**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to comprehensively assess for appropriate level of supervision for safety in the community for 1 of 3 residents (R1) who had cognitive impairment and a history falls in the community unsupervised. The facility failures resulted in an immediate jeopardy (IJ) when R1 was assaulted and suffered facial injuries while out in the community. The immediate jeopardy began on 8/20/23, when R1 left the facility without staff awareness, was found by law enforcement 9.3 miles away with facial injuries and transferred to hospital. The immediate jeopardy was identified on 10/5/23, and the administrator was notified on 10/5/23, at 4:14 p.m. The immediate jeopardy was removed on 10/6/23, at 4:02 p.m. but noncompliance remained at a lower scope and severity of a D with no actual harm with potential for more than minimal that is not immediate jeopardy. Findings include: R1's admission record included diagnosis of alcoholic cirrhosis of liver with ascites (build up of fluid in the belly), alcohol dependence in remission, anxiety disorder, repeated falls, and altered mental status unspecified. R1's significant change Minimum Data Set (MDS) dated [DATE], noted R1 was cognitively intact. R1 was independent with activities of daily living (ADL)'s. R1 required setup help only with eating, personal hygiene, and bathing. R1 was always steady with walker. R1's Elopement Risk Evaluation dated 4/21/23, at 10:18 p.m. indicated R1 was not at risk for elopement. R1's fall care plan initiated on 4/27/23, included R1 was at risk for falls with a history of not complying with leave of absence (LOA) policy. Falls/being pushed by someone-which has resulted in skin tears, bruises, and pain. Corresponding interventions dated 6/2/23, included R1 is not required to have an escort with him for all outings. R1's cognition care plan dated 4/27/23, identified R1 was at risk for alteration in cognition due to diagnoses of altered mental status and alcohol abuse; Associated Clinic of Psychology (ACP) resident continued to present with a level of memory loss that would suggest a dementia syndrome. Corresponding intervention was to provide and maintain a consistent environment. R1's record did not include a comprehensive assessment that addressed R1's vulnerabilities and safety needs in the community. R1's Release of Responsibility for Leave of Absence form, indicated R1 had signed himself out 8 times between 4/22/23 through 8/23/23. The form included: date out, time out, signature of person accepting responsibility, destination contact person phone number, date of return and estimated time of return. Not all of R1's entries on the form were completed and/or legible, including the date, time out, date/time returned. The Destination section included only a phone number. Additionally, R1's progress notes did not include entries when R1 had signed himself out of the facility or that he had notified staff when he left the faciity on the recorded dates. R1's progress note dated 4/23/23, included R1 left on LOA at 4:45 with his walker, did sign out, said he's going to his mom's house and will be back at 6:00 p.m. Further indicated staff asked R1 if someone was picking him up, R1 responded, yes. Review of the LOA form identified R1 signed out however, the date was not clearly written and looked like 3/23/23. R1's progress note dated 4/23/23, at 8:35 p.m. authored by a registered nurse included At around [SIC] the writer received a call [did not identify who called] that the resident was seen walking along Texas Avenue. I went and met him seated on the side of the road. I asked him where he was going and he said, I was waiting for my ride of which has not come and I decided to [NAME] cub foods and buy some fruits. The writer assisted him into the vehicle and brought him back without any issue. Nursing to continue to monitor Review of the LOA log that appeared to identify 3/23/23 did not include a time of when R1 returned to the facility. R1's progress note dated 5/1/23, at 2:03 p.m. indicated physical therapy (PT) and occupational therapy (OT) both reported a decline in resident's participation. R1 was rated moderate to high risk for falls. R1 was currently an assist of one staff/supervision with his walker but had been seen carrying his walker instead of walking with it. Also, non-compliant with using his call light for assistants. R1 scored a 21/30 on the St. Louis University Mental Status (SLUMS) Alzheimer screening suggesting a mild neurocognitive disorder (decreased mental function, but able to stay independent and do daily tasks). R1's progress note dated 5/18/23, at 1:36 p.m. indicated R1 had an appointment, and a community escort service would pick up R1. Nurse manager stated resident was ok to go unescorted if he has door to door services. R1's progress note dated 5/24/23, 10:30 p.m. indicated resident came to desk and reported he had a fall outside in the courtyard, he stated he tried to jump over the flower beds and was instructed to stay on the sidewalk. R1's Elopement Risk Evaluation dated 5/31/23, at 10:18 p.m. identified R1 was not a risk for elopement. No other elopement assessments were completed after that date also there was no indication of the SLUMS assessment completed on 5/1/23, identifying he had mild neurocognitive disorder. R1's progress note dated 6/1/23, 10:49 p.m. indicated R1 went out for paracentesis (procedure to remove extra fluid from the belly) and decided to go to Taco Bell. The transportation driver went to pick R1 up from the appointment, but he was not there and was not receiving his calls. At around 5:00 p.m. he was brought back to the facility by the health unit coordinator (HUC.) R1 stated he fell and that was why he was soiled all over. R1 was to be accompanied to all upcoming appointments for his safety. Physician order dated 6/2/23 included resident to go with a responsible party to his paracentesis appointments going forward. R1's physician progress note dated 6/2/23, nurse practitioner (NP) indicated R1 falls frequently likely related to hepatic encephalopathy (complication of cirrhosis of the liver that causes mental and physical symptoms), he reported that he was inconsistently taking his lactulose (medication that lowers ammonia in the blood). R1's physician progress note dated 6/7/23, indicated R1 sodium had slowly improved but he continued to be non-compliant with fluid restrictions, impaired decision-making as shown in his fluid noncompliance despite extensive education as well as frequent excursions from the building with frequent falls. Last week was found to have Ativan (medication used to treat anxiety) at bedside filled by an outside provider. Assessment indicated R1 appeared to have severe impaired decision-making. Despite education on topics such as fluid restrictions he continues to disregard advise and puts himself in critical danger. He also has frequent falls, fell off a retaining