**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Comprehensive Plan of Care and Plan of Care [NAME], indicated he/she required extensive assistance from two staff members during transfers for safety, the Facility failed to ensure staff consistently implemented and followed interventions identified in his/her Plans of Care, when on 07/03/24, CNA #1 transferred Resident #1 using a Sit/Stand Lift device (lift device that helps individuals who have difficulty standing up, from a seated position), without having another staff member present to assist her with the transfer, Resident #1 became weak during the transfer, started to slide out of the lift seat, CNA #1 then tried to lower him/her to the floor, Resident #1 immediately complained of pain, was diagnosed with a right femur (thigh bone) fracture and required transfer, with admission to the Hospital for treatment. Findings include: Review of the Facility's Policy, Comprehensive Care Plans, dated 03/21/24, indicated it is policy of the Facility to develop and implement a Comprehensive Person-Centered Plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment, qualified staff responsible for carrying out interventions specified in the residents care plan and notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Review of the report submitted by the Facility via the Health Care Facility Reporting System, dated 07/03/24, indicated while being transferred and sitting in the Sit/Stand (mechanical transfer device), Resident #1 was lowered to the floor. The Report indicated Certified Nurse Aide (CNA) #1 used the Sit/Stand device incorrectly, and did not have another staff member assist her when transferring the resident back to bed to offer peri-care. The Report indicated Resident #1 complained of right hip pain, was assessed and an order was obtained to transfer him/her to the Hospital Emergency Department (ED) for evaluation. Review of the Facility's Internal Investigation's Final Report, dated 07/08/24, indicated that although Resident #1's ED Discharge Summary (from 07/03/24) indicated he/she did not have any fractures, he/she continued to experience pain to his/her right knee area, and an X-ray of his/her right knee was ordered. On 07/08/24, the facility was notified that Resident #1 had an acute distal right femur (thigh bone) supracondylar fracture (bone broken at the knee) with slight posterior displacement. The Report indicated Resident #1 was transferred and admitted to the Hospital. Resident #1 was admitted to the Facility in August 2023, diagnoses included Hemiplegia (paralysis on one side of the body) and Hemiparesis (muscle weakness or partial paralysis on one side of the body) following a Cerebral Infarction (stroke) affecting the left non-dominant side, difficulty walking, lack of coordination, unsteadiness on feet, and Anemia in the setting of Chronic Kidney Disease (Stage 4). Review of Resident #1's Fall Risk Assessment, dated 05/15/24, indicated he/she was assessed by Nursing as being at high risk for falls. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 05/16/24, indicated that Resident #1 had severe cognitive impairment and required maximum assistance from staff with transfers and mobility. Review of Resident #1's Activities of Daily Living (ADL) Care Plan, related to mobility status, reviewed and renewed in conjunction with completion of his/her May 2024 MDS, indicated that for transfers he/she required extensive assistance from two staff members. Review of Resident #1's Fall Care Plan, reviewed and renewed in conjunction with completion of his/her May 2024 MDS, indicated safety interventions included to ensure that Resident #1 wore appropriate footwear when ambulating or mobilizing while in wheelchair. Review of Resident #1's Certified Nurse Aide (CNA) Care [NAME] (used as a reference guide by CNA's, provides direct care staff with a brief overview of each residents' care needs), dated 06/01/24, indicated that Resident #1 required extensive assistance from two staff members for all transfers. Review of a Nurse Progress Note, dated 07/03/24, (written by Nurse #1) indicated that approximately 4:00 P.M., CNA #1 came to the Nurses Station and said she had lowered Resident #1 to the floor. The Note indicated Resident #1 was found in his/her room, laying on the floor in front of the Sit/Stand Lift device, he/she had no socks or shoes on his/her feet and Resident #1's right hip was partially internally rotated (knee and foot twist toward the midline of the body). The Note indicated Resident #1 was unable to recall what