**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to protect the residents' right to be free from physical abuse by staff for Resident #1, free from physical and verbal abuse and psychosocial harm by staff for Resident #5, and free from verbal abuse by staff for Residents #10, #11, and #12 (5 residents) out of 11 (#1, #2, #3, #4, #5, #6, #10, #11, #12, #14 and #15) sampled residents reviewed for abuse. The deficient practice resulted in an Immediate Jeopardy when: 1. On 12/23/2023 at approximately 7:30 p.m., S3CNA (Certified Nursing Assistant) physically abused Resident #1 by hitting Resident #1 on right shoulder and right cheek and slapping Resident #1's lower arm. Resident #1 is cognitively impaired and nonverbal, with the exception of the word Si. Resident #1 is capable of answering questions by nodding yes/no, using hand gestures and saying Si for yes. Resident #1 was able to communicate S3CNA hit her on the right shoulder and twice on the right cheek. Resident #1 acknowledged physical abuse by S3CNA hurt and Resident #1 was afraid of S3CNA. S1Administrator and S2DON (Director of Nursing) were made aware of the abuse on 12/23/2023 when Resident #4, who is cognitively intact, reported having witnessed S3CNA aggressively hit Resident #1 on the right shoulder. After this incident of abuse, staff were not retrained on abuse prevention to include residents with poor cognition, impaired communication, dementia, and behaviors. 2. The immediate jeopardy continued on 01/15/2024 at 10:17 p.m., when S4CNA physically and verbally abused Resident #5, who is cognitively impaired, while providing peri-care. Observation of surveillance video revealed S4CNA aggressively pushed and pulled on Resident #5's contracted left leg to position and reposition Resident #5. S4CNA bent Resident #5's right thumb backwards in a forceful manner, in an attempt to release Resident #5's grip on the handrail. Resident #5 was noted to be in pain and agitated. Resident #5 repeatedly expressed pain to S4CNA during peri-care. Resident #5 yelled in part, G___ d___, don't push on me no more . don't dig your claws into me like that; that hurts . G___ d___, that hurts. S4CNA was heard cursing at Resident #5 and with a raised voice stated in part, Well, roll your a__ over . I'm not going to keep trying to roll you and you steady rolling that way to f___ . Y'all hurting my back with this dumb s____ . I shouldn't have to deal with dumb s___ like this. S1Administrator was made aware of the abuse to Resident #5 by S4CNA, on 01/18/2024, by viewing video surveillance provided by Resident #5's RP (Responsible Party). Even though there was no significant decline in mental or physical functioning, it can be determined that the reasonable person would have experienced severe psychosocial harm as a result of the physical and verbal abuse, since a reasonable person would not expect to be treated in this manner in his own home or a health care facility. After this incident of abuse, staff were not retrained on abuse prevention to include residents with poor cognition, impaired communication, dementia, and behaviors. By the facility failing to implement protective measures, there was a high likelihood that additional severe harm, injury, or death could occur to the 118 residents residing in the facility per the Resident Census and Conditions Report dated 01/18/2024. S1Administrator and S2DON were notified of the Immediate Jeopardy on 01/24/2024 at 11:30 a.m. The Immediate Jeopardy was removed on 01/25/2024 at 10:25 a.m. The facility implemented an acceptable Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to exit. Findings: Review of the facility's Abuse and Neglect Policy, with a revision date of 11/07/2023, revealed in part: This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free of abuse, corporal punishment, involuntary seclusion, and financial abuse. Policy: 1. The facility will prohibit neglect, mental and physical abuse of residents. Definitions: Abuse means the willful infliction of injury . pain or mental anguish. Physical Abuse includes hitting, slapping, kicking, shoving, pinching and controlling behavior through corporal punishment. Verbal Abuse is defined as the use of oral, written or gestured language that willfully includes disparaging or derogatory terms to residents or their families or within their hearing distance regardless of their age, ability to comprehend or disability. Mental abuse includes, but is not limited to humiliation, harassment, and threats of punishment of depravation Resident #1 Resident #1 was admitted to the facility on [DATE] with diagnoses, which included in part, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, aphasia, and dysphagia. Review of Resident #1's Quarterly MDS (Minimum Data Set) dated 11/04/2023 revealed in part, Resident #1 