Based on record review and interviews, the facility failed to ensure 1 (#1) of 3 (#1, #2, #3) residents reviewed for accidents received the necessary supervision to prevent avoidable accidents including a fall. The deficient practice resulted in an actual harm for Resident #1 on 08/22/2024 at 12:25 p.m. when Resident #1 suffered major injuries from falling out of the bed to the floor while left unattended during a bed bath. S4 CNA (Certified Nursing Assistant) was providing a bed bath to Resident #1. S4 CNA left the room to get more supplies for the bath and Resident #1 rolled off the bed and to the floor. Resident #1 was sent to a local hospital ER (Emergency Room) on 08/22/2024. Review of the hospital records revealed Resident #1 suffered bilateral supracondylar fractures of the right and left femurs requiring ORIF (open reduction internal fixation) of the right femur and a closed reduction and Ex-Fix application of the left distal femur on 08/22/2024. Resident #1 remained in the hospital at the time of the investigation. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. The Completion date was 08/26/2024. Findings: On 09/03/2024, review of the record for Resident #1 revealed an admit date of 12/27/2021. Further review of the record for Resident #1 revealed diagnoses in part of atresia and stenosis of urethra and bladder neck, schizoaffective disorder, seizures, multiple sclerosis, muscle wasting and atrophy, lack of coordination, cognitive communication deficit, aphasia and a past history on 01/09/2020 of non-displaced extra-articular fracture of the left calcaneus, and displaced fracture of medial malleolus of left tibia. Review of the August 2024 Physician orders revealed to use the Vander-Lift with 2 people for transfers and 2 person total assist with bed mobility. Further review of the record revealed on 08/04/2024 Resident #1 weighed 256 pounds. Review of the quarterly MDS (Minimum Data Set) dated 05/10/2024 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 9 indicating Resident #1 had moderate cognitive impairment. Further review of the MDS revealed Resident #1 had the following functional abilities: limited range of motion to bilateral upper extremities and lower extremities. Review of Resident #1's MDS revealed Resident #1 required total dependence for bed mobility with two person assist. Resident #1 was always incontinent of bowel and bladder. Review of the current plan of care revealed Resident #1 was at risk for falls. Review of the approaches in part revealed transfer using 2 person assist with Vander-Lift. Review of the facility incident report dated 08/22/2024 at approximately 12:25 p.m. revealed Resident #1 was receiving personal care by S4 CNA. During the care, Resident #1's bowels had moved and S4 CNA realized she did not have enough supplies to complete the care, so she left the room to gather more. While she was gathering supplies, she heard Resident #1 yell out and she immediately returned to the room. S4 CNA found Resident #1 beside the bed, on the floor, on her knees, between the bed and the wall. S4 CNA immediately called for assistance. S5 LPN (Licensed Practical Nurse) arrived to find Resident #1 on her knees, on the floor, with her hands on top of the mattress, complaining of pain to both of her legs. Resident #1 reported that she fell out of the bed. S5 LPN assessed the resident for injuries and noted a skin tear to her right knee. S5 LPN contacted the physician and orders were received to send to hospital for further evaluation. On 08/22/2024 at 9:35 p.m., S9 LPN received a call from the emergency room informing her that Resident #1 had fractures in bilateral legs and would be having surgery to repair them. S9 LPN immediately notified the DON (Director of Nurses) who then informed the Administrator. Review of the hospital record regarding the injuries sustained from this incident revealed Resident #1 received supracondylar fractures of the right and left femurs. Treatment received was an ORIF to the right and closed reduction and Ex-Fix application of the left distal femur fracture on 08/22/2024. On 09/04/2024 at 11:30 a.m., an interview with S4 CNA revealed on 08/22/2024 about 12:25 p.m. she was assisting the CNAs on the hall. The CNA that normally cares for Resident #1 was on lunch break and had already put supplies in the room for Resident #1 to get a bath. S4 CNA said this was only the second time she had provided care to Resident #1 and said she was giving Resident #1 a bath by herself and was not aware Resident #1 required a 2 person assist with bathing and transferring and failed to review the wall care plan in the resident's room that noted Resident #1 was a 2 person assist. S4 CNA said during the bath, Resident #1 had a bowel movement and she did not have enough supplies in the room. S4 CNA said she turned Resident #1 to face the wall and the resident's hands were touching the wall. S4 CNA lowered the bed and stepped out of the room. S4 CNA said she was not sure if the bed was locked and she did not check the break on the bed before she started the bath or before leaving the room. S4 CNA said she did not even have enough time to get the towel off the cart in the hall when she heard Resident #1 hollering for help. S4 CNA said when she came back in the room, Resident #1 was on her knees between the wall and the bed and Resident #1 was complaining of her right knee hurting. S4 CNA said the bed had moved away from the wall. On 09/04/2024 at 1:30 p.m., an interview with S5 LPN revealed she was at the main desk and S4 CNA came and told her that Resident #1 was on the floor. S5 LPN said she went to the room and Resident 1 was on her knees between the bed and the wall with her hands on the mattress. S5 LPN reported Resident #1 only complained of her right knee hurting and she noticed a skin tear to