happened, but said he/she had pain in his/her right hip and Resident #1 was transferred to the hospital. During an interview on 07/24/24 at 1:20 P.M., Nurse #1 said on 07/03/24, CNA #1 came to her and said Resident #1 was on the floor in his/her room. Nurse #1 said upon arrival to Resident #1's room, she observed him/her laying on his/her back on the floor in front of the Sit/Stand Lift device. Nurse #1 said CNA #1 told her that she had transferred Resident #1 by herself, (from the wheelchair to the bed to provide care) that Resident #1 lost his/her balance during the transfer, and that she lowered him/her onto the floor. Nurse #1 said she also noted that Resident #1 did not have socks or shoes on his/her feet at the time, and should have. During a telephone interview on 08/07/24 at 2:59 P.M., CNA #1 said she was aware that each resident had a Care [NAME] and that she knew how to access them. CNA #1 said that they (CNA's) needed to review the Care [NAME] for each of their residents before providing care, but that she had not reviewed Resident #1's CNA Care [NAME] on 07/03/24. CNA #1 said when she cared for Resident #1, she had always provided care to him/her by herself, and did not ask for help. CNA #1 said she knew how to work the Sit/Stand Lift and that she had transferred Resident #1 by herself without any assistance from another staff member before without an incident. CNA #1 said Resident #1 became weak during the transfer so she lowered him/her to the floor. CNA #1 said she thought Resident #1 was strong enough to participate, so she did the transfer without assistance from anyone else. Although CNA #1 said that Resident #1 had socks and shoes on his/her feet during the transfer, this conflicted with Nurse #1's interview in which she said when she went to Resident #1's room on 07/03/24 at CNA #1's request, she observed that he/she did not have socks or shoes on. Review of Resident #1's Facility's Radiology Report of his/her X-ray knee exam, dated 07/08/24, indicated he/she had an acute distal femur supracondylar fracture. Review of Resident #1's Medical Record indicated on 07/08/24, Resident #1 was sent to the Hospital for further evaluation, treatment and was admitted . During an interview on 07/24/24 at 4:08 P.M., the Director of Nursing (DON) said it was her expectations that nursing staff be knowledgeable about the residents' Plan of Care and to implement and follow interventions accordingly. The DON said, prior to providing care, including transfers, that the CNA's need to identify how a resident's transfers and how many staff are needed (using the CNA Care [NAME]) and CNA's must also follow the Facility's Policies and Procedures. During an interview on 07/24/24 at 5:31 P.M. the Administrator said that on 07/03/24, CNA #1 told her, she was going to provide ADL care to Resident #1, that she used the Sit/Stand lift so she could transfer him/her back to bed for care, that while Resident #1 was standing on the Sit/Stand Lift, he/she started to fall and that she lowered Resident #1 to the floor. The Administrator said she had asked CNA #1 if she had reviewed Resident #1's CNA Care [NAME] regarding how Resident #1 transferred, and that CNA #1 replied No. On 07/24/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidence by: A. 07/03/24, Resident #1 fell, was immediately assessed by Nursing for any injuries, Resident #1 had reported he/she had pain to right hip, and was transferred to the Hospital Emergency Department (ED) for evaluation. B. 07/03/24, Resident #1's Care Plan was reviewed and updated to include the 07/03/24 fall, and to ensure transfer status indicated he/she required physical assistance of two staff for all transfers. C. 07/03/24, Resident #1 returned to the facility, nursing reviewed the Hospital ED Discharge Summary (Final Report ) which indicated Resident #1 was assessed and treated at the ED with no fractures found. However the he/she continued to experience pain and an X-ray completed at the facility a few days later indicated he/she had a right femur fractures. D. 07/09/24, Resident #1's Care Plan was updated to include that on 07/08/24, Resident #1 was in pain, Facility X-ray, dated 07/8/24, indicated Resident #1's right femur was fracture status post fall on 07/03/24, which was not previously diagnosed, that he/she had been transferred back to the ED and was admitted to the Hospital. E. The Facility's Morning Meeting and the Weekly Risk Meeting Fall Review minutes indicated the Interdisciplinary Team (IDT) reviewed Resident #1's fall that occurred on 07/03/24, his/her