had a BIMS (Brief Interview of Mental Status) score of 12 out of 15 indicating moderately impaired cognition. Resident #1 was always incontinent of bowel and bladder and dependent on staff for ADL (Activities of Daily Living) care. Resident #1 required extensive assist by one staff for bed mobility. Review of Resident #1's comprehensive care plan revealed Resident #1 was care planned for a communication problem related to stroke and diagnosis of aphasia, with approaches including staff to speak on an adult level and speak clearly and slower than normal. Resident #1 is able to communicate by gestures with an intervention for staff to validate Resident #1's message by repeating aloud. Resident #1 has impaired cognition with approaches including staff to ask yes/no questions, in order to determine Resident #1's needs. Further review of Resident #1's comprehensive care plan revealed Resident #1 was care planned for physical and verbal, aggressive behaviors with approaches including staff to intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, and if response is aggressive, staff to walk calmly away and approach later. Review of Resident #1's medical record revealed an interdisciplinary note dated 12/23/2023 at 7:39 p.m. by S5LPN (Licensed Practical Nurse) which read in part, Resident #4 wheeled to S5LPN while down the hall passing medication, stating Resident #3 and I (Resident #4) just called S1Administrator because S3CNA hit Resident #1 on the shoulder. Resident #4 stated, Resident #1 also told me (Resident #4), S3CNA slapped Resident #1's face. Review of signed witness statement provided by Resident #1 dated 12/26/2023 revealed in part, S1Admininistrator and S2DON spoke to Resident #1 about the incident with S3CNA. Resident #1 stated S3CNA used the back of her hand to slap Resident #1's right cheek while in the room with S3CNA, alone. Resident #1 is afraid of S3CNA and does not want to work with her again. Resident #1's witness statement was written by S2DON. Review of signed witness statement by Resident #4 dated 12/26/2023 revealed in part, Resident #4 stated she saw S3CNA use the back of her hand to hit Resident #1's arm and tell Resident #1 it was time to get changed. Resident #1did not move and Resident #4 stated S3CNA swung Resident #1 around in wheelchair to take into the room. Review of signed witness statement by S5LPN dated 12/30/2023 revealed in part: S3CNA yelled down the hall stating . Resident #1 is acting up again . I (S5LPN) walked down the hall to speak with Resident #1 who was sitting on the middle of the hall screaming loud and crying . Resident #1 began taking brief off .smearing (bm) bowel movement against the wall and started screaming louder. S5LPN informed S3CNA to leave Resident #1 alone and let resident calm down; then I will speak with Resident #1 again. I (S5LPN) went back down the hall to administer medication . Resident #4 reported S2DON and S1Administrator were notified because she (Resident #4) witnessed S3CNA hit Resident #1. During an interview on 01/18/2024 at 2:00 p.m., Resident #1 responded by nodding yes/no, using gestures and stating Si for yes. Resident #1 nodded head yes and stated Si when asked if she had been taken care of by S3CNA. Resident #1 nodded yes and stated Si when asked if she recalled an incident on 12/23/2023 with S3CNA. Resident #1 took her open right hand and placed it on her right cheek twice to demonstrate where S3CNA had hit her. Resident #1 nodded yes several times, answered Si, Si, and held up two fingers to confirm S3CNA hit her twice on the right cheek. Resident #1 further demonstrated S3CNA hit her on the arm by repeatedly touching her right shoulder. Resident #1 confirmed S3CNA hit her on the right shoulder by nodding yes and answered Si, Si. Resident #1 acknowledged the physical abuse by S3CNA hurt and she was afraid of S3CNA. During an interview on 01/18/2024 at 2:15 p.m., Resident #4 reported she had witnessed S3CNA, during the evening shift, on 12/23/2023, approach Resident #1 in the hall and start smacking Resident #1's right shoulder with the back of S3CNA's hand in a very aggressive manner. Resident #4 further reported S3CNA continued smacking on Resident #1's right arm, swung the wheelchair around, pushed Resident #1 into Resident #1's room, and shut the door. Resident #4 further reported, later into the shift, Resident #1 was sitting in the hall, crying and gesturing at her face. Resident #4 reported Resident #1 replied Si and nodded yes, when asked if S3CNA had hit her on the face. Review of Resident #4's Quarterly MDS dated [DATE] revealed in part a BIMS score of 15 out of 15, indicating intact cognition. During an interview on 01/18/2024 at 4:00 p.m., S2DON reported she was informed of the allegation of abuse on 12/23/2023 when S1Administrator telephoned and merged