wall last week, days later he took himself to Taco Bell after his paracentesis and had another fall, was found incontinent with soiled pants, and returned to the facility. Provider ordered patient not to leave for his paracentesis without an escort. R1's progress note dated 6/22/23, at 5:48 p.m. indicated R1 approached health unit coordinator (HUC) and stated Hey guess what? I don't have to have an escort anymore. I talked to the bosses up front, and they said it's probably been long enough and nothing bad has happened, so they will just ask therapy to make sure. And I can wrap around the block alone too since I haven't tried to run off. The note indicated R1 did not know who he talked to or what they looked like. HUC spoke with admin personnel who informed R1 had not been cleared by therapy to go out alone. R1's progress note dated 6/26/23, 7:02 p.m. included Writer called patient [R1] to know his whereabouts after he was noted to take off the grounds. He stated that he went to help his friend to change a flat tire. He stated he will be back soon. He was reminded of the need to sign out LOA whenever he leaves the building. The facility LOA log dated 6/26/23, did not identify R1 signed himself out. Further R1's record did not identify when R1 returned to the facility and/or if R1 was assessed for injuries or other changes upon his return. R1's ACP visit note dated 8/7/23, 3:57 p.m. indicated R1 scored 19/30 on SLUMS Alzheimer screening which indicated 0-20 was dementia. R1 appeared to be functioning adequately within the secure setting and continued to present with memory loss. He was most likely dependent in all ADLs at this time. R1 would most likely benefit from power of attorney (POA) or guardianship if not already in place. He was struggling cognitively and most likely not presenting with the capacity to make good decisions. He appeared to want to do well but struggled to follow through. R1's physician note dated 8/18/23, included R1's mentation is a bit foggier today, having very mild word finding difficulty (Struggling with more complex words like Hernia, Butrans patch). More lethargic than normal. Physician gave order to send R1 to the emergency department (ED) for imaging to rule out abdominal Hernia strangulation/incarceration. R1's hospital notes dated 8/19/23 indicated R1 was admitted to the hospital on [DATE] for abdominal pain and distention. R1 was discharged back to the facility on 8/19/23, at 1:19 p.m. however, a couple of hours later R1 was returned to the hospital by emergency medical services (EMS) after he had been found down with a temperature of 102.7 degrees Fahrenheit and incontinent of urine. R1 was subsequently re-admitted to the hospital on [DATE], with diagnosis that included heat stroke, fever, and syncope, he was discharged back to the facility on 8/20/23. R1's progress note dated 8/20/23, indicated R1 was re-admitted from the hospital at 2:00 p.m. R1 stated the driver dropped him at the front entrance but could not remember the name of the company or vehicle that transported him. R1's progress note dated 8/20/23, at 10:16 p.m. R1 readmitted earlier today. At around 6:00 p.m. R1's family member (FM)-A called the facility and asked if R1 had arrived safely from the hospital. FM-A was told R1 was in the facility and had last been seen around 5:30 p.m. walking down the hall. At 8:30 p.m. FM-A called again and informed the facility that R1 had called her and told her he was in Bloomington and wanted FM-A to pick him up. FM-A stated soon after that call she was unable to reach R1. A search within the facility and surrounding areas was conducted and R1 could not be located. R1 had not signed the LOA book or informed staff he was leaving. Police were called and a missing vulnerable adult report filed. Police were given FM-A's phone number as she was the last person to speak to R1. At 10:00 p.m. police called the facility to report they had located R1 in Edina and were sending him to the hospital for an evaluation as he had blood on his shirt. St. Louis Park Police Department report dated 8/20/23, at 9:40 p.m. indicated a missing person report was filed and officer had been dispatched to the facility. Officer reported she had talked to staff and been informed that R1 was a vulnerable adult and was missing from the facility. Officer stated facility informed her that they had recently talked to FM-A who advised them R1 was in Bloomington. FM-A also informed officer, R1 had kidney failure, which often caused him mental health issue and R1 had just been discharged back to the facility that morning. While officer was talking to FM-A R1 again called FM-A and stated he was in Edina at a car wash. FM-A called Edina police department, they located R1, he had been covered in blood, and they would be taking him to the hospital. R1's emergency department notes dated 8/20/23-8/21/23 indicated R1 presented to the ED for a fall evaluation following a missing person report. R1 told hospital staff he got back to the nursing home last night but then he wanted to go out to get some nicotine and soda. He took an Uber to convenience store. Then at the convenience store, he could not get his phone to work right to get another Uber. R1 reported to the police he had been assaulted; he was pushed from behind and fell forward into railing causing an injury to his face/mouth. He did not lose conscious. R1 reported pain to his upper lip. Physical exam identified an abrasion to the upper lip and chin contusion. Notes indicated because R1 was not the best historian, physician ordered imaging for the head/neck, which were negative for acute brain bleed and concussion. R1 was discharged from the hospital back to the facility on 8/21/23. R1's progress note dated 8/21/23,a t 2:51 a.m. indicated R1 would be returning to the facility with no new orders. Further review of the notes did not identify what time R1 was re-admitted to the facility. However, note dated 8/21/23, at 3:31 p.m. indicated he met with his mental health provider. R1's record reviewed between 8/21/23 to 9/23/23, identified R1 on 8/24/23 resident had an unwitnessed fall, was shaking uncontrollably, and was readmitted to the hospital. On 9/17/23 R1 returned to the facility on 9/17/23 at 1:34 p.m. however, note at 6:05 p.m. indicated R1 had a fall with head strike and was sent back to the hospital. R1 subsequently died on 9/23/23. During an interview on 10/5/23, at 2:00 p.m. RN-A stated he had worked with R1 several times and had worked the night of 8/20/23. RN-A had seen R1 after dinner walking in the hallway. Ten minutes later R1's FM-A called and informed her R1 had returned from the hospital and had just seen him. Later at almost 8:00 p.m., FM-A had called again saying R1 had just called her and was lost somewhere. RN-A told FM-A he was not aware of R1 leaving the building. RN-A checked the LOA book and with other staff members and found out R1 had not signed out nor informed any