**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, and facility policy review, the facility staff failed to recognize abuse and take action to prevent abuse to residents (Resident #921, #919, #77, #905, #912, #916, #927, #2, #17, #66, #303) reviewed for abuse for 11 out of a total sample of 21 residents. These actions resulted in the finding of an Immediate Jeopardy which was identified on 7/10/24 at 4:30 PM. An IJ summary tool was provided to the facility on 7/10/24 at 4:48 PM. The facility submitted a draft of their plan to remove the immediacy on 7/10/24 at 6:30 PM and it was not accepted. The facility submitted a 2nd draft of their plan to remove the immediacy on 7/10/24 at 7:36 PM and it was not accepted. The facility submitted a 3rd plan on 7/10/24 at 8:30 PM and it was accepted by the state agency at 8:40 PM. After removal of the immediacy, the deficient practice remained with a scope and severity of H. The Immediate Jeopardy was removed on 7/12/24 at 9:30 AM after on-site confirmation of the completion of the facility's plan of removal. The findings include: The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Brief Interview of Mental Status (BIMS) is a standardized test used to get a quick snapshot of the cognitive function and is a required screening tool used in nursing homes to assess cognition. A score of 13-15 points indicates an intact cognition, 8-12 points indicates moderately impaired cognition, and 0-7 points indicates severely impaired cognition. 1) A medical record review for Resident #921 on 7/10/24 at 6:51 PM revealed a MDS with an assessment reference date (ARD) of 2/4/24 that documented the resident had moderately impaired cognition, suffered from delusions, and exhibited physical and verbal behavior symptoms towards others. The resident wandered. Review of a physician's progress note dated 2/13/24 revealed the resident had the following, but not limited to diagnoses of dementia with behavioral disturbances. The resident had a care plan for aggressive behaviors which included an intervention to walk away and attempt care later if the resident becomes aggressive. On 7/10/24 at 7:15 PM a review of the facility's investigation file for self-reported incident #MD00203605 revealed a witness statement from geriatric nursing assistant (GNA) #130. The statement read that on 3/14/24 at approximately 6:00 AM, she and Registered Nurse (RN) #152 were attempting to move Resident #921 from one wheelchair to another. The resident was sitting in another resident's wheelchair. According to the statement, RN #152 was cussing at the resident telling him/her to sit down. The resident was agitated and became combative. The resident hit the nurse in the mouth. RN #152 responded by cursing and calling the resident names and slapped him/her on the head multiple times. GNA #130 wrote in her statement that she transferred Resident #921 to a regular chair, offered the resident something to eat and eventually the resident calmed down. A timeline of the events revealed that GNA #130 had not reported the incident to the Director of Nursing (DON) until 3/14/24 at 7:23 AM. This was 1 hour and 23 minutes that RN #152 continued to have access to vulnerable residents in the building. Further review revealed RN #152 was terminated and then referred to her state licensing board for review. A copy of Resident #921's order for a psychiatric consult was included. The Certified Registered Nurse Practitioner's (CRNP) note dated 3/18/24 was included, however it stated that the resident was being seen for hitting a nurse. There was no mention of the abuse endured by the resident. A review of RN #152's employee file revealed she last had dementia, behavioral health, and communication training in January of 2023. The training was required to be completed annually. An interview with Nurse Practice Educator on 7/11/24 at 11:54 AM revealed she had been hired in August of 2023. She reported that she was aware staff were due their annual trainings starting in January of 2023, and she was attempting to get staff to complete their required training. When asked the reason RN #152's training requirements were not up-to-date, she had no rationale to offer. An interview with the psychiatric CRNP on 7/11/24 at 2:44 PM revealed that she would have included in her note that the resident had been abused by a nurse had she been aware of the situation. Furthermore, she stated she has been seeing Resident #921 for quite a while and she would have seen the resident the same day of the incident of abuse if she had been aware. The DON was interviewed regarding the incident on 7/11/24 at 1:23 PM. She reported that she talked to the GNA about reporting to her immediately if she observed or received an allegation of abuse. When asked about the psychosocial/emotional support of the resident following abuse, she reported that the facility will refer them to psychiatric services. She reported that she and the Unit Managers will review the psychiatric notes. She stated that she was not aware that the visit psychiatric services had with Resident #921 on 7/18/24, had not addressed the abuse the resident endured. She reported that she was sure that the CRNP