a call with Resident #4. Resident #4 reported to S2DON and S1Administrator, she had witnessed S3CNA slap Resident #1 on the arm. S2DON reported during an interview with Resident #1, S2DON and S1Administrator, Resident #1 took S1Administrator's hand and placed it on her right cheek to demonstrate where S3CNA had struck her. S2DON acknowledged Resident #1 was afraid of S3CNA. S2DON reported she trusted Resident #4 who had a high BIMS score and believed what Resident #4 had reported. During an interview on 01/22/2024 at 8:00 a.m., S1Administrator reported S3CNA was immediately suspended pending investigation and terminated on 01/02/2024 upon substantiating physical abuse. During an interview on 01/22/2024 at 9:15 a.m., Resident #2 reported he had witnessed S3CNA slap Resident #1's arm on the evening shift of 12/23/2023. Resident #2 reported he was sitting on his bed and had a clear view into Resident #1's room. Resident #2 reported he could hear the slap from across the hall. Review of Resident #2's Annual MDS dated [DATE] revealed in part a BIMS score of 14 out of 15, indicating intact cognition. Review of facility's Life Satisfaction Rounds dated 12/26/2023 revealed in part, Resident #2 answered S3CNA had been rude to and had yelled at Resident #2. Resident #2's comment revealed Resident #2 does not allow S3CNA to provide care. During a telephone interview on 01/23/2024 at 8:50 a.m., S5LPN reported Resident #4 informed her (S5LPN), she had witnessed S3CNA hit Resident #1 on the arm. S5LPN reported she approached Resident #1 for assessment and Resident #1 kept shaking her head no and tapping on her right arm. S5LPN reported Resident #1 was unable to communicate further findings. During an interview on 01/23/2024 at 1:00 p.m., S1Administrator reported decision to terminate S3CNA was based on Resident #4's witnessed account and results of Life Satisfaction Rounds, which had raised concerns regarding S3CNA. Review of in-service dated 12/27/2023 revealed in part, all departments had been educated on facility's general abuse policy. Further review failed to reveal staff had been instructed on allegations of abuse of residents with behaviors, dementia, and residents with impaired cognition. Resident #5 Resident #5 was admitted to the facility on [DATE] with diagnoses, which included in part, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, contracture of left knee, dementia with other behavioral disturbance, schizoaffective disorder, and bipolar II disorder. Review of Resident #5's Quarterly MDS dated [DATE] revealed Resident #5 had a BIMS score of 03 out of 15, indicating severely impaired cognition. Resident #5 was always incontinent of bowel and bladder and dependent on staff for ADL care. Resident #1 was totally dependent for bed mobility and required two staff assistance. Review of Resident #5's comprehensive care plan revealed in part, Resident #5 was care planned for impaired cognitive function and impaired thought process related to dementia and BIMS score. Approaches included ask yes/no questions in order to determine Resident #5's needs, communicate with necessary cues and stop and return if Resident #5 was agitated. Further review of Resident #5's comprehensive care plan revealed Resident #5 was care planned for socially inappropriate, disruptive behaviors with approaches including, staff to speak in a calm manner, explain all procedures to the resident before starting and allow resident to adjust to changes. During an interview on 01/22/2024 at 8:30 a.m., S1Administrator reported Resident #5's RP came into the office on 01/18/2024 and presented a surveillance video of verbal and physical abuse by S4CNA toward Resident #5 which occurred on 01/15/2024. S1Administrator reported he and S6Corporate Nurse watched the video. S1Administrator acknowledged physical and verbal abuse and identified employee in the video as S4CNA. Review of video with audio, provided by Resident #5's RP, from 01/15/2024 at 10:14:47 p.m. to 01/15/2024 at 10:20:30 p.m. revealed in part: 10:14:54 p.m. S4CNA entered Resident #5's room. Resident #1 was observed to be lying flat in bed covered with blanket. 10:15:29 p.m. S4CNA pulled Resident's #5's blanket back, revealing Resident #5's left knee contracture. S4CNA removed Resident #5's brief. 10:15:41 p.m. S4CNA exited Resident #5's room and Resident #5 was left fully exposed. 10:17:08 p.m. S4CNA returned to Resident #5's room carrying supplies. S4CNA began performing peri-care to Resident #5 from the left side of the bed. 10:17:22 p.m. S4CNA pushed Resident #5's contracted left leg over towards the right side of the bed until Resident #5 was positioned on Resident #5's right side. 10:17:27 p.m. Resident #5 yelled G___ d___, don't push on me no more. S4CNA proceeded to clean Resident #5's buttocks area. 10:17:49 p.m. Resident #5 yelled, Don't dig your claws into me like that. That hurts! 