staff he was leaving. RN-A had the staff search the building, he drove around the neighborhood, and was not able to find R1. Around 8:00 p.m. to 9:00 p.m. RN-A called 9-1-1 to file a missing person's report. RN-A reported to the police the details he had been given from FM-A and her phone number. The police later called back to the facility informing they had located R1 and he was taken to the hospital because he was bleeding. RN-A indicated after he returned from the hospital there were no treatment or care plan changes. R1's ACP visit notes dated 8/21/23, 3:32 p.m. indicated R1 was lethargic but cooperative with the interview. R1 struggled to identify what had happened but talked about being pushed in the local community. He remembered walking and walking for a long time but that was all he could remember. R1 scored 11/30 on his SLUMS presenting with deficits in short-term memory and comprehension. This level of cognitive impairment would suggest dementia. Ruling out dementia will be of value to help guide treatment interventions and placement. R1 most likely needed more help than he believed in staying on top of his medical appointments. R1 continued to present with dysfunctional behavior without insight. R1's SLP Evaluation and Plan of Treatment dated 8/22/23 indicated reason for referral to SLP to assess patients' cognition to determine if he requires guardianship per social work. Patient has had a history of unsafe LOA's. R1's Brief Cognitive Assessment Tool (BCAT) was 30/50 indicating mild dementia, ADL deficit, typically requires residential support services, clear objective evidence of memory and other cognitive declines. Prior therapy indicated patient was noncompliant with treatment and refused therapy (2/2023-5/2023). During an interview on 10/5/23, at 9:10 a.m. assistant director of nursing (ADON) stated R1 had one fall on 6/1/23 after going to his paracentesis appointment. After the appointment, he had walked to McDonalds and slipped in the mud. He then called the facility to request a ride back. Following the incident, the team discussed R1's elopement risks, looked at his BIMS (brief interview for mental status) score on 5/13/23 that listed him as cognitively intact, and his 5/15/23 PT discharge summary that stated he was able to walk unlimited distance. Administration made the decision after R1's 6/1/23 fall that he could go out independently. On 10/5/23, at 1:08 p.m. an unsuccessful call was placed to nursing assistant (NA)-B. A message was left with no return call. On 10/5/23, at 1:11 p.m. an unsuccessful call was placed to NA-C. A message was left with no return call. On 10/5/23, at 1:11 p.m. NA-D stated she did not remember R1 nor if any residents had been missing from the facility. On 10/5/23, at 1:15 p.m. an unsuccessful call was placed to NA-E. A message was left with no return call. On 10/5/23, at 1:15 p.m. an unsuccessful call was placed to NA-F. A message was left with no return call. During an interview on 10/5/23, at 2:00 p.m. RN-A stated he was not aware if R1 had ever signed himself out on the log form without his knowledge or if R1 had left the facility without his knowledge. RN-A thought R1 was safe to be in the community unsupervised because he would say where he was going, what he was doing, and when he would return. RN-A stated he had not completed a community safety assessment and he was not aware of formal process that determined a resident's ability to be independent in the community. During an interview on 10/4/23, at 1:42 p.m. RN-B stated elopement risk evaluations were completed on all residents. If a resident was a high risk for elopement a wander-guard safety device was placed on the resident that alerted staff when the resident left the facility. RN-B explained if the resident was confused, or they had frequent falls it would not be appropriate to allow the resident to leave the facility unsupervised. RN-B indicated he frequently worked with R1 and thought despite R1's waxing and waning cognition he was safe to leave the facility without supervision. RN-B indicated if a resident needed an escort there would a note in their record under the special instructions that would instruct if an escort was required. RN-B could not recall if R1 had special instructions. Residents who are able to leave the facility unsupervised are given risks and benefits and were supposed to sign out on the LOA form. If the resident did not sign out, RN-B would report it to the supervisor. During an interview on 10/5/23, at 2:31 p.m. RN-C stated she worked with R1. RN-C stated R1 was pretty independent, he needed help with little things. RN-C did not recall R1 being confused but had started getting weaker and more forgetful, however was not sure when. RN-C recalled R1 getting lost after an appointment. RN-C thought maybe after that happened, he required an escort when he went out for appointments but was not aware if he could sign himself out of the facility. During an interview on 10/4/23, at 10:37 a.m. social worker (SW) stated therapy usually would do an assessment for resident safety in the community. SW was not sure who was responsible for putting the information into Point Click Care (PCC-electronic health record) under the resident's profile. The interdisciplinary team (IDT) which consisted of nursing, therapy, social workers and administration, discussed the residents and would make the decision if someone can go out on LOA or leave independently. SW was not aware of a formal assessment and hoped the HUC had a list of residents who needed escorts for supervision to appointments in the community. During an interview on 10/4/23, at 1:22 p.m. health unit coordinator (HUC) stated she looked at the special instructions in PCC on the resident's chart, if there were no instructions then resident is good to go independently. HUC stated she uses her common sense if she feels she needs to send an escort or not, if a resident seems confused or if she wonders about them, she will check with nurse managers, therapy, or social workers. HUC stated R1 would have community escort service or family go with him to all appointments after 6/1/23, however was not aware if R1 could leave the facility unsupervised for LOA's not associated with appointments. During an interview on 10/4/23, at 3:13 p.m. occupational therapy (OT)-A stated upon every resident admission OT would complete a SLUMS assessment. OT was unable to recall R1's admission SLUMS score. The OT-A progress note dated 4/23/23 indicated staff was unable to hold R1's attention to task when attempted to complete SLUMS cognition screening. OT-A stated the SLUMS assessment helps to identify if a resident would be safe in the community, helps the nurses determine how to provide care, and how much supervision is needed. R1 was discharged from OT on 5/24/23, with a history of refusals. OT-A reported R1's last Montreal Cognitive Administration and scoring (MOCA) completed by speech