X-ray results from 07/08/24, and need for him/her to be transferred back to the Hospital ED for evaluation. The minutes indicated the the IDT continues to discuss (and update as needed) Resident #1's Plan of Care including orthopedic appointments, weight bearing status, nutritional status, and overall health status. F. The Facility Nursing Staff completed an Audit to ensure all residents who used any type of mechanical device, that their individual Care Plan and the CNA Care [NAME] indicated the appropriate type of device to be used and how many staff were needed for assistance with the transfer. G. 07/09/24, The Staff Development Coordinator (SDC) and the DON initiated mandatory education for all Licensed Nurses and CNA's, which included completion of competencies on Sit/Stand Lift device, and staff were required to complete return demonstration of appropriate use of the transfer device. Education also included nursing staff requirement to review and follow residents plan of care, knowledge of how to access and review the CNA Care [NAME], prior to providing care. H. 07/12/24, Resident #1's Care Plan was updated to include, right distal femur fracture related to a fall, and that he/she required extensive assistance from two staff members using a Hoyer Lift (mechanical lift used to safely transfer patients). I. 07/17/24, All Sit/Stand Lift devices were Inspected by the Maintenance Department, to ensure all parts were functioning properly and transfer device was safe to use. J. Physical Therapy Department Staff also initiated and completed Audits related the incident to ensure all residents including new admissions, that their transfer status degree and number of staff needed for assistance during the provision of all care need areas identified were up to date on residents Plan of Care and CNA Care [NAME]. K. Random Audits were completed by administrative staff, on Resident transfers with the Sit/Stand Lift to ensure that transfer procedures from Sit/Stand Lift Competencies are being followed by staff. Random Audits will be completed by the DON three times weekly for 3 months. L. The DON presented the Audit results at monthly Quality Assurance Performance Improvement (QAPI) meeting, where the QAPI Committee discussed the results. The DON will present the Audit results for three months, then quarterly until the Committee determines 100 % staff compliance is met, and the concern area thereafter will be present for yearly review. M. Review of the facility's most recent QAPI meeting minutes indicated leaderships plan is to continue to review the concern areas for potential deficient practice, including falls, to ensure that residents were provided with appropriate level of assistance as determined by assessments and identified in the residents Plan of Care and CNA Care [NAME]. N. The Director of Nurses (DON) and/or designee are responsible for overall compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk of falls, was known to have poor safety awareness, weakness due to a stroke and required the assistance of two staff members for transfers, the Facility failed to ensure Resident #1 was provided with the necessary level of staff assistance during a transfer to prevent an incident/accident resulting in a serious injury. On 07/03/24, CNA #1 transferred Resident #1 with a Sit/Stand Lift device (device that helps individuals who have difficulty standing up, from a seated position) without having another staff member present to assist her, during the transfer Resident #1 started to slide out of the lift seat, CNA #1 then tried to lower him/her to the floor, Resident #1 immediately complained of pain to his/her right hip, was transferred to the Hospital Emergency Department (ED) and was diagnosed several days later with a right femur (thigh bone) fracture which required surgical intervention to repair. Findings include: Review of the Facility's Policy, Fall Prevention Program Policy and Procedure, dated reviewed 02/26/24, indicated it is policy of the Facility's Accidents/Supervision to ensure resident safety is a commitment to provide an environment that is free from Accident hazards over which the facility has control and provides supervision and assistance devices to each resident based on the identified hazards or risks to each resident to prevent accidents. Review of the Facility's (Sit/Stand Lift) Stand Aid Lift Competency Checklist, dated January 2023, indicated staff to check the residents' Plan (CNA) Care [NAME] for the correct number of assistants necessary to transfer the resident