10:18:36 p.m. S4CNA finished cleaning Resident #5 and prepared a new brief. 10:18:49 p.m. S4CNA grabbed Resident #5's contracted left leg and pulled Resident #5 towards the left side of the bed. 10:18:52 p.m. Resident #5 yelled G___ d___ that hurts. S4CNA responded Well, roll your a__ over. 10:18:56 p.m. S4CNA began placing clean brief on Resident #5. S4CNA stated in a raised voice I'm not going to keep trying to roll you and you steady rolling that way to f___. Y'all hurting my back with this dumb s___. 10:19:04 p.m. S4CNA yelled, Roll over . I shouldn't have to deal with dumb s___ like this. 10:19:12 p.m. Resident #5 yelled It hurts and S4CNA replied, G___ d___, you're hurting me too. 10:19:25 p.m. S4CNA walked to the right side of the bed and attempted to roll Resident #5 to his left side. Resident #5 was observed to be gripping the left side rail. S4CNA began pulling Resident #5's fingers back and aggressively bent Resident #5's right thumb in a backward motion. 10:19:41 p.m. Resident #5 yelled G___ d___ that hurts. 10:19:44 p.m. S4CNA replied with a raised voice That's how my back feels. 10:19:59 p.m. S4CNA instructed, with a raised voice, Relax your arm, Resident #5 and S4CNA continued to pull Resident #5's right arm away from left handrail. 10:20:15 p.m. S4CNA stated to Resident #5 You're being such an a__. 10:20:30 p.m. Resident #5 stated, Well, that hurts too. Peri-care was completed. During an interview on 01/22/2024 at 2:40 p.m., Resident #5's RP acknowledged having become more aware of issues with Resident #5's care after installing a camera in Resident #5's room for monitoring. An observation on 01/22/2024 at 4:30 p.m. revealed Resident #5 sitting upright in bed watching television. Resident #5 was observed to be clean, without odors and appeared comfortable. Resident #5 was unable to participate in an interview. During an interview on 01/23/2024 at 1:00 p.m., S1Administrator confirmed, upon review of Resident #5's surveillance video on 01/18/2024, S4CNA was immediately suspended pending investigation. S1Administrator further confirmed the determination was made to substantiate physical and verbal abuse and S4CNA was terminated on 01/22/2024. Review of in-service dated 01/18/2024 revealed in in part, all departments had been educated on facility's general abuse policy. Further review failed to reveal staff had been instructed on allegations of abuse of residents with behaviors, dementia, and residents with impaired cognition. During an interview on 01/24/2024 at 10:00 a.m., S2DON acknowledged training provided to staff after the incidents on 12/23/2023 and 01/15/2024 was on the general abuse policy and failed to address allegations of abuse of residents with behaviors, dementia, and residents with low BIMS scores. S2DON acknowledged both Resident #1 and Resident #5 had exhibited behaviors and acknowledged facility did not have a formal process in place to address the training needs for staff for allegations of abuse toward residents with a low BIMS score or residents with severe behaviors. During an interview on 01/24/2024 at 1:40 p.m., S1Administrator acknowledged staff had not received focused training on abuse for vulnerable residents and should have. S1Administrator confirmed this could have contributed to the abuse circumstances. Resident #10 Review of Resident #10's medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included in part, encephalopathy, history of septic shock, chronic obstructive pulmonary disease, cerebral vascular accident, type 2 diabetes, cognitive communication deficit, lack of coordination, bipolar disease and essential hypertension. Review of Resident #10's MDS dated [DATE] revealed Resident #10 had a BIMS score of 12 out of 15 indicating moderately impaired cognition. Review of Resident #10's comprehensive care plan revealed in part, Resident #10 was care planned for impaired cognitive function and impaired thought processes related to Resident #10's diagnosis of dementia and BIMS score of 12 with approaches that included in part; give meds as ordered, monitor for side effects and effectiveness, communicate with resident using his name, reorient resident as often as needed, communicate with family as needed, monitor, document and report any changes to resident family and medical doctor. Review of facility's Life Satisfaction Rounds dated 01/24/2024 revealed in part, Resident #10 had reported S8CNA had been verbally abusive. During an interview on 01/29/2024 at 2:00 p.m., Resident #10 reported in the past, S8CNA just went off and yelled at her when Resident #10 asked S8CNA to help her look for something. Resident #10 reported S8CNA was very rude and told her to get the other one to help you look for it. Resident #10 further