language pathologist (SLP) was 21/30 with 26 or above considered normal. A score of 21 suggests mild Alzheimer's disease this had been completed at the start of therapy dated 4/24/23. OT-A stated based on the information he could locate in the computer for R1 it would not have been recommended that he be able to leave the facility independently. During an interview on 10/4/23, at 3:43 p.m. assistant director of nursing (ADON) stated the facility did not have a formal system in place to make the decision of residents going into the community independently or with escorts. ADON stated the IDT would discuss the residents in morning meetings and decide who was able to be independent and or needed escorts to appointments, who was requesting LOA's ect. ADON stated the IDT made the decisions, but the nurse managers thoughts carried the most weight in the decisions because they worked most with the residents. ADON indicated there was documentation of the IDT's decision making related to R1's ability to leave the facility without supervision. During an interview on 10/5/23, at 8:17 a.m. with NP stated she believed R1 would be safe to be independent in the facility but would not consider him safe to go into the community independently. NP stated she was not involved in the decision making of him being able to leave the community. NP stated she believed the order she made on 6/2/23 made it clear R1 needed an escort to his appointments. She would not feel safe with him to be alone in the community. During an interview on 10/5/23, at 10:18 a.m. administrator stated IDT reviewed residents in morning meetings and discuss residents and the appointments. Administrator stated the facility does not have a formal assessment to decide if a resident is safe to go out independently on appointments or LOA's. Administrator stated she did recognize the facility needed a better way to determine if a resident is safe to leave independently or not. Based on her understanding R1 was ok to leave independently on 8/20/23 and because of that did not feel it was a reportable elopement. Administrator could not articulate how they made the determination that R1 was safe to leave independently. A facility policy titled Elopement Policy, revised 6/2023, indicated Monarch Healthcare Management is committed to provide a safe environment for all residents. Assure that each resident is assessed on an ongoing basis and has appropriate safety precautions in place. The immediate jeopardy that began on 8/20/23, was removed on 10/6/23 and was verified through observation, interview and document review, when the facility implemented the following interventions: -created and established community safety assessment for all residents -provided education related to the Leave of absence (LOA) orders and process specifically related to resident's going alone in the community to nursing, social services, therapy, and IDT/leadership on or before the start of their next shift -Created a plan for DON or designee to conduct audits on all new admissions, changes in conditions, and/or falls in the community for residents on independent LOA's

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure residents were free and protected from ongoing verbal, physical abuse, and deprivation of goods by nursing assistant (NA)-A for 11 of 13 residents (R1, R2, R3, R4, R5, R9, R10, R11, R12, R13, R14) who identified abuse by NA-A and were dependent on staff for daily living needs. The facility's failures resulted in an immediate jeopardy (IJ). The IJ began on 5/12/23 when NA-A returned to work after an allegation of sexual and physical abuse. This resulted in ongoing resident complaints of aggressive rough handling, deprivation of services, and ongoing resident expressions of fear, demoralization, humiliation, shame, and degradation. The immediate jeopardy was identified on 6/2/23 and the administrator, assistant administrator, and the director of nursing (DON), was informed of the IJ on 6/2/23 at 9:37 a.m. The immediate jeopardy was removed on 6/2/23 at 4:27 p.m., but noncompliance remained at the lower scope and severity of level 2 E- pattern which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings Include: Review of the facility reported incident dated 5/12/23, indicated employee (later identified as nursing assistant (NA)-A) and a resident (later identified as R1) was masturbating in R1's room, grabbing R1's ankles causing pain, and threatening to cause harm with a gun. The facility internal investigation for allegations submitted to the state agency (SA) on 5/18/23, identified NA-A was suspended immediately pending investigation and the allegations were unsubstantiated. Interventions included, R1 would see Associated Clinic of Psychology (ACP), the facility would attempt to keep NA-A off R1's unit, not work with her for as long as possible and only in the event of a staffing crisis. The facility's investigation did not identify NA-A was interviewed nor other staff interviewed regarding the allegations. NA-A's personnel file included a form titled Notice of Suspension Pending Investigation dated 5/12/23, that identified NA-A was suspended on 5/12/23 at 11:53 a.m. related to allegation of physical and sexual abuse. Further indicated, on 5/12/23 at 2:48 p.m., two hours and 55 minutes later, the facility had unsubstantiated the allegation, and NA-A's suspension was rescinded. The form was signed by NA-A, director of nursing (DON), human resource (HR) director, and administrator. In review of the facility's investigative file and NA-A personnel file did not identify any education was provided after the 5/12/23 allegations were made, NA-A returned to work the same day. NA-A's employees file contained the following documents titled teachable moments with relatable instances of reported concerns that did identify what had occurred; the file lacked details and/or investigation or education provided. -Document dated 10/6/17, indicated NA-A was suspended pending investigation of allegation related to joking that made a resident feel threatened. -Document dated 12/13/19, indicated NA-A had allegations of assault and refusal of cares resulting in education provided by facility as well as support of associated clinic of psychology (ACP). -ACP note dated 12/13/19, indicated NA-A was provided individualized education on dealing with resident with behaviors. Education including supporting and validating the resident and offering alternative approaches and responses to negative resident behaviors. NA-A provided personalized sample of appropriate statements to use in difficult situations. -Document dated 3/10/20, indicated NA-A had a reportable event and was investigated and unsubstantiated due to resident mental illness. During interview on 5/30/23 at 5:30 p.m., administrator stated she started with the facility on 3/13/23. Administrator indicated the facility completed a thorough investigation was completed and R1's