and use a gait belt if the resident requires help pulling themselves up. Review of the report submitted by the Facility via the Health Care Facility Reporting System, dated 07/03/24, indicated while being transferred and sitting in the Sit/Stand (mechanical transfer device), Resident #1 was lowered to the floor. The Report indicated Certified Nurse Aide (CNA) #1 used the Sit/Stand device incorrectly, and did not have another staff member assist her when transferring the resident back to bed to offer peri-care. The Report indicated Resident #1 complained of right hip pain, was assessed and an order was obtained to transfer him/her to the Hospital Emergency Department (ED) for evaluation. The Report indicated Resident #1 returned to the facility the same day, and that the ED Discharge Summary indicated there were no fractures. However, review of the Facility's Internal Investigation's Final Report, dated 07/08/24, indicated that Resident #1 continued to experience pain to his/her right knee area, and an X-ray of his/her right knee was ordered. On 07/08/24, the facility was notified that Resident #1 had an acute distal right femur (thigh bone) supracondylar fracture (bone broken at the knee) with slight posterior displacement. The Report indicated that when the facility's Physician Assistant reviewed Resident #1's Hospital Discharge Summary from 07/03/24, it was determined that although the Hospital ED Physician had ordered an X-ray of his/her right femur, that it had not been completed. Therefore, Resident #1 was not diagnosed with a right femur fracture until 07/08/24, at which point he/she was transferred back and admitted to the Hospital, for further treatment. Resident #1 was admitted to the Facility in August 2023, diagnoses included Hemiplegia (paralysis on one side of the body) and Hemiparesis (muscle weakness or partial paralysis on one side of the body) following Cerebral Infarction (stroke) affecting the left non-dominant side, difficulty walking, lack of coordination, unsteadiness on feet, and Anemia in the setting of Chronic Kidney Disease (Stage 4). Review of Resident #1's Fall Risk Assessment, dated 05/15/24, indicated he/she was assessed by Nursing as being at high risk for falls. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 05/16/24, indicated that Resident #1 had severe cognitive impairment and required substantial, maximum assistance (more than half the effort) from staff with transfers and mobility. Review of Resident #1's Fall Care Plan, reviewed and renewed in conjunction with completion of his/her May 2024 MDS, indicated safety interventions included the following; ensure Resident #1 wore appropriate footwear when ambulating and mobilizing (when in wheelchair). Review of Resident #1's Activities of Daily Living (ADL) Care Plan related to mobility and transfers, reviewed and renewed in conjunction with completion of his/her May 2024 MDS, indicated interventions included that for all transfers he/she required extensive assistance of two staff members. Review of Resident #1's Certified Nurse Aide (CNA) Care [NAME] (used as a reference guide by CNA's and provides direct care staff with an overview of each residents' needs), dated 06/01/24, indicated interventions included that he/she required extensive assistance from two staff members with all transfers. During a telephone interview on 08/07/24 at 2:59 P.M., CNA #1 said she was assisting Resident #1 in his/her room with a transfer from his/her wheelchair to his/her bed using a Sit/Stand Lift. CNA #1 said Resident #1 was unable to pull him/herself up from the wheelchair to the Sit/Stand Lift because he/she was too weak. CNA #1 said she had to pull Resident #1 up to standing position very hard, using her hand and then assisted Resident #1 onto the seat of the Sit/Stand Lift. CNA #1 said when she was moving the Sit/Stand Lift closer to Resident #1's bed, she observed that Resident #1 was sliding out of the lift seat, so she had held onto Resident #1 with one hand and used her other hand to push the lift away, while using her own body to lower Resident #1 to the floor. CNA #1 said after Resident #1 was on the floor, she called out for help, but no one came. CNA #1 said Resident #1 was in pain when he/she was on the floor, he/she was making groaning sounds, so she left Resident #1 alone on the floor and went to the Nurse's station to get help. CNA #1 said she had worked with Resident #1 in the past and had always provided care to him/her by herself. CNA #1 said she usually does her job by herself, and does not ask for