**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility reported incidents, record review and interview with facility staff it was determined that the facility staff failed to protect residents against incidents of abuse, and ensure measures were put in place to prevent further incidents of abuse. This was evident for 3 (#905, #901, and #45) of 9 residents reviewed for abuse. The facility was notified of the immediate jeopardy at 4:40 PM on 1/13/25. The facility developed a plan to sufficiently remove immediacy, which was reviewed and accepted after 3 attempts, at 6:37 PM on 1/13/2025 while surveyors remained onsite. The plan to remove immediacy that was presented to surveyors included: Resident #905 passed on 8/2/23, Resident #901 passed on 2/22/23. Resident #45 was interviewed on 1/8/25 by the social worker regarding his/her abuse claim. The facility reported the incident to the state on 1/8/25. A 5-day investigation was completed and submitted on 1/13/25. The conclusion was that alleged abuse could not be substantiated. GNA #1 was removed from resident #45 ' s care on 1/8/25. All residents in GNA #1 ' s group were interviewed by the social worker on 1/13/25 with no concerns identified. All other residents in WillowBrooke Court will be interviewed by nursing and the social worker on 1/13/25 to ensure there is no suspected abuse or neglect. Training on Abuse, Neglect, Reporting & Investigation was conducted by the Regional Clinical Director to the Director of Nursing (DON) & Assistant Director of Nursing (ADON). All team members currently working were educated on Abuse & Neglect Policy and protocol focusing on report abuse as soon as possible, obtaining witness statements, suspension pending investigation, Acts policy and state regulations on Abuse & Neglect, & who the abuse coordinator of the community is on 1/13/25 by nursing management (DON/ADON). The rest of the team members working in WillowBrooke Court will complete training by 1/17/25 by nursing management (DON/ADON). For those team members not on the schedule to work the training will be conducted by the DON and ADON by phone by 1/17/25. The management team (NHA, DON, & ADON) will round twice a week to randomly interview 5% of the current residents on different shifts and different times regarding the quality of their care and monitor team members' interaction with residents for 6 months. Any issues identified will be corrected immediately. Any concern from the resident will be reported per regulation requirement. Any alleged team member will be suspended immediately pending investigation. Random interviews by the NHA, DON, & ADON will be audited for 6 months or until 100% compliance is achieved and findings will be discussed in monthly QAPI. The findings include: 1) The facility reported incident #MD00182604 was reviewed by the surveyor on 1/9/25 at 11:30 AM. The facility substantiated through witnesses (Licensed Practical Nurse) LPN3 and (Geriatric Nursing Assistant) GNA6 that GNA7 physically assaulted Resident #905 at approximately 11:30 PM on 4/25/22. The report revealed that the incident was not reported to the DON until 4/26/22 at 6:03 PM by LPN3. Review of the facility ' s investigation documentation on 1/9/25 at 12:00 PM revealed a written statement by LPN3 dated 4/26/22. LPN3 indicated that at the change of shift on 4/25/22 Resident #905 was attempting to pull at the kitchen door because s/he thought it was the bathroom. LPN3 and GNA6 ' s attempts to redirect the resident were unsuccessful. GNA7 came over, grabbed Resident #905 by the back of his/her shirt and spun him/her around in the wheelchair and began to choke him/her. LPN3 indicated she stepped in between them and told GNA7 to calm down. She indicated that Resident #905 was sitting in the corner by the TV and was upset and yelling so GNA7 charged over and punched him/her in the stomach. Resident #905 was threatening to report GNA7 so GNA7 got mad and pulled him/her by the back of his/her hair and spun him/her around in the wheelchair until he/she was back in the corner. LPN3 indicated that she kept pulling GNA7 away to diffuse the situation, but she kept coming for Resident #905. LPN3 finally yelled at GNA7 and pushed her away and she went into the lounge area. LPN3 indicated she kept Resident #905 up front at the nurse ' s station with her all night and GNA6 was the residents GNA and provided care for Resident #905. In a written witness report dated Monday April 25th, 2022, GNA6 indicated that approximately 11:30 PM an altercation occurred between GNA7 and a resident. The resident was attempting to enter the locked kitchen while yelling s/he needed