her right knee. S5 LPN said they got multiple staff, lowered Resident #1 to the floor and then used the lift to get her up off the floor. Resident #1 was sent to the hospital. S5 LPN said she was not sure if the bed was in the lock position when the accident occurred. On 09/03/2024 at 2:30 p.m., an interview with S8 CNA Assistant Supervisor confirmed there should have been 2 staff present when providing care for resident #1 and S4 CNA should not have left the bed unlocked when she left the room. On 09/04/2024 at 2:00 p.m., an interview with S3 DON confirmed S4 CNA should not have been providing care to Resident #1 without another staff member present and S4 CNA should have ensured the bed was locked before leaving the room. During the survey, in-service records and QA (Quality Assurance) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. The facility implemented the following actions to correct the deficient practice with the completion date of 08/26/2024: 1. Resident #1 was sent to the hospital for evaluation. 2. S4 CNA was suspended pending investigation. 3. S4 CNA was in-serviced on 08/22/2024 on care of residents in bed, to read the wall care plan. The wall care plan is a piece of paper that is placed on each resident's wall by the bed that has the specific care needs for the resident. To make sure all supplies are obtained prior to beginning care, ensure bed wheels are locked, ensure resident in safe position in bed before leaving room (not close to edge of bed but in middle of bed). 4. All nurses and CNAs were in-serviced from 08/23/2024 to 08/26/2024 on the resident wall care plan, 2 person assist with mobility in the bed, toileting, incontinent care, turning and reposition, bathing, a CNA should be on each side of bed. Check with nurse if any questions. Never leave a room with the resident not in safe position, ensure the wheels are locked on the bed. 5. Baseline assessments of all residents functional capabilities performed, care plans updated for all residents with changes to baseline functional status, all in room resident care plans were updated and monitors were put in place to ensure compliance of corrective action. 6. QAPI (Quality Assurance/Performance Improvement) monitors were conducted to ensure that care received while in bed reflects what the baseline review of functional status and needs assessment are followed. 7. QAPI Monitor - Locks on bed monitored 3 times per week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to protect the resident's right to be free from physical and verbal abuse and psychosocial harm by staff for 1 (#1) of 3 (#1,#2, #3) sampled residents. The deficient practice resulted in actual harm for resident #1 (who was cognitively impaired with communication deficits) on 05/19/2024 at 6:10 p.m. when S3CNA (Certified Nursing Assistant) physically and verbally abused resident #1 by forcefully grabbing resident #1's lower extremities, hands and arms in an attempt to reposition resident #1 and the resident sustained two red bruises that were identified on the left upper arm, and a reddened bruise was noted to the left hand, between thumb and index finger, red bruise was noted on top of right hand and a red bruise noted to the upper right arm. S3CNA cursed resident #1 and expressed anger at resident #1. 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 her own home or a health care facility. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's Abuse Policy dated October 2023 revealed the following: The facility will not condone any form of resident abuse or neglect. Each resident residing in this facility has the right to be free from verbal, sexual, mental and physical abuse including corporal punishment. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, facility members or legal guardians, friends or other individuals. Physical abuse includes hitting, slapping, pinching, and kicking. Additionally, it included acts of corporal punishment to control behavior. Verbal abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend or disability. Additionally threats of corporal punishment to control behavior are considered verbal abuse. Review of resident #1's electronic health record revealed an admit date of 05/27/2021 with diagnosis that included encephalopathy, aphasia following cerebral infarction, abnormal weight loss, lack of coordination, muscle wasting, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has a BIMS (Brief Mental Status Interview) score of 3, which indicated the resident is cognitively impaired and unable to make daily decisions. Further review revealed the resident needs assistance with all activities of daily living including incontinence care. Review of the facility's investigation documentation revealed the following: On 05/20/2024 it was reported to the facility that S3CNA was physically rough and spoke rudely to resident #1 during incontinence care on 05/19/2024. Resident #1's responsible party brought a video of the incontinence care performed by S3CNA on 05/19/2024 at 6:10 p.m. After watching the video that was time and date stamped for 05/19/2024 at 06:10 p.m., the Administration contacted S3CNA and notified her of being suspended pending completion of the investigation. Law enforcement was notified and a report was made to the state in reference to the allegation of abuse. Review of the protective actions taken at this time was resident #1 was immediately examined by medical staff for injuries and supervision increased. Results of the exam revealed two red bruises were identified on the left upper arm, and a reddened bruise was noted to the left hand, between thumb and index finger, red bruise was noted on top of right hand and a red bruise noted to the upper right arm. Interview on 06/04/2024 at 10:10 a.m. with S1Administrator confirmed that during the video