reported, I called my son on the phone and told him about how rude S8CNA was and during the phone conversation S8CNA kept walking by my door listening to the conversation. Resident #10 further stated S8CNA came into her room a few days later and pointed her finger in her face and yelled at her you know my name, because you talked about me yesterday. Resident #10 stated when S8CNA would come in her room she felt anxious and nervous. Resident #10 stated I told the director of nurses when they came around asking about S8CNA. During a telephone interview on 01/29/2024 at 12:17 p.m., Resident #10's son reported his mother (Resident #10) called him and told him S8CNA had stormed into her room and pointed her finger at her aggressively and had been verbally abusive to her. During an interview on 01/30/2024 at 8:30 a.m., Resident #R19 (Resident #10's roommate) reported S8CNA was rude to Resident #10. Resident #R19 further reported S8CNA yelled at Resident #10 and pointed her finger in Resident #10's face. Resident #R19 stated, S8CNA talked sharp and rough to some residents. Review of Resident #R19's MDS revealed a BIMS score of 15 out of 15 indicating intact cognition. During an interview on 01/30/2024 at 8:00 a.m., S1Administrator reported S8CNA was suspended on 01/24/2024 when Resident #10 made allegations of verbal abuse during Life Satisfaction Rounds. S1Administrator confirmed the alleged verbal abuse was substantiated and S8CNA was officially terminated on 01/29/2024. S1Administrator also confirmed S8CNA should have been retrained on abuse after a previous allegation of abuse. Resident #11 Review of Resident #11's medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses, which included in part, hemiplegia following a cerebral vascular accident, cardiovascular disease, a history of breast cancer, polyneuropathy, seizures, bipolar disease, hypothyroidism, urine retention, contracture, schizophrenia, and essential hypertension. Review of Resident #11's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Review of Resident #11's comprehensive care plan revealed Resident #11 was care planned for an activities of daily living self-care performance deficit with approaches that included in part, active range of motion with care, allow extra time when communicating with resident, one person assistance with bed mobility, transfers, dressing, hygiene and bathing, monitor and document and report any changes and any potential for improvement. Review of facility's Life Satisfaction Rounds dated 01/24/2024 revealed in part, Resident #11 had reported S8CNA had been verbally abusive. During an interview on 01/30/2024 at 8:30 a.m., Resident #11 reported S8CNA was always mad at her. Resident #11 reported in the past when she asked S8CNA to shower her, S8CNA took her to the shower room, closed the door, and began to curse her out. Resident #11 further reported S8CNA told her to shut up when Resident #11 asked S8CNA to move to a different shower chair that was not slippery. Resident #11 stated, I told her she treats me like s___ and S8CNA raised her hand at me as if she was going to hit me and told me I was not going to get no d___ towel. Resident #11 stated S8CNA made me feel very uncomfortable. Resident #11 also reported S8CNA would tap the glass with her hand when Resident #11 attempted to drink wine, causing her to deliberately spill the prescribed wine. Resident #11 further stated, I reported this to administration when they asked me. During an interview on 02/01/2024 at 9:38 a.m., S10CNA reported overhearing Resident #11 say to another staff, S8CNA would make Resident #11 hold her urine and tell Resident #11stop drinking so much. S10CNA also reported Resident #11 had her shower moved to the day shift because S8CNA would go off on Resident #11 when she asked to be showered on the evening shift. During an interview on 01/30/2024 at 8:00 a.m., S1Administrator reported S8CNA was suspended on 01/24/2024 when resident #11 made allegations of verbal abuse during Life Satisfaction Rounds. S1Administrator confirmed the alleged verbal abuse was substantiated and S8CNA was officially terminated on 01/29/2024. S1Administrator also confirmed S8CNA should have been retrained on abuse after a previous allegation of abuse. Resident #12 Review of Resident #12's medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses which included in part, metabolic encephalopathy, and lack of coordination, gastronomy, muscle wasting left shoulder, cognitive communication deficit, polyneuropathy, major depressive disorder, joint derangement and dysphagia. Review of Resident #12's MDS dated [DATE] revealed Resident #12 had a BIMS score of 15 out of 15 indicating intact cognition. Review of Resident #12's comprehensive care plan revealed Resident #12 was care planned for limited physical