help. During an telephone interview on 07/25/24 at 10:10 A.M., the Nursing Supervisor said on 07/03/24, CNA #1 reported that Resident #1 fell in his/her room and that she lowered Resident #1 to the floor. The Nursing Supervisor said upon entering Resident #1's room, Resident #1 was on the floor, moaning, making sounds, and leaning slightly on his/her left side holding his/her right hip. The Nursing Supervisor said she was concerned about Resident #1's fall, his/her complaints of pain, and because Resident #1 was prescribed an anticoagulant medication which put him/her at risk for bleeding, that Resident #1 was transferred to the Hospital ED for evaluation. During an interview on 07/24/24 at 12:18 P.M., the facility's Physician Assistant (PA) said on 07/03/24, CNA #1 reported that Resident #1 fell. The PA said she had asked CNA #1 what happened, and that CNA #1 said Resident #1 let go of the handlebars of the Sit/Stand Lift and that she lowered him/her to the floor. The PA said upon arrival to Resident #1's room, he/she was found laying on his/her back on the floor in front of the Sit/Stand Lift device. The PA said Resident #1 said he/she had pain in his/her legs, and she observed that Resident #1's right leg was internally rotated (knee and foot twist toward the midline of the body). The PA said she assessed Resident #1 and ordered that he/she be transferred to the Hospital ED for further evaluation. The PA said Resident #1 returned to the facility on [DATE], and that the Hospital ED Report indicated that Resident #1 did not have any fractures. The PA said Resident #1 continued to have pain including to his/her right knee, and that nursing had observed and reported his/her right knee had become swollen. The PA said she re-assessed Resident #1 who was still complaining that he/she was in a lot of pain. The PA said on 07/08/24, the Facility obtained an X-ray of Resident #1's right femur (thigh bone) which indicated Resident #1 had a distal right femur fracture and Resident #1 was transferred back and admitted to the Hospital that same day. The PA said she reviewed Resident #1's Hospital ED Records from 07/03/24 and said the Hospital did not obtain an X-ray of Resident #1's right femur per Hospital ED Physician Orders. The PA said the type of fracture Resident #1 sustained would be the result of movement with force, and that Resident #1's fall on 07/03/24 would have been a contributing factor. The PA said when Resident #1 returned from the Hospital ED on 07/03/24, he/she had remained bed ridden, that he/she had not gotten out of bed at all, until 07/08/24, when he/she was transferred back to the Hospital. During an interview on 07/24/24 at 4:08 P.M., the Director of Nursing (DON) said on 07/03/24, upon entering Resident #1's room, Resident #1 had been laying on the floor, moaning and he/she seemed to be in a lot of pain. The DON said CNA #1 said she was using the Sit/Stand Lift to provide Activities of Daily Living (ADL) care (personal care) to Resident #1 which included the need to transfer him/her from the wheelchair back into bed. The DON said CNA #1 said Resident #1 was standing up on the Sit/Stand Lift device holding onto the handlebars, before she (CNA #1) lowered him/her to the floor. The DON said the Sit/Stand Lift was not to be utilized by staff during ADL care and was only to be used for short distances transfers. During an interview on 07/24/24 at 5:31 P.M. the Administrator said on 07/03/24, upon entering Resident #1's room, Resident #1 was laying on the floor, moaning, crying and was in pain. The Administrator said CNA #1 said she was providing ADL care to Resident #1, that he/she was standing on the Sit/Stand Lift, started to fall and that she lowered Resident #1 to the floor. However, during a telephone follow-up interview on 08/08/24 at 2:39 P.M., CNA #1 said that on 07/03/24, she had not put a gait belt belt or had a another staff member help her during Resident #1's transfer. CNA #1 confirmed that Resident #1 was sitting on the seat of the Sit/Stand Lift device, not standing, when he/she became weak, and started sliding out of the chair, before she lowered him/her to the floor. This contradicted what CNA #1 reported to the PA, DON and Administrator, when she told them that Resident #1 was standing up in the Sit/Stand Lift device, holding onto the handle bars, before she had lowered him/her down to the floor. On 07/24/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidence by: A. 07/03/24, Resident #1 fell, was immediately assessed by Nursing for any injuries, Resident #1 had