allegations were not substantiated. NA-A was removed from R1's care team unless there was a staffing crisis. The facility could not guarantee he would never work with R1. Administrator indicated the investigation did not identify any other concerns about NA-A from other residents that were interviewed. Administrator stated she was not aware, and there was no indication of other resident abuse allegations currently that involved NA-A and/or other staff. Administrator indicated that full investigation was in file. R1's current face sheet identified R1's diagnoses included schizoaffective disorder-bipolar type, and obesity. R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 did not have cognitive impairment, did not have sign/symptoms of delirium, and did not have behaviors. The MDS further indicated R1 required extensive assistance of two staff for transfers, toileting, dressing. R1 was always incontinent of bowel and bladder. R1's care plan dated 9/24/21, indicated R1 was at risk for abuse and or neglect. Interventions directed staff to be aware of statements or signs/symptoms of abuse. If they are present, update physician, director of nursing, and administrator immediately. Monitor for signs of emotional distress or mood/behavior changes and notify associated clinic of psychology (ACP) therapist of any allegations of abuse and/or neglect that involves resident. The ACP therapist will follow up with resident as needed. Safety monitoring will be implemented as needed to ensure residents safety (i.e. 15 min checks, 1:1, etc.) Staff will continue to follow the facility vulnerable adult & abuse reporting policy. The local Ombudsman, Adult Protection, Police, and/or state/financial agencies will be notified of any suspected abuse or financial exploitation as needed. During interview on 5/31/23 at 10:05 a.m., R1 was able to verbally recall NA-A by name and provided details of allegation she reported on 5/12/23. R1 was visibly upset during the interview as she described details, she looked down when speaking not making eye contact, clenched her jaw, displayed facial grimaces, and was wringing her hands or fidgeting. R1 described NA-A's behaviors as mocking, degrading, mean, stern, and yelled when he got angry. R1 stated NA-A would sometimes refuse to provide her personal cares. At times when NA-A had to provide cares, he would be physically aggressive and/or would mock her ability to care for herself. R1 explained she could not complete her own peri care, when she asked NA-A for help he would say things like you do it yourself, I am not going to do that. R1 reported NA-A had grabbed her left hand and ankle to pull her over onto her stomach in a quick motion that caused her to be in pain, when she asked NA-A what he was doing, NA-A responded in a sarcastic tone you know what I am doing. R1 stated she had recently informed NA-A of a family members funeral and NA-A responded by making insensitive sarcastic jokes about her attending. NA-A's joking comments were very degrading and made her feel ashamed. R1 indicated she has reported her concerns to the facility but felt the facility was not doing anything because NA-A's treatment and behavior towards her was ongoing. R1 stated she did not want NA-A to take care of her; she not only feared him taking care of her but also scared he would not provide cares. R1 stated since NA-A continued to care for her, she did not want to keep reporting her concerns in fear of further retaliation, and it would make things worse for her. R1 explained she tries to protect herself by staying in her room or leave the facility to avoid NA-A. During an interview on 6/2/23, at 10:40 a.m. family member (FM)-A stated she has been to the facility. FM-A explained had been a video camera in R1's room and had witnessed staff being rough with cares and verbally curt. FM-A indicated the camera kept getting unplugged. FM-A stated she did not report to administration, she was afraid R1 would be retaliated against by facility staff. FM-A reported this past Mother's Day she had come to the facility to give R1 a framed picture as a gift. Staff yelled at FM-A and made her feel as though she was a burden to the staff, although was unable to recall the names of staff members. FM-A indicated the video was not available for review. During interview on 5/30/23 at 4:38 p.m. NA-A stated he has had residents complain to him that he spoke meanly, but it was just the way he speaks. He has also had residents complain to him he was too rough when he provided care and when that happened, he would just apologize to the resident. NA-A stated he said things to residents in a joking manner that have been taken out of context, however, did not identify how his joking could be interpreted to some residents as offensive and demeaning. NA-A explained he was aware R1 had made allegations he grabbed her and threw her into bed with her clothes on. NA-A indicated he could not physically lift R1 on his own, so that allegation was not true. The day that R1 made the allegations (5/12/23), he was not placed on administrative leave, he gave a statement to administration, did not work with R1 directly, and was moved from R1's unit to another unit. NA-A further explained if R1 would be in the dining room and wanted food heated or wanted water, he could assist with those tasks. NA-A stated he did not receive any education/training. NA-A reported historically there have been residents that filed reports alleging he abused them but through the investigation it was determined to be untrue. NA-A stated he was not sure why residents kept on alleging he was abusing them. During a subsequent interview with NA-A on 6/2/23 at 8:07 a.m., NA-A gave an example of his joking around with residents would be; he would walk up to a resident and say, what's up man, he has a girlfriend call him all the time, is your girlfriend calling you, why doesn't she call you anymore. Ohhh does she not talk to you anymore NA-A indicated that because of R1's delusions you never know where she is going to stand when you are joking with her. NA-A indicated what R1 hears sticks, she keeps thinking about it. During interview on 6/1/23 at 7:11 a.m., licensed practical nurse (LPN)-A indicated NA-A jokes a lot and at times it may be too much, pushing the point of humor. LPN-A stated NA-A's jokes were not appropriate because they could be demeaning or offensive. One example is when NA-A went into the dining room, abruptly hit his palm on the table and say, okay residents I am here, which could frighten residents or be taken the wrong way. LPN-A has personally provided education/counseling to NA-A. NA-A seemed to understand the discussion in the moment, however, had not noticed any on-going changes. LPN-A did not document education/counseling provided to NA-A. LPN-A indicated she would report allegations of verbal abuse, however did not report NA-A's demanding and offensive jokes to administration or other team