN) #7/Unit Manager on 11/22/2022 at 3:00 PM, revealed she had been provided education by the Facility Consultant on the abuse policy; reporting immediately, within two (2) hours and within twenty-four (24) hours; the types of abuse; the Elderly Justice Acts; required postings in the facility; protecting the residents immediately and suspension of the alleged perpetrator. LPN #7 stated she had to pass a quiz covering all those subjects. Interview with the ADON on 11/23/2022 at 5:45 PM, revealed she was provided education by the Facility Consultant on the abuse policy; reporting immediately, within two (2) hours and within twenty-four (24) hours; the types of abuse; the Elderly Justice Acts; required postings in the facility; protecting the residents immediately and suspension of the alleged perpetrator. The ADON stated she was required to take a quiz and pass it with 100%. Interview with the DON on 11/23/2022 at 6:00 PM, revealed the Facility Consultant provided in-services on the abuse policy; reporting immediately, within two (2) hours and within twenty-four (24) hours; the types of abuse; the Elderly Justice Acts; required postings in the facility; protecting the residents immediately and suspension of the alleged perpetrator. Interview with the Administrator on 11/23/2022 at 6:15 PM, revealed the Facility Consultant covered the abuse policy; reporting immediately, within two (2) hours and within twenty-four (24) hours; the types of abuse; the Elderly Justice Acts; required postings in the facility; protecting the residents immediately and suspension of the alleged perpetrator with him. 6. Review of the facility's sign in sheets for the in-services provided for staff revealed one hundred and one (101) staff's names, which represented 100 % of the facility's staff employed at that time. Per review, all education was completed by 04/08/2022. Interviews conducted with thirty-four (34) facility staff on 11/22/2022 through 11/23/2022, revealed very staff member interviewed was able to name the seven (7) types of abuse, when to report incidents (immediately), who to report to incidents to (their direct supervisor), the DON, and the Administrator. In addition, all staff interviewed were able to identify that resident safety was the number one (1) priority, and the alleged perpetrator would be suspended pending investigation. Further interview revealed staff also expressed understanding that it was not up to them to decide if a situation was abuse or not, it had to be reported so management could investigate. Interview with the Facility Consultant, on 11/23/2022 at 6:00 PM, revealed she provided reeducation to the Administrator and all staff were provided education on 04/04/2022. Interview revealed she immediately activated the Performance Improvement Plan (PIP) and started doing quizzes with staff. According to the Facility Consultant, all staff were present and took the quiz and were required to get 100%. She stated if the staff member did not get 100% score, reeducation was conducted on the spot and the quiz was taken again until 100% was achieved. 7. Interview with the Facility Consultant on 11/23/2022 at 6:20 PM, revealed she was present for the quizzes for the majority of staff members. She revealed she was at the door where the quiz was given and graded it on the spot. Continued interview revealed any missed items were immediately reviewed with the staff member and then the staff member had to take the quiz again until 100% was achieved. She further stated staff were not scheduled to work again until the task was completed. 8. Review of the facility's signed document revealed the Administrator completed the alleged education for Housekeeper #1 regarding the abuse policy, types of abuse, timely reporting of abuse and immediate protection of the resident listed on 04/07/2022. Per review, Housekeeper #1 was disciplined, and warning disciplinary action was validated by the SSA Surveyor. Interview with the Administrator on 11/23/2022 at 4:30 PM, revealed he provided the re-education for Housekeeper #1 back in April 2022, when the incidents arose. He revealed he went over the F600 regulation with the staff member and a warning disciplinary action was given to the Housekeeper #1. 9. Review of the facility's certified mail receipts revealed letters were sent as alleged, and the card received back prior to 04/15/2022. The review revealed no concerns were noted. 10. Review of the last five (5) staff hired revealed the abuse packet in orientation and review of the policy to ensure new staff were educated and understood the expectation. Interview on 11/22/2022, with Housekeeper #2 and Housekeeper #3, Laundry Staff #1, Cook, and Nurse Aide Student revealed all the staff each knew the seven (7) types of abuse; knew to make sure the resident was safe; to report to management immediately; and that they did not determine what was or was not abuse. Interview with the Staff Development Coordinator on 11/23/2022 at 1:25 PM, revealed she had helped with ongoing training for new staff in orientation. She revealed all staff were trained on abuse before they access the floor, and this had included her. Per the SDC, the Facility Consultant did the orientation with her and went over the facility policies and procedures since she was new to this agency. She revealed she had been doing on going education with staff on abuse. Interview with the DON on 11/23/2022 at 1:40 PM revealed she was provided education when she came on board with the facility. 