reported he/she had pain to right hip, and was transferred to the Hospital Emergency Department (ED) for evaluation. B. 07/03/24, Resident #1's Care Plan was reviewed and updated to include the 07/03/24 fall, and to ensure transfer status indicated he/she required physical assistance of two staff for all transfers. C. 07/03/24, Resident #1 returned to the facility, nursing reviewed the Hospital ED Discharge Summary (Final Report ) which indicated Resident #1 was assessed and treated at the ED with no fractures found. However the he/she continued to experience pain and an X-ray completed at the facility a few days later indicated he/she had a right femur fractures. D. 07/09/24, Resident #1's Care Plan was updated to include that on 07/08/24, Resident #1 was in pain, Facility X-ray, dated 07/8/24, indicated Resident #1's right femur was fracture status post fall on 07/03/24, which was not previously diagnosed, that he/she had been transferred back to the ED and was admitted to the Hospital. E. The Facility's Morning Meeting and the Weekly Risk Meeting Fall Review minutes indicated the Interdisciplinary Team (IDT) reviewed Resident #1's fall that occurred on 07/03/24, his/her X-ray results from 07/08/24, and need for him/her to be transferred back to the Hospital ED for evaluation. The minutes indicated the the IDT continues to discuss (and update as needed) Resident #1's Plan of Care including orthopedic appointments, weight bearing status, nutritional status, and overall health status. F. The Facility Nursing Staff completed an Audit to ensure all residents who used any type of mechanical device, that their individual Care Plan and the CNA Care [NAME] indicated the appropriate type of device to be used and how many staff were needed for assistance with the transfer. G. 07/09/24, The Staff Development Coordinator (SDC) and the DON initiated mandatory education for all Licensed Nurses and CNA's, which included completion of competencies on Sit/Stand Lift device, and staff were required to complete return demonstration of appropriate use of the transfer device. Education also included nursing staff requirement to review and follow residents plan of care, knowledge of how to access and review the CNA Care [NAME], prior to providing care. H. 07/12/24, Resident #1's Care Plan was updated to include, right distal femur fracture related to a fall, and that he/she required extensive assistance from two staff members using a Hoyer Lift (mechanical lift used to safely transfer patients). I. 07/17/24, All Sit/Stand Lift devices were Inspected by the Maintenance Department, to ensure all parts were functioning properly and transfer device was safe to use. J. Physical Therapy Department Staff also initiated and completed Audits related the incident to ensure all residents including new admissions, that their transfer status degree and number of staff needed for assistance during the provision of all care need areas identified were up to date on residents Plan of Care and CNA Care [NAME]. K. Random Audits were completed by administrative staff, on Resident transfers with the Sit/Stand Lift to ensure that transfer procedures from Sit/Stand Lift Competencies are being followed by staff. Random Audits will be completed by the DON three times weekly for 3 months. L. The DON presented the Audit results at monthly Quality Assurance Performance Improvement (QAPI) meeting, where the QAPI Committee discussed the results. The DON will present the Audit results for three months, then quarterly until the Committee determines 100 % staff compliance is met, and the concern area thereafter will be present for yearly review. M. Review of the facility's most recent QAPI meeting minutes indicated leaderships plan is to continue to review the concern areas for potential deficient practice, including falls, to ensure that residents were provided with appropriate level of assistance as determined by assessments and identified in the residents Plan of Care and CNA Care [NAME]. N. The Director of Nurses (DON) and/or designee are responsible for overall compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed, for one of three sampled residents (Resident #2), whose primary spoken language was not English, the Facility failed to ensure he/she was free from abuse, when on 4/08/24, during the evening shift, when Resident #2 approached Nurse #1, who was in the hallway at the medication cart, to ask for his/her supplement, Nurse #1 yelled at Resident #2 in a humiliating and verbally aggressive manner saying, you are in America now, you