members. LPN-A indicated all staff were aware R1 repetitively made and reported allegations against NA-A and aware of the allegation R1 made on 5/12/23. LPN-A indicated R1 was not reliable; NA-A could not possibly pick up R1 and throw her as per the allegation. When R1 made that allegation to LPN-A, LPN-A told R1 oh you know he didn't do that. During an interview on 6/2/23, at 8:23 a.m. DON stated NA-A has a big personality, he would get excited and loud, and at times could be hard to understand. DON stated she was not able to give an example of NA-A's humor and had not worked with him or seen many of his interactions with the residents. DON stated she was aware of two reports against NA-A; the administrator and assistant administrator investigated them. DON indicated the administrator directed to have NA-A avoid R1, DON was not able to provide details of the facility's investigation. During an interview on 6/1/23, at 8:31 a.m. with RN-E nurse manager for 2nd floor stated he had done a verbal coaching with NA-A in February (2023) related to report of call lights not being answered and for not providing incontinence cares to residents or following up with the call lights. RN-E was aware of the investigation related to R1 and NA-A being suspended pending the investigation. RN-E stated he has never talked to R1 or her family about any care concerns. R2's current face sheet identified R2 had diagnoses that included morbid obesity and schizoaffective disorder, bipolar type. R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 did not have cognitive impairment, did not have signs/symptoms of delirium, and did not have behaviors. R2 required extensive to total assistance from two staff for transfers, toileting, and dressing and was frequently incontinent of bowel and bladder. R2's care plan dated 4/22/21, indicated R2 was risk for alterations in behavior related to being a veteran in active combat during the Vietnam war. Behaviors included yelling, being jumpy, nightmares/night terrors, and depressive like symptoms. R2's care plan dated 11/10/22, identified a goal for R2 to remain free from abuse and/or neglect. Interventions included be aware of statements or signs/symptoms of abuse and update the physician, DON, and administrator immediately. During an interview on 5/31/23 at 8:13 a.m. R2 stated when NA-A worked it took a few hours to all day to get changed after having an incontinent accident. NA-A usually started his shift between 2:00 p.m. and 2:30 p.m., he (R2) would put on his call light for help, NA-A would come into his room and shut off the call light without providing care. That was a common practice of NA-A's. R2 indicated he took bowel medications and was sometimes incontinent of bowel that had a really foul odor that could not go unnoticed; NA-A still would shut off the call light and not clean him up. Instead, NA-A would respond by rudely and abrasively telling R2 I don't have time for you or this mess right now, we have other patients to take care of! R2 stated this made him feel embarrassed and ashamed for having accidents and sitting in urine and feces caused pain and sores on his butt. One time after R2 was told by NA-A he did not have time, R2 saw NA-A go sit down at a table in the dining room from 3:30 p.m. to 4:00 p.m. There was another time, when R2 was assisted to bed by NA-A, NA-A told R2 You get in that bed, you stay in that bed!. R2 indicated when asking for NA-A's help with personal cares NA-A would get sassy thinking he was funny, or it was a show of power over him. R2 thought NA-A's actions were willful and hurtful. R2 stated he has requested for NA-A to not provide him care anymore because of NA-A behaviors that made him feel worthless and undignified, however NA-A still provided care. R2 indicated he filed a grievance and reported it to the social worker, but no one has followed up with him and seemingly nothing done to correct R2's concerns. During a subsequent interview on 6/2/23, at 1:27 p.m. R2 stated when NA-A completed incontinent cares a while ago, he had scrubbed his scrotum so hard to the point of R2 had to say stop, it did cause a sore spot that got better. R2 stated his experiences with NA-A have made him feel withdrawn I just don't care anymore, I just want to quit dealing with being treated this way. R2 stated he wanted to move to another facility because of how NA-A treated him and the pain NA-A caused when he provided care to him. Facility grievance dated 4/6/23, indicated R2 turned on call light at 1:30 p.m. NA-A came into room at 2:00 p.m. NA-A turned off the call light and left the room. It was not until 6:30 P.M. that night when he received assistance to change his incontinence pad. The form did not identify any actions taken, there was no indication the grievance was investigated or resolved. During interview on 6/2/23 at 8:49 a.m., FM-B stated she has had to call the facility to have staff provide incontinence care to R2 on multiple occasions. She was upset regarding the lack of care R2 received and has tried to report concerns to different facility staff. FM-B indicated that she has reported concerns several times to the DON and felt she was being ignored. When she reports concerns it was a temporary fix, as in someone will go up to the floor to address it at that time, but there has been no permanent solution or resolution of ongoing issues. FM-B explained she lived out of state, because of the unaddressed concerns she needed to purchase a video phone. FM-B has witnessed via video call on different occasions (could not recall dates), waiting for hours at a time to be changed after incontinent episodes.FM-B was unable to provide video. FM-B heard NA-A say to R2 If I change you, you know you have to stay in bed. Some days R2 was not able to get out of bed even if he asked staff and R2 would tell her after he was cleaned, he still smelled of feces. FM-B indicated she thought R2 was being bullied in the facility and should not need to beg to go to the bathroom or get out of bed and receive basic needs. FM-B stated R2 has told her he had depressed feelings and sadness regarding his care at the facility. FM-B reported she has noticed R2 was more and more withdrawn since admitting to the facility. He did not engage in the typical things because of the lack of opportunity to have been provided basic activities such as sitting on a toilet. During an interview on 6/1/23 at 2:46 p.m. RN-A indicated he worked on the overnight shift with NA-A. RN-A indicated that nurses should know and be involved in the grievance process. RN-A stated he was not aware of any grievances filed by R2. RN-A reviewed R2's grievance dated 4/6/23, he acknowledged it was not completed and stated something should have been done to resolve it. RN-A indicated since there was an allegation of neglect, it was a reportable incident to the State Agency. During an interview on 5/31/23 at 11:08, DON indicated an awareness R2 would prefer