11. Interview with the Facility Consultant on 11/23/2022 at 6:00 PM, revealed she called the State Board of Nursing and was informed they were not where that information needed to be reported to. She stated she was told to contact the State Community College to make the report. Per interview she called the State Community College and was informed they did not take that type of report either. She called back to the Board of Nursing, and they did not have a different answer. Further interview revealed the Facility Consultant had a signed form to account for the phone calls she had made regarding determining the correct reporting path, which she had been unable to do. 12. Starting 04/15/2022, the facility would interview five (5) staff members to determine if any new allegations of abuse were not reported, when it required reporting and to whom. This was conducted by the DON, ADON, UM and/or the Administrator. Staff were selected randomly, to account for different shifts and different units with the focus on direct care staff members. Audits of five (5) staff per week were completed for four (4) weeks, two (2) staff per week for two (2) weeks, one (1) staff per week for two (2) weeks and one (1) staff per month for two (2) months. Review of the facility's audits revealed the facility interviewed staff members as alleged in the IJ Removal Plan within the specified timeframes and no concerns were noted. Interviews with staff conducted between 11/22/2022 and 11/23/2022 revealed thirty-four (34) staff plus management staff, to include housekeepers, laundry, maintenance, dietary staff, nurse aides and licensed nurses were able to account for each subject they received education on. Each staff member could report the seven (7) types of abuse, identify they were to keep the resident safe, and report immediately to management. Also, staff reported it was not up to them to decide if something was abuse or not, just report anything that was a concern. It was determined through these interviews, two (2) staff members could use a bit more education on the exact requirements, but they knew the basics. The facility was made aware of the concerns. This does not put them to a later compliance date because of the special needs of those two (2) staff members. Interview with the MDS Coordinator on 11/23/2022 at 1:00 PM, revealed she helped with in-services and did pop up interviews on staff randomly and ask them abuse questions. Further interview revealed she felt the facility had done a great job making sure everyone knew the expectation on abuse and what had to happen. 13. Review of the facility's documentation of staff audits revealed the number of staff audits was provided and noted to be accounted for each timeframe represented above. Per review, the staff interviewed were able to verbalize the seven (7) types of abuse, state they were to report incidents immediately and to keep the residents safe. Further review revealed as of 11/22/2022, the facility had provided much abuse training for many staff regarding the ongoing education over the months by all management staff, with no concerns found. 14. Interview with Resident #4 on 11/22/2022 at 10:00 AM, revealed the facility had interviewed him/her, and he/she felt safe in the facility. Resident #4 stated staff treated him/her well and if there were any concerns, he/she knew to report to the charge nurse or the DON. Interview with Resident #7 on 11/22/2022 at 10:35 AM, revealed the facility had interviewed him/her and he/she felt safe in the facility. The resident revealed staff were kind and provided good care and if there were any concerns, he/she would report it to the DON and/or Administrator. Interview with the Social Services Director (SSD) on 11/23/2022 at 12:40 PM, revealed she helped with the facility's removal plan and completed the Safe Surveys with residents and no concerns were found. 15. Review of the facility's QAPI minutes documentation and sign in sheet for 04/04/2022 revealed the Facility Consultant, Dietary Manager, Unit Manager, Social Service Director, and Administrator were present. Per review, they identified the abuse allegation, the resident involved, the staff members named as perpetrator and witness and an investigation was started. Review revealed audits tools were created and education was started, with quizzes given to all staff present at the facility and staff who were not present were called and asked to come in for education. Interview with the Quality Improvement (QI) Nurse, on 11/23/2022 at 12:20 PM, revealed she was a floor nurse before she was selected for the QI Nurse position after the 04/04/2022 QAPI. She revealed in the QAPI meetings she attended, the Administrator, DON, ADON, both UM, Housekeeping Manager, Maintenance Director, Dietary, SSD, MDS staff had all been present. She revealed the Medical Director was present on the phone or sometimes present in person. Per interview, abuse prevention and awareness were ongoing. Interview with the Social Services Director (SSD) on 11/23/2022 at 12:40 PM, revealed she had been present at the 04/04/2022 QAPI meeting. She revealed in the QAPI meeting they had gone over the allegation of abuse, and it was determined at that time to put a plan in place. Continued interview revealed they discussed new admissions, discharges and discussed any other corrective plans that might be in place or needed. The SSD stated the Administrator, DON, Housekeeping Manager, Maintenance Director, Dietary, QI Nurse, UM, ADON, MDS, SDC, and the Medical Director attended the QAPI meetings. Further interview revealed the Medical Director had been present via the phone. Interview with the MDS Coordinator on 11/23/2022 at 1:00 PM, revealed she had attended every QAPI meeting except one (1). She stated the main focus had been abuse, the process and why it was important to report within the necessary timeframe. Continued interview revealed in the QAPI meetings, they discussed concerns that some staff might not identify certain things as abuse, but they had been educated