the bathroom. I, GNA6, went up to attempt to convince him/her to go to his/her room where the bathroom was. After a couple of minutes, the nurse came to convince him/her as well. GNA7 intervened, seeing the situation still unresolved. She pulled his/her hands off the door handle and yanked on his/her shirt ' s neckhole to pull him/her backwards. She moved him/her back to the corner with the TV. At this point I backed away letting the nurse handle it. The only other thing I saw after was the resident swatting at GNA7 and GNA7 raising her arm as though to threaten hitting him/her back. GNA7 ' s written statement indicated she was down the hall and heard Resident #905 screaming and hollering. S/he was at the kitchen door. GNA7 pulled him/her back from the door and told him/her that he/she could not go home that way. Resident #905 continued to scream and was hitting. LPN3 told him/her not to do that. GNA7 indicated the reason why she went to Resident #905 was because sometimes she can redirect him/her. That she didn ' t want Resident #905 to wake up the other residents and that she left him/her in the hall and walked away from him/her. Written follow-up interviews were conducted by the Regional HR (Human Resources) Director and the DON on 4/27/22 with GNA6, LPN3 and GNA7. GNA6 indicated during her interview that she did not report the incident because the nurse stated she was going to. The Regional HR Director and DON did not ask LPN 3 why she did not report the abuse immediately. The surveyor called LPN3 for an interview on 1/13/25 at 9:00 AM. The call went to voicemail, and a message was left asking for her to return the call. LPN3 did not return the surveyor's call prior to the end of the survey. The time punch records for GNA7 were reviewed on 1/9/25 at approximately 4:00 PM. The punches revealed GNA7 worked from 3:00 PM on 4/25/22 until 7:51 AM on 4/26/22. She worked again on 4/26/22 from 2:57 PM until 7:01 PM. The facility staff failed to protect residents from abuse by allowing GNA7 to work 12 additional hours in the facility after witnessed abuse of Resident #905. In an interview on 1/9/25 at 4:30 PM the DON confirmed that GNA7 was not suspended until after she became aware of the incident at 6:03 PM on 4/26/22. She indicated that GNA6 did not report the incident. In an interview on 1/10/25 at approximately 9:30 AM the DON was asked to provide verification of abuse training for LPN3. She explained she was agency staff; we don ' t have her abuse training. The agency provides us with their license, background checks, the things that are required in Maryland, but we don ' t get their abuse training. The facility failed to ensure that all staff working in their facility had the required training for abuse and abuse prohibition. The DON was asked and indicated that a Root Cause Analysis was not done for this event. When asked if the Quality Assessment Performance Improvement (QAPI) committee reviewed and investigated the root cause, she indicated we discussed it but as far as documentation there is only the investigation I gave you. The facility failed to implement a QAPI process to address the incident and lack of immediate response. Review of GNA7 ' s employee file failed to reveal performance evaluations after 2011. The DON was made aware of this finding on 1/13/25 at 10:35 AM. She indicated that when she first came to the facility as the DON it was July 2020, during COVID, she did not do evaluations. When asked when she started doing the performance evaluations again, she paused then stated I only do evaluations of my ADON (Assistant Director of Nursing). On 1/13/25 at 1:30 PM when asked to further clarify who does performance evaluations for the other nursing staff the DON stated, they ' re not done. 2) Facility reported incident #MD00185366 was reviewed on 1/8/25 at 10:15 AM. The facility report indicated: on 1/11/22 a family member reported Resident #901 alleged that the previous morning s/he called an employee a bitch and the employee smacked him/her on the mouth and told him/her not to call her names. The DON interviewed the resident who did not recall an altercation with staff nor remember the conversation with his/her family member 30 minutes prior. No injuries were noted. The DON interviewed multiple employees that worked on the unit over the 4 days leading up to the event. There were no reports to corroborate the family member ' s concern. The report contained no evidence that the abuse allegation was reported to the police. The facility ' s investigation documentation included a written statement from Resident #901 ' s family member, dated 10/31/22. The statement revealed