mobility with approaches that included in part; resident is dependent on assistance with bed mobility, locomotion, personal hygiene toileting requiring extensive assistance, requiring total assistance with transfers. Review of facility's Life Satisfaction Rounds dated 01/24/2024 revealed in part, Resident #12 had reported S8CNA had been verbally abusive and stated, S8CNA would yell at me. During an interview on 01/30/2024 at 1:45 p.m., Resident #12 reported S8CNA's words were mean all the time. Resident #12 stated, She wouldn't put me to bed when I wanted to go. She would speak rudely to me when I asked to be changed and say I will change you but you will stay in the bed and not get up again. Resident #12 stated, I like to be up in my chair, so I can go and smoke and socialize. When she made me stay in my room I feel isolated. Resident #12 reported she told the director of nurses about S8CNA's mean attitude. During an interview on 01/30/2024 at 8:30 a.m., Resident #R19 reported S8CNA was rude to Resident #12. Resident #R19 reported S8CNA told Resident #12 when she asked to be changed and cleaned up, If I clean you up, I'm not going to get you back up in the chair. Resident # R19 reported Resident #12 wanted to be up in the daytime, but S8CNA told Resident #12 she had to either not be cleaned up or get cleaned up and stay in the bed. Resident #R19 further reported S8CNA had a flip mouth and was always telling residents what she was not going to do. Review of Resident #R19's MDS revealed a BIMS score of 15 out of 15 indicating intact cognition. During an interview on 01/30/2024 at 1:25 p.m., S2DON confirmed Resident #12 reported S8CNA had been rude to her. S2DON reported Resident #12 told her S8CNA yelled at her when it was time for her to be changed, and when it was time for her to go to bed. Resident #12 told S2DON she didn't want to get put down for the night so early, so she didn't go get changed. S2 DON further reported Resident #12 was told by S8CNA, Next time I change you, you will not get back up and you will have to wait until 11pm to be changed. S2DON stated she reported this to the administrator who initiated an investigation. S8CNA had already been suspended on 01/24/2024 and was officially terminated on 01/29/2024. During an interview on 01/30/2024 at 8:00 a.m., S1Administrator reported S8CNA was already suspended on 01/24/2024 when Resident #12 made allegations of verbal abuse during Life Satisfaction Rounds. S1Administrator confirmed the alleged verbal abuse was substantiated and S8CNA was officially terminated on 01/29/2024. S1Administrator also confirmed S8CNA should have been retrained on abuse after a previous allegation of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Based on interview and record review, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 5 (#1, #5, #10, #11, and #12) of 11 residents (#1, #2, #3, #4, #5, #6, #10, #11, #12, #14 and #15) reviewed for abuse: 1. by failing to ensure a system was in place to protect Resident #1 from physical abuse by staff, Resident #5 from verbal abuse and psychosocial harm by staff, and Residents #10, #11, and #12 from verbal abuse by staff, prevent abuse from happening again and ensure all residents were free from abuse; 2. by failing to ensure a system was in place to provide ongoing staff training to identify vulnerable residents at risk for abuse and address residents with behaviors, dementia, and low BIMS (Brief Interview for Mental Status) scores. The deficient practice resulted in an Immediate Jeopardy when: 1. On 12/23/2023 at approximately 7:30 p.m., S3CNA (Certified Nursing Assistant) physically abused Resident #1 by hitting Resident #1 on right shoulder and right cheek and slapping Resident #1's lower arm. Resident #1 is cognitively impaired and nonverbal, with the exception of the word Si. Resident #1 is capable of answering questions by nodding yes/no, using hand gestures and saying Si for yes. Resident #1 was able to communicate S3CNA hit her on the right shoulder and twice on the right cheek. Resident #1 acknowledged physical abuse by S3CNA hurt and Resident #1 was afraid of S3CNA. S1Administrator and S2DON (Director of Nursing) were made aware of the abuse on 12/23/2023 when Resident #4, who is cognitively intact, reported having witnessed S3CNA aggressively hit Resident #1 on the right shoulder. After this incident of abuse, staff were not retrained on abuse prevention to include residents with poor cognition, impaired communication, dementia, and behaviors. 