need to learn to speak English! The altercation was witnessed by two other residents, who said Resident #2 was upset and crying after Nurse #1 yelled at him/her. Findings include: Review of the Facility's Policy titled Prevention, Identification, Investigation and Reporting of Abuse, Neglect, Mistreatment or Exploitation of Resident or Misappropriation of Resident Property, dated January 2023, indicated the following: - Employees, consultants, contractors, volunteers, and other caregivers will provide an environment for residents that is safe and free from abuse, neglect, exploitation, mistreatment, and misappropriation, treating each resident with respect, dignity, and the provision of privacy. - Verbal abuse means the use of oral, written, or gestured language that willfully includes disparaging and 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, threats of punishment, deprivation, or abuse and further includes Nursing Home Staff taking, keeping, distributing, or using photographs or recordings of a resident and/or resident's personal space in any manner that would demean or humiliate a resident. Resident #2 was admitted to the Facility in March 2023, diagnoses included Parkinson's disease without dyskinesia, type 2 diabetes mellitus, major depressive disorder, sleep terrors, spinal stenosis, and hypertension. Review of Resident #2's Annual Minimum Data Set (MDS) Assessment, dated 3/13/24, indicated that he/she was cognitively intact, made his/her own decisions, could speak and understand a limited amount of English, and utilized a translation application on an electronic device (his/her iPad) to communicate his/her needs to staff. The MDS indicated that Resident #2 required moderate assistance from one staff member to meet his/her care needs. Review of the Facility's Investigation, dated 4/11/24, indicated Resident #1 reported he/she heard Nurse #1 state to Resident #2, You are now in America, and you need to learn English because no one is going to understand you! The Investigation also indicated that Nurse #1 made {inappropriate}statements regarding Resident #1, and those statements were confirmed by a second nurse (later identified as Nurse #2) who worked on the same unit on 4/08/24. The Investigation indicated that Nurse #2 reported that while they were charting around 10:00 P.M., Nurse #1 stated, I told the Chinese patient that he/she needs to learn English, and that Nurse #1 went on to say to Nurse #2 and the Certified Nurse Aides (CNA's) who were also present at the nursing station, I came from [NAME], and I learned English, why can't he/she? The Investigation indicated the Administrator received an email on 4/11/24 at 2:40 A.M., from Resident #1's Family Member (FM #1) concerning Nurse #1 being rude to Resident #1 on 4/08/24 (during the evening shift). The Investigation indicated FM #1 also included in the email that Resident #1 reported to her that Nurse #1 was also verbally abusive towards Resident #2. The Investigation indicated that Nurse #1 refused to participate in the Facility's Investigation into the allegations, conducted by the Administrator. Review of Nurse #2's Written Witness Statement, dated 4/08/24, indicated that she spoke to Resident #2's Family Member (FM #2) on the phone on 4/08/24, and that FM #2 told her (Nurse #2) that Resident #2 reported being yelled at by Nurse #1 for asking for his/her supplement. The Statement indicated that FM #2 stated he did not like it that Resident #2 was crying. The Statement indicated Nurse #2 reported the incident to the Nurse Supervisor. Further review of Nurse #2 Written Witness Statement indicated that at 9:15 P.M., while providing care to Resident #1, he/she reported to her (Nurse #2) that he/she had overheard Nurse #1 yelling loudly at Resident #2, and that he/she felt sorry for Resident #2. During an interview on 4/30/24 at 3:02 P.M., Nurse #2 said that on 4/08/24 at approximately 7:30 P.M., Resident #2 approached her, he/she crying and looked sad. Nurse #2 said that when she asked Resident #2 what was wrong, he/she said {using his/her iPad as an interpreter}, that Nurse #1 yelled and screamed at him/her, which scared and humiliated him/her. Nurse #2 said that while Resident #2 was describing the incident, Resident #3 came over and stated that he/she had witnessed Nurse #1 yelling and humiliating Resident #2, and that it also scared him/her. Nurse #2 said she spoke to Resident #2's Family Member (FM #2) that night, who reported receiving a very emotional call from Resident #2, who was crying about being yelled at for