was aware of the incident for which she was seeing Resident #921. Furthermore, she was unable to provide a rationale for the resident waiting 4 days to be seen for psychosocial/emotional support. The concerns were reviewed 07/11/2024 3:33 PM with the Regional [NAME] President (RVP), Regional Clinical Consultant (RCC), and the DON. 2) A medical record review for Resident #919 on 7/9/24 at 11:50 AM revealed a physical therapy evaluation dated 1/17/24 that documented the resident needed partial/moderate assistance to go from a sitting position to a standing position and to transfer from one surface to another (such as the bed to the chair). However, to move around in bed the resident required substantial/maximal assistance. A physician progress note, dated 1/18/24, read that Resident #919 was admitted to the facility for rehabilitation services following an acute care admission. The resident was diagnosed with the following but not limited to: an acute upper right arm fracture and weakness in the upper and lower extremities. It was recommended that the resident remain NWB (non-weight bearing) with the right arm. Review of the MDS (minimum data set) with the assessment reference date of 1/22/24 revealed the resident had moderate impairment of cognition (the ability to think and process). Review of section J revealed the facility failed to do an assessment of the resident's pain. A review of the physician's orders revealed that the resident was non-weight-bearing for the right arm and was ordered to wear a sling upon admission. On 7/9/24 at 11:26 AM a review of the facility's investigation file revealed a written statement dated 2/26/24 from Registered Nurse (RN) #116 that read that at 7:45 PM on 2/26/24, Resident #919 reported to her that Geriatric Nursing Assistant (GNA) #140 had been rough with care and s/he was scared. RN #116 reported that the resident stated they had not been able to sleep for fear that GNA #140 was taking care of other residents. A handwritten interview (that had no date/time or who had conducted the interview, but later determined it was the Administrator) with GNA #81 revealed that she reported she had heard the resident yelling and went over to the resident's room. The resident stated that s/he wanted GNA #81 to stay with him/her because s/he thought GNA #140 was trying to kill him/her. A second handwritten interview that was in the same handwriting and green ink as the previous interview, however it had no name of the interviewee. The person being interviewed (which was later thought to be GNA #140 by the Director of Nursing) The interviewee had reported the resident had soiled themselves and the GNA was unable to change the bedding because the resident had difficulty moving. When asked if the resident told them to be careful with their arm, the interviewee confirmed that the resident had said that. The interviewee confirmed that the resident was yelling for help and that GNA #81 had responded. Facility staff failed to interview any other staff who may have had knowledge of the care provided by GNA #140 and to interview other residents who were within the GNA's care. A review of the final investigation report revealed that the facility determined that allegation of abuse was inconclusive. On 7/9/24 at 3:34 PM an interview with GNA #140, the accused GNA, she stated she could not recall the incident with Resident #919. An interview with RN #61 on 7/10/2024 at 10:19 AM, revealed that Resident #919 was a non-weight bearing status for the right arm. She stated that the resident should not be rolled onto his/her right side due to the broken arm because it would cause the resident pain. She reported that the resident wore the arm sling as ordered. When asked if a GNA came in to provide incontinence care would she expect them to roll the resident on the right side with a broken arm and she stated that she would not. An interview with GNA #81 on 7/10/2024 at 10:46 AM revealed she had been in the next room providing care to another resident on 2/26/24, when she heard Resident #919 yelling help me. She reported that she went over to the resident's room. When she walked in the resident was laying on his/her right side She stated the resident asked her to stay with her and asked that GNA #140 leave the room. She reported that she told GNA #140 that she would continue the care and GNA #140 left the room. When finished, GNA #81 reported the incident to the nurse assigned to the resident. During a subsequent interview with GNA #81 on 7/10/2024 at 11:15 AM she was asked how she provided care to the resident that day. She reported that the resident can stand and pivot, so she put the resident in a chair while she changed the bedding. Then she stood the resident to remove the brief and wash the resident. When asked again about how the resident had been lying in bed when she first walked in, she confirmed the resident was lying on their right side with the right arm under their body. An interview with RN #116 on 7/10/24 at 1:37 PM, via a phone call, revealed that the GNA #81 had told her that the resident wanted to see her. When she went in Resident #919 reported that GNA #140 had been rough with him/her during