NA-A did not provide cares. Typically if a resident did not want to work with a certain staff, the resident would be interviewed to find out the reason why. Sometime customer service education needed to be provided to the staff member. DON stated the facility could not guarantee the staff member would not work with the resident or the resident would not see the staff member. R3's current face sheet identified R3 had diagnoses of morbid obesity, bipolar disorder, moderate intellectual disabilities. R3's quarterly MDS dated [DATE], R3's cognition was not assessed. Prior MDS dated [DATE], identified R3 did not have cognitive impairment. The MDS dated [DATE], indicated R3 did not have sign/symptoms of delirium and did not have behaviors. R3 required extensive to total assist of two staff for transfers, toileting, and dressing tasks and R3 was always incontinent of bowel and bladder. R3's vulnerable adult care plan dated 4/22/21, identified R3 was vulnerable due to residing in long term care facility with diagnosis of bipolar disorder that increases resident vulnerability. Interventions included minimize risk for abuse to remain safe and be treated with respect. R3's communication care plan intervention directed staff to provide resident adequate time to communicate needs and process information. During an interview on 5/30/23 at 5:09 p.m., R3 stated he had concerns with his care and had been hit in the mouth by a staff member. R3 would not say which staff member. R3 stated NA-A has yelled at him and he would get frustrated when providing cares because he (R3) was slow; getting yelled at made him feel bad. R3 explained he was scared to talk about it and did not tell anyone about the incident. During a subsequent interview on 6/1/23, R3 further disclosed it was NA-A who hit him in the mouth when he was on a different unit. R3 liked to have his teeth brushed however, NA-A would not brush his teeth. NA-A has refused to give him water because then he (R3) would need to go to the bathroom. NA-A treated him roughly when providing cares, he has yelled and raised his voice, and NA-A has told him he does not have time for him. R3 stated he was sad, angry, and uncomfortable living in the facility. R3 has told his family about these situations but has not told anyone at the facility because he was scared of retaliation. FM-D was contacted but did not respond R3's family member was contacted but did no respond. R4's current face sheet identified an admit date of 7/6/22, and included diagnoses of Schizophrenia, morbid obesity, anxiety disorder, urge incontinence and insomnia. R4's annual MDS dated [DATE], identified R4 did not have cognitive impairment, no signs/symptoms of delirium and did not have behaviors. R4 required extensive assist of one staff for bed mobility, transfers and dressing and was always incontinent with bowel and bladder. R4's mood/behavior care plan dated 6/8/12, indicated R4 had behaviors of yelling during cares and swearing when frustrated, irritated, or anxious and had difficulty regulating emotions. Vulnerable adult care plan intervention dated 8/26/21, directed for staff to avoid the use of sarcastic humor. Incontinence care plan interventions included, R4 needs to return to her unit by 12-1 a.m. to get ready for bed (dated 10/21/14.), Met with resident to discuss incontinence voiding on floor in common areas on 1st floor reviewed plan to decrease and prevent voiding on floors (dated 7/20/20). 1. toilet before going to first floor. 2. Return to floor every two hours to toilet during day/evening 3. XL pull up brief; this has helped with independence and ease of toileting for resident. Toilet upon arising, after meals and before bedtime (dated 7/21/20). During an interview on 5/31/23, at 12:58 p.m. R4 stated staff were nasty to residents sometimes. NA-A was mean to her and has physically pushed her back into her wheelchair when she was attempting to stand up. R4 explained when she has told NA-A he was mean to her, he responded by telling her she was lying. When she (R4) asked NA-A for help he would tell her, No. NA-A has accused her (R4) of deliberately having incontinent episodes, he would call me lazy and make me feel bad. R4 stated some of her friends really like NA-A, they would take his side. R4's friends have warned her she would have consequences like not getting her makeup put on or not go to the country store if she continued to have incontinent episodes. R4 reported she has seen NA-A being rough with other residents in the facility. Several months ago, NA-A told her (R4) he was not going to change her and she had to wait for the next shift to be changed; R4 became upset and called NA-A a name, then told NA-B. NA-B then told the overnight charge nurse RN-A who then blamed R4, RN-A told R4 it was my fault I did not get changed because I stayed up until 2:00 a.m. so they did not change me. R4 stated she was called a liar by RN-A so she became angry and replied, thanks a lot. RN-A replied you're welcome. R4 stated she became so flustered she dropped a book, she asked RN-A to help to pick it up, RN-A said no When R4 asked another resident to help pick the book up, RN-A told the resident not to help R4. I [R4] told him [RN-A] I hated him and he responded by saying good. RN-A then said, hey [R4] you're supposed to be in bed, get in bed. R4 stated she had not reported the incident to anyone else aside from NA-B and RN-A because she was afraid things would only get worse R4 reported at night she did get afraid because staff would tell her to not turn the call light on because they were too busy for her. The staff always complained to her they have to clean her up after she has accidents. Review of R4's medical records and facility incident reports dated 3/1/23-6/1/23, did not identify the allegations or documentation related to R4's reported concerns to NA-B and RN-A. During an interview on 6/1/23 at 9:33 a.m. LPN-A stated it would not surprise her if NA-A told a resident not to lie after a resident reported concerns because that was how NA-A talked to residents. LPN-A witnessed NA-A say to R4 he could not help, or he would not help. LPN-A indicated NA-A was dishonest. One morning she saw R4's call light on, NA-A entered the room, turned it off, and came back out. NA-A told her that R4 did not need anything, she was sleeping. LPN-A stated she immediately went to R4's room and found R4 wide awake and R4 stating Darn him! LPN-A explained R4 would often go tell the health unit coordinator (HUC) no one was helping her; the HUC would have to call the nurse's station to get help for R4. During an interview on 6/1/23, at 8:31 a.m. RN-E indicated R4 was very particular about how she looks, but has not heard any concerns related to NA-A refusing to help R4. RN-E stated R4's care plan showed she should be encouraged to toilet every 2 to 3 hours at night and as needed without her putting her call light on. If R4 reported call light concerns at