2. The Immediate Jeopardy continued on 01/15/2024 at 10:17 p.m., when S4CNA physically and verbally abused Resident #5, who is cognitively impaired, while providing peri-care. Observation of surveillance video revealed S4CNA aggressively pushed and pulled on Resident #5's contracted left leg to position and reposition Resident #5. S4CNA bent Resident #5's right thumb backwards in a forceful manner, in an attempt to release Resident #5's grip on the handrail. Resident #5 was noted to be in pain and agitated. Resident #5 repeatedly expressed pain to S4CNA during peri-care. Resident #5 yelled in part, G___ d___, don't push on me no more . don't dig your claws into me like that; that hurts . G___ d___, that hurts. S4CNA was heard cursing at Resident #5 and with a raised voice stated in part, Well, roll your a__ over . I'm not going to keep trying to roll you and you steady rolling that way to f___ . Y'all hurting my back with this dumb s____ . I shouldn't have to deal with dumb s___ like this. S1Administrator was made aware of the abuse to Resident #5 by S4CNA, on 01/18/2024, by viewing video surveillance provided by Resident #5's RP (Responsible Party). Even though there was no significant decline in mental or physical functioning, it can be determined that the reasonable person would have experienced severe psychosocial harm as a result of the physical and verbal abuse, since a reasonable person would not expect to be treated in this manner in his own home or a health care facility. After this incident of abuse, staff were not retrained on abuse prevention to include residents with poor cognition, impaired communication, dementia, and behaviors. By the facility failing to implement protective measures, there was a high likelihood that additional severe harm, injury, or death could occur to the 118 residents residing in the facility per the Resident Census and Conditions Report date 01/18/2024. S1Administrator and S2DON (Director of Nursing) were notified of the Immediate Jeopardy on 01/24/2024 at 11:30 a.m. The Immediate Jeopardy was removed on 01/25/2024 at 10:25 a.m. The facility implemented an acceptable Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to exit. Findings, Cross Reference F600: During an interview on 01/24/2024 at 10:00 a.m., S2DON acknowledged training provided to staff was general abuse policy and failed to address behaviors, dementia, and residents with low BIMS scores. S2DON acknowledged both Resident #1 and Resident #5 had exhibited behaviors and acknowledged facility did not have a formal process in place to assess residents with a low BIMS score or residents with severe behaviors for abuse. During an interview on 01/24/2024 at 1:40 p.m., S1Administrator acknowledged staff had not received focused training on abuse for vulnerable residents and should have. S1Administrator confirmed this could have contributed to the abuse circumstances. II. Based on interview and record review, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for and for 2 (#16, #17) of 6 (#7, #8, #9, #13, #16, #17) residents reviewed for pressure ulcers. The facility failed to ensure 2 (#16, #17) of 6 (#7, #8, #9, #13, #16, #17) residents received wound care as ordered. The deficient practice resulted in an immediate jeopardy for Resident #16 on 12/15/2023 when S7 Wound Care FNP (Family Nurse Practitioner) assessed Resident #16's sacral wound as deteriorating and with s/s (signs and symptoms) of infection. On 12/15/2023, S7Wound Care FNP wrote a new order to change the wound care treatment and increase the frequency of Resident #16's sacral pressure ulcer wound care dressing changes from M/W/F (Monday/Wednesday/Friday) to every day. The facility did not provide wound care every day as ordered from 12/16/2023 to 12/25/2023 and instead provided wound care on M/W/F from 12/16/2023 to 12/25/2023. No wound care was provided on Wednesday 12/20/2023 and from 12/16/2023 to 12/25/2023 wound care was only provided 3 times. Resident #16 was sent to a local hospital on [DATE] due to sacral wound not healing properly. Resident #16's hospital records for 12/25/2023 indicated Resident #16 presented with sacral wound, low grade fever of 100.4 F (degrees Fahrenheit), and a foul odor was noted to the 6cm (centimeter) decubitus ulcer of the sacrum. Current active problems noted in the hospital records on 12/25/2023 included decubitus ulcer of sacrum stage 4 (acute), fever (acute), leukocytosis (acute), and sepsis (acute). A 12/25/2023 CT (Computed Tomography) of the abdomen pelvis revealed an impression of large right sacral decubitus ulcer extending to the coccyx with some osseous changes suggestive of underlying osteomyelitis. The immediate jeopardy continued for Resident #17 on 01/05/2024 when Resident #17's sacral pressure wound was initially found, wound care orders were received, and wound care orders were not carried out as ordered. The facility did not provide wound care as ordered by: 1. not providing wound care daily as per S7 Wound Care FNP's 01/05/2024 order and instead provided wound care each day Monday through Friday, excluding Saturday and Sundays, from 