care. The resident reported fearing the GNA #140. RN #116 stated that she called the Director of Nursing (DON) to report the incident. She stated that she asked GNA #140 about the incident and the GNA reported that she had not meant to be rough with the resident, but the resident was hard to move so she had to push harder. RN #116 reported that after talking with GNA #140 the GNA was asked to leave the facility pending investigation. The concerns were reviewed 07/10/2024 4:30 PM with the Regional Clinical Consultant (RCC), and the DON. 3) Review of a facility's policy titled, Compliance with Reporting Allegations of Abuse/ Neglect/ Exploitation, dated 03/22/23, indicated .It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment .Abuse .The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include .certain resident to resident altercations .Physical Abuse which includes hitting, slapping, pinching, kicking . 1. Review of R77's undated admission Record, located in the resident's electronic medical record (EMR) under the profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Alzheimer's disease, anxiety, and depression. Review of R77's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/23/24 revealed a Brief Interview for Mental Status (BIMS) of three out of 15, which indicated the resident was severely cognitively impaired. Further review of the MDS with the ARD of 05/23/24 revealed R77 hallucinated and could be verbally aggressive during care but did not have refusals of care. Review of R77's EMR care plan, located under the care plan tab and dated 01/20/23, revealed the following focus area of .[R77] can be combative/resistant with hands on care . by pushing away at staff during care and with the intervention, .Make Resident [R77] aware of each step of the process of care before and during the care process. If resident resists with activities of daily living (ADLs), reassure resident, leave, and return 5-10 minutes later and try again . Review of a facility reported incident (FRI) with an incident dated 05/12/24 at 10:25 PM, Geriatric Nurse Aide (GNA) 139 reported .while caring for another resident, she heard this resident [R77] hollering out and went to check on [R77]. [GNA139] stated she heard [GNA138] reply to [R77] .shut up . in response to [R77's] non-sensical verbalizations. [GNA139] entered [R77's] room and [R77] was provided care by [GNA138]. [GNA139] educated [GNA138] on how to provide care while R77 is resistive to care. While in [R77's] room assisting [GNA138], [R77] stated to [GNA139] he [GNA138] is hurting me, (slapping his knee) and he punched me here (on his right thigh) . Continued review of the facility investigation revealed GNA139 failed to have GNA138 removed from providing care to R77, failed to report the allegation of physical abuse to the nurse on shift at the time of the incident and left a handwritten note for the Director of Nursing (DON) under her office door. The DON found the note on 05/13/24 at approximately 10:00 AM. During an interview on 07/10/24 at 1:00 PM, the DON stated GNA138 and GNA139 were both .agency staff . and they have not returned to the facility since the 05/12/24 incident. The DON also stated GNA138 was immediately placed on .administrative leave . while the investigation was in process. The DON stated GNA138's agency was notified of the allegation, and that he would not be allowed back to the facility. The DON further stated GNA139 was .educated . by the DON and Administrator regarding the facility policy and reporting any abuse concerns immediately to the DON or Administrator. During an interview on 07/10/24 at 1:30 PM, the DON verified that GNA138 worked .05/12/24 on the 3:00 PM to 11:00 PM shift on the memory care unit and then the 11:00 PM to 7:00 AM shift on the rehab unit .9) Review of R303's Face Sheet, located in the EMR under the Profile tab, revealed R303 was admitted to the facility on [DATE] with a diagnosis of a rib fracture and adjustment disorder with anxiety. Review of R303's admission MDS with an ARD of 06/24/24 located in the EMR under the MDS tab, revealed R303 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Per the MDS, the resident did not exhibit any behavior during the assessment period. During an interview on 07/08/24 at 11:50 PM, R303 stated sometimes at night she was told by staff to go to the bathroom in her brief. She stated it felt awful and she did not like doing it. She stated sometimes she also had a bowel movement in her brief which felt very uncomfortable. She stated she would wiggle in the chair. She stated last night she was told this by a GNA who provided care. R303 stated she reported this to GNA148 this morning. During an interview on 07/11/24 at 2:26 PM, R303 stated she had told GNA148 about the overnight CNA, when her shift started, at approximately 7:15 AM on 07/08/24. During an interview on 07/11/24 at 2:28 PM, DON said she had spoken with GNA148. She said GNA148 confirmed she had provided care with R303 on the morning of 07/08/24. She said GNA148 said R303 reported to her that overnight when R303 told her GNA she had to go to the bathroom. the GNA told her to pee in her diaper. The DON said GNA148 told the RN. The DON said that neither the nurse nor GNA148 reported the incident to the Administrator or the DON until after noon on 07/08/24. She said the report made by the surveyor and the report made by the nurse were made simultaneously. 