night, the facility would try to solve the problem internally, and would ask the overnight supervisor to do an audit. RN-E stated he did not work overnights so it would not be him doing the audits and he was unaware who would complete the audits if they were needed RN-E stated if someone had a complaint about an overnight supervisor that complaint would come to him. RN-E stated that if R4 stated no one was checking on her at night she was alert and oriented she would know if someone checked on her or not. RN-E stated he was not aware of any other complaints related to NA-A. During an interview on 6/1/23, at 11:38 a.m. with HUC stated she has talked to R4 almost every day. HUC stated R4 has said NA-A told R4 I am too slow and tell me, Move it, Move it. R4 has told HUC, NA-A has refused to provide care and told her I shouldn't have gone in my diaper, I shouldn't be too lazy, I should take myself to toilet, she shouldn't have to go to the bathroom because she had just gone not too long ago, he's [NA-A] is too busy and other people to take care of. HUC stated R4 has never reported physical abuse abuse, only verbal. HUC explained R4 would get really down on herself because of the things NA-A has said to her. R4 would say things like, I know I am too slow. HUC stated she had reported her concerns about NA-A to the assistant administrator about a month ago. During an interview on 6/1/23 at 9:33 a.m. with LPN-A indicated she has worked when HUC has called after R4 reported complaints to the HUC she was not getting assistance from NA-A. LPN-A stated recently she came to work in the morning and R4 was still awake in her chair stating she had been sitting up all night. LPN-A asked R4 why she had not asked staff to lay down, R4 reported she did not ask them to lay her down because she didn't want to make them mad. R4 was afraid to get others made and would not name any names because her friends like NA-A. LPN-A stated the night staff that would have included NA-A and RN-A have told her if R4 did not ask them they did not offer to lay her down. LPN-A stated R4's care plan indicated that the staff are to ask R4 to toilet every 2-3 hours and offer to lay her down. LPN-A stated R4 told her no one was asking her and she was afraid to get others mad. R4 would not name any names out of fear of upsetting her friends and retaliation of staff. LPN-A indicated even though R4 had sat up in her chair without being toileted according to the care plan and R4 reported she was fearful of staff, she did not report it administration. During an interview on 6/1/23 at 2:46 p.m. RN-A indicated he worked on the overnight shift with NA-A. RN-A denied having any awareness of NA's loud tone, aggressiveness, and refusing cares. Further denied awareness of any residents complaints about NA-A and/or residents not being provided with incontinence care. RN-A stated I am surprised of complaints at all at night! RN-A indicated that nurses should know and be involved in the grievance process. RN-A stated he was not aware of any grievances filed by R2. RN-A reviewed R2's grievance dated 4/6/23, he acknowledged it was not completed and stated something should have been done to resolve it. RN-A indicated since there was an allegation of neglect, it was a reportable incident. During an interview on 6/2/23, at 8:23 a.m. DON stated she was unaware of any allegations of abuse related to R4 but stated she can be obsessive, to the extent one male staff member requested a different work location. R4 had a hard time regulating her emotions and would have explosions. DON stated R4 also had a history of inappropriate incontinence in public areas and can be reluctant with cares. R5's current face sheet identified R5 had diagnoses that included hemiplegia, hemiparesis following cerebral infarction (stroke) affecting dominant side, major depressive disorder with severe psychotic symptoms, psychotic disorder with delusions due to known physiological condition R5's Quarterly MDS dated [DATE], identified R5 did not have cognitive impairment, did not have signs/symptoms of delirium or behaviors. R5 required extensive assistance of one staff for bed mobility, transfers, dressing, hygiene, toilet use and was always incontinent with bowel and bladder. R5's care plan dated 3/23/21, identified R5 was at risk for abuse and or neglect as resident resides in a LCT facility. R5 is at risk for cognitive and physical decline related to her diagnosis of adjustment disorder with delusions due to known condition and major depressive disorder with psychotic symptoms including catatonic disorder. Interventions included be aware of statements or signs or symptoms of abuse. If present, update physician, DON and administrator immediately. R5's care plan further indicated R5 was under a psychiatric commitment order related to history of suicidal ideation, refusal of cares and physical aggression to staff. An intervention directed staff to notify ACP therapist and mental health therapist (MHT) of any allegations of abuse and or neglect that involves the resident and ACP therapist will follow up with resident as needed (start date 12/14/21). Review of R5's progress notes dated 3/1/23-6/1/23, did not identify any reported allegations of abuse/neglect. During an interview on 6/1/23, at 12:16 p.m. R5 stated NA-A is not my favorite. When R5 was asked why? R5 responded, It's the whole thing! Changing me, turning me over; he is rough, it just hurts! R5 stated she had told someone but could not remember who. R5 explained she did not like NA-A coming into her room and would just ignore him. R5 did not feel educating NA-A would do any good because he is naturally rough. R5 indicated NA-A had hurt her head; R5 demonstrated on herself striking herself in the head with her hand. During the interview when discussing NA-A with R5 she became increasingly visibly distraught; R5 was tearful, displayed facial grimacing, and wincing as she recalled details of her encounters with NA-A. R5 stated she was scared of NA-A tearful and stated she was fearful of NA-A. During this interview NA-E entered room, NA-E stated she has never witnessed R5 cry or grimace and is normally just flat or calm. During an interview on 6/2/23, at 1:21 p.m. FM-C stated she visited R5 between 5/25/23 and 5/30/23. During the visit, R5 looked really upset, kind of hurt, just shut down and would not express anything. FM-C stated she questioned R5 about her mood because it was out of character, she was not acting at all like herself; R5 did not say anything. FM-C stated they had brought R5 a lazy boy, a couple of weeks ago and came to visit R5 a couple of days after she had brought it and it was gone. When FM asked R5's nurse where her chair went, FM-C was told they didn't know and she could go look for it. During an interview on 6/1/23 at 9:33 a.m. LPN-A stated she was aware of residents who did not want NA-A to provide cares to them or want him in their rooms; R5 [TRUNCATED]