asking Nurse #1 for his/her supplement. Nurse #2 said that FM #2 stated that he did not like it that Resident 2 was crying. Nurse #2 said she immediately reported the incident to the Nurse Supervisor after she spoke to FM #2. Nurse #2 said later that night, around 9:15 P.M., while providing care to him/her, Resident #1 also reported that he/she overheard Nurse #1 yelling and screaming at Resident #2, telling him/her, You are in America and need to learn English. This is America! Nurse #2 said later that same night when she was at the nursing station doing her charting, Nurse #1 was on the other side of the nursing station, and that two Certified Nurse Aides, were also there. Nurse #2 said Nurse #1 bragged to them and said, I told the Chinese patient that he/she needs to learn English. Nurse #2 said Nurse #1 went on to say, I came from [NAME] and learned English, why can't he/she learn? I am not catering to him/her. Nurse #2 said that as Nurse #1 got up and was passing her, that she (Nurse #1) looked at her and said, Don't let me go ghetto on you. Nurse #2 said Nurse #1 made her uncomfortable, and that she could not imagine how the residents' felt. During an interview on 4/30/24 at 1:05 P.M., Resident #2, due his/her limited English, requested that the Surveyor contact and speak to Family Member #2 about the incident. During a telephone interview on 5/07/24 at 9:00 A.M., Family Member #2 (who spoke on Resident #2 behalf, with his/her permission) confirmed receiving a call from a very emotional Resident #2 on 4/08/24, during which he/she reported that Nurse #1 (whom Resident #2 identified by name) had very aggressively and loudly yelled at him/her that night. FM #2 said that Resident #2 told him that Nurse #2 had yelled at him/her and said Why don't learn English? This is America! FM #2 said Resident #2 told him that he/she had only gone to Nurse #1 to ask for his/her supplement. During an interview on 4/30/24 at 3:40 P.M., Certified Nurse Aide (CNA) #3 said when she was at the nursing station area doing her documentation on 4/08/24 for the evening shift, that Nurse #1 was on the other side of the nursing station bragging about what she (Nurse #1) had done, and that Nurse #1 made the following statements; I told the Chinese patient that he/she needs to learn English, I came from [NAME], and I learned English, why can't he/she? and I am not catering to him/her! During an interview on 4/30/24 at 12:55 P.M., Resident #3 said he/she had witnessed Nurse #1 suddenly snap at Resident #2, that Nurse #1 had been aggressively yelling at Resident #2 in humiliating manner. Resident #3 said he/she could see that Resident #2 was scared and that he/she was crying. Resident #3 said that he/she felt terrible for Resident #2. Resident #3 said he/she was distraught because Nurse #1 was treating Resident #2 that way, and said after witnessing Nurse #1's behavior, he/she was fearful of Nurse #1 and did not interact with her (Nurse #1) the rest of the night. During an interview on 4/30/24 at 1:10 P.M., Resident #1 said he/she had witnessed Nurse #1 yelling and in an aggressive manner at Resident #2. Resident #1 said he/she was in the hallway, had been standing close to Nurse #1's medication cart during the altercation and said that Resident #2 looked scared and was crying. Resident #1 said Nurse #1 was also rude to him/her during the shift. Resident #1 said that the next day, he/she told Family Member #1 about how rude Nurse #1 was throughout the shift. Review of the Facility's Investigation Summary Report, dated 4/11/24, indicated that upon their investigation, Nurse #1 admitted to making inappropriate comments at the nurse's station in the presence of other staff members. The Surveyor was unable to interview Nurse #1 as she did not respond to the Department of Public Health's telephone call or letter requests for an interview. During an interview on 4/30/24, at 1:50 P.M., the Administrator said she received an email from Resident #1's Family Member (FM #1) at 2:40 A.M. on 4/11/24, that alleged Nurse #1 had been verbally inappropriate to Resident #1 and Resident #2. The Administrator said she immediately called the Nursing Supervisor, initiated an investigation, and suspended Nurse #1. The Administrator said Nurse #1 was from the Agency and had been scheduled to work 4/08/24 (3:00 P.M. to 11:00 P.M. & 11:00 P.M. to 7:00 A.M.) which was the unit in which Resident #1 and Resident #2 resided on. The Administrator said Nurse #1 was terminated and would no longer be contracted through the Agency to work at their facility.