7) The facility failed to remove Staff #137 after an allegation of abuse and continued to allow Staff #137 to participate in Resident #2''s care. Review of a facility reported incident on 7/09/24 revealed Resident #2 reported on 1/4/22 Staff #137 was rough with care. Review of Resident #2 ' s medical record on 7/10/24 revealed the Resident was admitted to the facility with a diagnosis of quadriplegia, complete. Complete quadriplegia is characterized by a complete loss of control over the arms and legs. This is a near-total form of paralysis where a person is wholly unable to move their extremities aside from their head. Interview of Resident #2 on 7/9/24 at 8:45 AM, Resident #2 stated in January 2022 he/she was in the shower room with Staff #137 and Staff #77 and asked the staff to stop showering him/her because of the pain. Resident #2 stated Staff #77 stopped but Staff #137 continued to wash his/her hair. Resident #2 states he/she has rods in his/her neck and Staff #137 was too rough and caused him/her pain. Resident #2 stated he/she spit on Staff #137 until they stopped. Resident #2 stated he/she started counseling because of the incident and is still upset about it to this day. Resident stated with other the traumas in his/her life of his/her friend being shot, his/her accident that caused the paralysis over 20 years ago and being admitted to a nursing home, this is the first time he/she felt like he/she needed to get counseling. Interview with Staff #77 on 7/9/24 at 4:28 PM, Staff #77 stated when Resident #2 began yelling you are hurting me, she stopped care immediately but Staff #137 continued to rinse Resident #2's hair with a shower nozzle until I told her to get out. Further review of Resident #2 ' s medical record revealed Staff #137 ' s nurse note on 1/5/22 at 3:03 PM, Staff #137 stated at 2:00 PM this writer and A/B Unit manager (Staff #77) assisted resident to obtain a shower. This writer and Staff #77 transferred resident via hoyer lift to shower bed without complication. At no point did the resident verbally state he/she did not want this writer in his/her room or resident did not want this writer to assist resident in shower, this writer and Staff #77 entered the shower room and directed shower bed into the stall with feet first and head at the opening of the shower stall. This writer turned water on and allowed water to warm up. Resident asked this writer to place water on him so he/she could feel the temperature. This writer placed water on the resident ' s right leg. Resident stated, Of course you put it on my leg where I can ' t feel! This writer asked resident where resident would like water placed? Resident stated, Put it on my shoulder. This writer placed water on Resident ' s right shoulder. Resident stated, That ' s fine start with my head, one do my hair, and one wash my body. This writer wet resident hair and placed shampoo in hair, during this time Staff #77 wet washcloth on resident upper body, resident screamed I ' m hypersensitive! Staff #77 then removed all hands from resident. Staff #77 then lightly placed washcloth on resident abdomen. Resident then screamed get the f___ off of me! Staff #77 then put washcloth down and stepped away. This writer began to rinse shampoo out of resident hair. This writer never placed hands on resident during the rinsing process. Resident then began screaming get the f___ off me you b___h Resident then began to spit at this writer and Staff #77. This writer showed resident both hands and stated, my hands are right here, I am not touching you, I was only trying to rinse the shampoo out of your hair so it doesn ' t run in your eyes. Resident then began spitting again screaming I ' m calling the cops and filing charges get the F___ out of here you B___h! This writer turned off the water and stepped away leaving the shower room to go get help. Further review of Resident #2 ' s medical record on 7/10/24 revealed a nurse' s note on 1/4/22 at 4:25 PM that stated, Resident was heard by this RN yelling from the shower room on C wing. Staff #137 came out of the shower and reported the resident had spit in her face. Resident reports to this RN that Staff #137 was rough with him/her while washing his/her hair. This RN and a geriatric nursing assistant (GNA) assisted resident with the rest of his/her shower and put him/her back to bed. Resident wanted to call the police to report Staff #137 for being rough during his/her shower. Further review of Resident #2 ' s medical record revealed Staff #137 ' s nurse ' s note on 1/5/22 at 10:49 AM that stated, This writer informed Wound Nurse Practitioner (Staff #141) that I was not able to enter Resident room. This writer asked GNA to assist Staff #141 in holding resident over so Staff #141 could measure resident sacral wound. This writer never entered resident room and stood in the doorway still remaining in the hallway so this writer could document wound measurements as Staff #141 stated them verbally. As