that the resident indicated s/he needed to move due to people problems. That the perpetrator accused the resident of calling her a bitch and slapped him/her. The statement also indicated that Resident #901 did not want the family member to say anything for fear of retaliation. The statement did not indicate a date of the alleged incident. The investigation included statements from 5 staff members: GNA8 ' s statement dated 11/2/22 indicated she saw another resident touch Resident #901 on 10/28/22 at 6 AM. They were redirected. GNA9 ' s statement dated 11/4/22 indicated she cared for Resident #901 7AM - 9PM on 10/29/22 and 7AM - 3PM on 10/30/22. There were no concerns. GNA1 ' s statement dated 11/4/22 indicated she didn ' t notice anything different with Resident #901 or staff on 11/29/22 and 11/30/22. GNA5 indicated in her statement dated 11/1/22 that she had not heard or had any situations or problems with Resident #901. Had never heard him/her cuss or fuss about anything. An undated statement written by GNA10 indicated that while assisting Resident #901 to bed at 7:30 PM on October 28th. He/She mentioned to me, about being slapped in the face, during the day by someone in the T.V. Room. Two times in the face. I meant to report it but forgot due to a busy night. Sorry! GNA10 failed to immediately report an allegation of abuse. There was no evidence the facility acted on the additional allegation of abuse after it was brought to their attention in GNA10 ' s written statement. Staff schedules revealed 26 staff worked on the unit where Resident #901 resided between 10/28/22 and 10/30/22. The facility ' s investigation did not include statements from 21 staff who worked during that time. During an interview on 1/9/25 at 10:31 AM the DON confirmed that the police were not notified of the allegation of abuse and she was not able to recall why. She was asked if she expanded her investigation once she received GNA10 ' s staff statement. She confirmed she was aware of the statement and that once she saw the statement was not sure why she wouldn ' t have gotten more statements. During an earlier interview conducted on 1/8/25 at approximately 7:35 AM when asked who the facility ' s abuse coordinator was, the DON responded - I guess I am because I ' m the DON.3.) During an interview on 01/07/25 at 11:25 AM R45 stated that GNA1 hates him/her just because s/he is him/her. R45 said GNA1 mouths off to him/her and when s/he reports something about GNA1 to administration, GNA1 gets even with him/her by reporting something false about him/her. R45 stated that GNA1 killed his/her dog. R45 stated that GNA1 ignores her job duties and called him/her a bitch. S/he said s/he reported it to the DON who told R45 that GNA1 ' s behavior was unacceptable. R45 said GNA1 and GNA2 would gang up on him/her and talk about him/her in the hall because s/he could hear them. On 01/07/25 at 11:45 AM, R45 ' s allegations of verbal and mental abuse were reported to the Administrator and the DON by the surveyor. An interview on 01/08/25 at 12:27 PM the DON and Administrator revealed that they do not believe R45 and that GNA1 was allowed to continue working the 7am to 3pm shift on 01/07/25. Interview with the Corporate nurse on 01/08/25 stated that staff are to be suspended while the facility is investigating allegations of abuse. Review of the Abuse policy dated 07/2023 revealed after an allegation of abuse was made they would immediately protect the resident from further risk. Review of R45 ' s Face Sheet revealed the resident was admitted to the facility on [DATE]. Review of R45 ' s Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/24 and located in the resident ' s EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated no cognitive impairment. During an interview on 01/08/25 at 12:27 PM the DON stated that she had a discussion with the Administrator after they became aware of R45 ' s allegations on 01/07/25 and that nothing had happened because she was waiting to discuss it with the Regional Clinical Nurse. During an interview on 01/08/25 at 12:42 PM the Administrator stated that he consulted with the DON and Medical Director. He said that they decided there was no validity to R45 ' s allegations based on the fact that s/he never had a dog here, and that GNA2 has not worked here for a long time. The Administrator stated that he did not interview the resident or any staff before making this conclusion. He stated that when he does conduct an investigation, he will interview the resident and any staff that have been identified. He stated that he did not investigate the allegation, and that GNA1 was not suspended.