of incontinence care for resident #1 it showed S7CNA was also in the room with S3CNA and several other CNA's were standing in the doorway. During this video recording S3CNA was seen in the room, with the door open to the hallway, curtain opened in view of the roommate, and window blinds opened. S1Administator stated all staff involved were suspended and later terminated due to staff not reporting the incident of abuse. During an interview on 06/04/2024 at 11:10 a.m. S2DON (Director of Nurses) stated S3CNA, S4CNA, S5CNA, S6CNA, S7CNA and S8LPN (Licensed Practical Nurse) were all suspended on 05/20/2024 while the allegation of abuse was being investigated and they were all terminated on 05/23/2024. S2DON stated S7CNA was on one side of resident #1's bed on her phone, while S3CNA was pulling and trying to move the resident in bed very roughly, S7CNA assisted S3CNA pulling the resident up in the bed and then left the resident's room. S2DON confirmed S4CNA, S5CNA, and S6CNA were standing in resident 1's doorway when the care was provided. S2DON stated the physical exam of resident #1 on 05/20/2024 revealed two red bruises on the left upper arm, a reddened bruise to the left hand, between the thumb and index finger, a red bruise was noted on top of the right hand and a red bruise noted to the upper right arm. On 06/04/2024 at 1:45 p.m. observation of the video with audio, date and time stamped as 05/19/2024 at 06:07 p.m., revealed a one minute and 59 seconds footage of resident #1 undressed lying in a fetal position on her right side in the bed. S3CNA was observed handling the resident roughly, grabbing onto her lower extremities which were bent at the knees and rapidly, with force attempting to turn her over to the opposite side of the bed. Resident #1 was observed to nearly fall off the edge of the bed, but was caught by S3CNA. S3CNA could be heard on the video cursing using the word s___ and expressing anger at times during the care. S3CNA was also observed to be grabbing at the resident's hands and arms forcefully in order to turn the resident over. Phone interviews were attempted with S3CNA, S4CNA, S5CNA, S6CNA, S7CNA and S8LPN during the survey with no success on 06/04/2024 at 2:30pm, 6/05/2024 at 9:10 a.m. and 06/05/2024 at 1:10 p.m. On 06/04/2024 at 8:30 a.m. observation of resident #1 revealed she was sitting in her wheelchair in the dining room eating breakfast. Resident #1 was unable to answer questions asked by the surveyor due to cognitive impairment. During the survey, in-service records and QA (Quality Assurance) monitoring records were reviewed, and it was determined that the facility had implemented the following actions to correct the deficient practice. 1. On 05/20/2024 at 02:50 p.m. responsible party of resident #1 produced video footage of the previous evening (05/19/2024) beginning at approximately 06:07 p.m. through 06:23 p.m. that revealed physical and verbal abuse against resident #1 by S3CNA and S7CNA. 2. On 05/20/2024 all CNA's and LPN involved were suspended pending the results of the investigation. Statements were obtained from staff members present during the care on 05/19/2024 were S3CNA, S4CNA, S5CNA, S6CNA, S7CNA and S8LPN. 3. On 05/20/2024 body audits were performed on all residents who were cared for by S3CNA and S7CNA. Body audits were then conducted on all resident in the facility and were completed by 05/23/2024. 4. On 05/20/2024 through 05/23/2024- the following In-services were done. 1. Dignity for residents with cameras 2. Dignity and maintaining dignity 3. Abuse and Neglect 4. Definitions and policies for abuse and neglect 5. Reporting abuse and neglect 5. On 05/21/2024 interviews were conducted with residents who were cared for by S3CNA and S7CNA. 6. On 05/23/2024 all CNA's and LPN involved were terminated. The QA (quality assurance) implemented changes and will be monitored by QAPI Quality Assurance Performance Improvement plan) began on 05/20/2024. 1. A QAPI monitor has been developed to ensure staff is reporting any signs of abuse/neglect/dignity. This will be completed by interviewing a random sample of residents by the DON (director of Nurses) three times a week for four weeks then monthly until compliance is reached. Any non-compliance will be addressed. 2. An additional QAPI monitor has been developed to ensure staff is reporting any signs of abuse/neglect/dignity. This monitor will be conducted by reviewing a random sample of Incident and Accident reports by the DON three times a week for four weeks then monthly until compliance is reached. Any non-compliance will be addressed. 3. An additional QAPI monitor has been developed to ensure staff is reporting any signs of abuse/neglect/dignity. This monitor will be conducted by reviewing a random sample of nurse's notes by the DON three times a week for four weeks then monthly until compliance is reached. Any non-compliance will be addressed. 4. An additional QAPI monitor has been developed to ensure staff is reporting any signs of abuse/neglect/dignity. This monitor will be conducted by reviewing a random sample of skin inspection monitors by the DON three times a week for four weeks then monthly until compliance is reached. Any non-compliance will be addressed. The effectiveness of the corrective actions will be discussed weekly for four weeks at the Quality Assurance and Performance Improvement meeting with findings added to the minutes. Additional in-services and or corrective actions will be implemented as needed. The facility was determined to be in compliance as of May 23, 2024 after completing their action plan that included termination of the employees involved in the incident, assessment of residents, completion of the in-services to all facility staff, and continued review of the QAPI monitoring that was put into place by the facility.