soon as resident heard my voice resident started yelling Get out of my F___ing room! This writer informed resident in fact was not in his/her room and was still standing in the hallway. Resident screamed again Get the F___ out of my room! Staff #141 stated calm down she is only documenting out in the hallway. Resident stated Then shut my f___ing door! This writer shut resident door and remained in hallway with Staff #141 and GNA in resident room. Review of the facility investigation on 7/10/24 revealed Staff #141 wrote, went to see patient today for wound rounds Staff #137 assisted by standing outside the room to write down measurements. Resident #2 heard Staff #137 outside the room and stated, "get her out of my room" Staff #137 proceeded to say that she was not in the room. Resident #2 shouted "get the f___ out of my room! and demanded that his/her door be shut. Further review of Resident #2 ' s medical record on 7/10/24 revealed a nurse ' s note on 1/6/24 at 6:59 AM that stated, Resident proceeded to tell me his/her version of an event that he/she states occurred in the shower room yesterday. He/she stated the nurse manager (Staff #137) was very rough with him/her and kept jerking his/her head back and forth. He/she stated he/she asked her to stop about 15 times and panicked when she would not stop. That is when he/she stated he/she began spitting at her as a defense mechanism and admitted to calling her a b___h. During interview with the Director of Nursing (DON) on 7/10/24 at 1:50 PM, the DON was asked if Staff #137 was suspended pending the investigation of Resident #2 ''s allegation of abuse on 1/4/22. The DON stated no.4) Documentation requested included any other change in conditions that occurred with Resident #913 after the reported incident on 11/6/22. Review on 7/12/24 at 9:28 AM revealed that on 12/22/22 Resident #913 was observed rubbing another resident's stomach in the common area. Resident #913 indicated I was pulling [resident's] shirt down. The DON at the time documented that the victim was moved to the nurse's station. The change in condition note however, was not completed until 12/30/22 and the interventions for Resident #913 that included placing him/her on a 1:1 was not implemented until 12/28/22 although the incident was reported to occur on 12/22/22 with the previous occurrence on 11/6/22 with no noted interventions. Resident #913 was seen by the facility psychiatrist on 12/30/22. The psychiatric note documented that s/he was evaluated 'again' for concerns with sexual impulse control after another patient reported concern though [Resident #913] reported no interactions with residents of the opposite sex and verbalized that s/he is supposed to be 6 feet away from the opposite sex. The only intervention recommended by the psychiatrist was for melatonin for sleep and to continue to monitor for worsening symptoms. According to physician orders and the medication administration record (MAR) Resident #913 remained on 1:1 from 12/30/22 through his/her discharge on 2/2024. This was verified on the physician orders and verified on the MAR for each shift according to a record review completed on 7/12/24 at 9:40 AM. However, on 7/21/23 Resident #913 was found in the room of Resident #912, alleged victim #3. According to this facility report Resident #912's diaper was down exposing the private area. Resident #913 was noted standing overtop of Resident #912 with [his/her] hands on Resident #912's incontinence product that was open. Resident #913 was seen looking in Resident #912's private area. A staff member interrupted and redirected Resident #913 out of the room. When Resident #913 was asked what s/he was doing, s/he stated that they were 'helping Resident #912' Resident #912 who had a BIMS of 4 assessed on 5/7/23 which indicated severe cognitive impairment and had a documented need for assistance with personal care. According to the facility reported incident related to the occurrence on 7/21/23 the facility interventions included to update the care plan for both residents. A review of the care plans on 7/12/24 revealed that there was no update or change for Resident #913. Intervention #2 included to move Resident #913 to a private room. A review of Resident #913's census report revealed that this did not occur. A concurrent review of Resident #913's MAR revealed that on the day of the 7/21/23 incident staff did sign off that 1:1 was in place. However, a closer review revealed that on the night shift of 7/22/22, 1 day later, staff signed off a '7, see nursing progress notes.' This was also on 7/13, 7/14, 7/15, 7/25. According to the corresponding progress notes the nurse stated, 'no one on one provided at night.' On 7/12/24 at 10:55 AM surveyor reviewed the concerns related to Resident #913 and the ongoing failed implementation of interventions related to his/her sexual preoccupation with residents of the opposite sex including the delay of the implementation of the 1:1 order from 12/28/22 and failure of the staff to follow through, monitor and implement the order to prevent additional occurrences. This was reviewed again with the facility Regional Clinical Consultant and Regional [NAME] President at exit on 7/12/24. At this time the Regional Clinical Consultant was asked again what happened and she stated that after the 7/21/23 incident they really 'buckled' down on the 1:1 monitoring with Resident #913 to ensure there were no more occurrences. 