01/08/2024 to 01/31/2024; 2. not utilizing the ordered 0.125% Dakin's Solution during wound care and instead used 0.25% Dakin's Solution for wound care during the Monday through Friday wound care from 01/08/2024 to 01/31/2024; and 3. not conducting wound care as per S7 Wound Care FNP's 01/26/2024 order by utilizing 1% Flagyl instead of the ordered 0.1% Gentamycin and Santyl for wound care from 01/27/2024 to 01/31/2024. This deficient practice had the likelihood to cause more than minimal harm to the remaining 24 residents receiving wound care as per the Order Type: Wound Orders dated 01/31/2024. S1 Administrator, S6 Corporate Nurse and S2DON were notified of the Immediate Jeopardy on 02/01/2024 at 4:15 p.m. The Immediate Jeopardy was removed on 02/02/2024 at 4:00 p.m. when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through onsite interviews and record reviews prior to exit. Findings, Cross Reference F686: During an interview on 01/31/2024 at 3:05 p.m. S2DON reported if wound care had been ordered for every day, the wound care should have been conducted every day, Monday through Sunday. S2DON further reported she was not aware that daily wound care was not being conducted on the weekends and not conducting wound care as ordered could result in worsening of a wound. During an interview on 02/05/2024 at 2:13 p.m. S2DON and S6Corporate Nurse reported it was the DON's responsibility for monitoring of wound care and wound care orders and this was not done. During an interview on 02/05/2024 at 2:20 p.m., S1Administrator acknowledged Resident #16 and Resident #17's wounds had worsened. S1 Administrator further reported daily orders should be done every day and it is understandable how a wound could get worse if wound care was not done as ordered. III. Based on interview and record review, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for and for 2 (#16, #17) of 6 (#7, #8, #9, #13, #16, #17) residents reviewed for wound care staff competency. The facility failed to ensure S9Wound Care Nurse was competent to enter wound care orders accurately and perform wound care as ordered for 2 (#16, #17) of 6 (#7, #8, #9, #13, #16, #17) residents reviewed for wound care. The deficient practice resulted in an immediate jeopardy for Resident #16 on 12/15/2023 when S9Wound Care Nurse failed to enter Resident #16's wound care order timely and accurately leading to a delay in care, resulting in a decline and worsening of Resident #16's sacral pressure ulcer and impending hospitalization on 12/25/2023. Resident #16's 12/15/2023 wound care order was entered: 1. on 12/20/2023, five days after the order was written, 2. utilizing wound cleanser instead of the ordered 0.125% Dakin's Solution, and 3. with a frequency of M/W/F (Monday/Wednesday/Friday) instead of daily. The immediate jeopardy continued for Resident #17 on 01/05/2024 when S9Wound Care Nurse failed to enter Resident #17's order for wound care treatment and wound care frequency accurately potentially resulting in a worsening of Resident #17's sacral pressure ulcer. Resident #17's 01/05/2024 wound care order was entered: 1.utilizing 0.25% Dakin's Solution instead of the ordered 0.125% Dakin's Solution and 2. with a frequency of every day shift every Monday, Tuesday, Wednesday, Thursday, Friday instead of once daily, to include Saturday and Sunday. This deficient practice had the likelihood to cause more than minimal harm to the remaining 24 residents receiving wound care as per the Order Type: Wound Orders dated 01/31/2024. S1 Administrator, S2DON (Director of Nursing) and S6Corporate Nurse were notified of the Immediate Jeopardy on 02/05/2024 at 3:00 p.m. The immediate jeopardy was removed on 02/06/2024 at 4:00 p.m. when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through observations, onsite interviews and record reviews prior to exit. Findings, Cross Reference F726: During an interview on 02/05/2024 at 11:51 a.m., S2DON reported it was always S9Wound Care Nurse who entered wound care orders and confirmed there was no process for entering wound care orders when S9 Wound Care Nurse was out. During an interview on 02/05/2024 at 2:13 p.m., S2DON and S6Corporate Nurse reported it was the DON's responsibility for monitoring of wound care and wound care orders and this was not done. During an interview on 02/05/2024 at 2:20 p.m., S1Administrator reported training of S9Wound Care Nurse had been conducted by the prior wound care nurse, S2DON was responsible for monitoring of the wound care nurse and daily orders should be done every day. During an interview on 02/06/2024 at 11:43 a.m., S7Wound Care FNP (Family Nurse Practitioner) reported he had assumed wound care orders were entered correctly and he did not have access to the electronic medical record to see if they had been entered correctly.