5) Review on 7/10/24 of a facility reported incident revealed that on 9/5/23 there was an allegation that while on the dementia unit, in the dining room, during a visit with their respective family identified as Resident #70, the visiting family member yelled at Resident #926 while pointing in his/her face, stating I've already told you to stop it multiple times. If you keep reaching, I'm going to give you a hand smack. GNA #76 intervened and moved Resident #926 away from that visiting family member and then proceeded to escort Resident #70 out of the dining room to their respective room. Upon their arrival to the residents' room or soon thereafter, Resident #70's roommate, Resident #916, who resided in the 'A' bed, was there. According to the GNA statement in the investigation packet, provided to the survey team, that was read and verified with GNA #76 on 7/10/24 at 11:11 AM, she did take Resident #70 out of the dining room and hoped that the family would follow. She also did state when asked, that she did leave the room for an unknown amount of time to go and get supplies. This left the family member and both residents in the room alone for an unknown amount of time. Interview concurrently on 7/10/24 at 11:11AM with the Memory Support Program Director, staff # 142 who also confirmed her statements from the incident. She stated that she was alerted to the incident that occurred in the dining room by staff #76. As she went to the resident's room, she could then hear an argument occurring between the family member and Resident #916, who resides in bed 'A.' At this time there was another GNA in the room in addition to staff #76 and staff #142. The other GNA stated that the family accused Resident #916 of taking Resident #70's items and wanted to go through her family members [resident #70's] personal items to confirm. An argument ensued between the family member and Resident #916. The family member continued to rant and argue with the resident and staff #142 who asked the family to calm down and notified the family of her inappropriate behavior, tone and body language. Staff #142 stated that there was another aide that was with Resident #916 that stayed with him/her at this time attempting to keep him/her content. However, as in the statement the family refused to leave, was argumentative and ranting and arguing. It was not until the Administrator and the DON arrived that they were able to get the family member to leave who continued to yell through the facility. A care plan meeting was held 1 week later along with further dementia care education with the family member. The family member was eventually allowed to visit in a separate area with her family member, Resident #70 away from other residents, unsupervised. A care plan was implemented at that time regarding this intervention. The DON was interviewed on 7/10/24 at 11:42 AM and asked about that care plan and why it was no longer in place as it was discontinued on 3/8/24. She stated that it was not needed anymore, and she believed that there was a follow up care plan meeting about it and would follow up. The DON was also asked if there had been other incidents with this identified family member. There was no follow-up information provided prior to exit. It was reported to the survey team that the family member was ill and had not been in for a while. Further review on 7/10/24 of the care plans for Resident #70 revealed that there was a care plan initiated a month after admission that the resident had historical episodes related to suicidal ideations and verbal expressions when frustrated and or feelings of hopelessness. This was updated to note that it occurred when this identified family member visits. Staff #142 who was interviewed on 7/10/24 at 11:11 AM was questioned about this. She stated that they, the staff, know residents get teary when family leave and it's a process, however, they were noting that Resident #70 was more upset and seemed to have more concerns after that family member had visited. There were no interventions related to that family member to prevent Resident #70 from any further distress. 6) Review of the facility reported incident on 7/11/24 at 12:02 PM that occurred on 11/9/22 revealed an allegation that GNA #151 allegedly pushed Resident #905 during care, hurting and scaring him/her and their roommate, Resident #927. After the incident both residents reported to the DON the next day that they were scared but at that time felt safe in the facility. Interventions reported to have been implemented to the OHCQ were not completed, including psychiatric, social work or emotional support for either resident and neither care plan was updated related to the incident. Resident #927 was only referred to psychiatry on 11/15/22 after the facility staff became concerned of his/her change in behavior after they had witnessed the incident between Resident #905 and GNA #151. In addition, no [TRUNCATED]