Based on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent Resident #1, a vulnerable resident, from leaving the facility premises unsupervised for one (1) of six (6) residents reviewed. Resident #1. On 3/22/25 at 8:17 AM, Resident #1, who has a Brief Interview for Mental Status (BIMS) score of 7, left the facility unsupervised. The facility's transportation aide let the resident out of the front door to sit on the porch. Licensed Practical Nurse (LPN) #1 encountered Resident #1 in the facility parking lot and attempted to redirect the resident back to the facility. She left the resident unsupervised to get help from additional staff. When staff returned, the resident had moved further off-site, and was across the street in a daycare parking lot, approximately one-fourth (1/4) of a mile from the facility. The resident was out of sight and unsupervised for approximately 13 minutes. The facility's failure to adequately supervise Resident #1, a vulnerable resident, put this resident and all other vulnerable residents at risk for serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 3/22/25, when Resident #1 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 3/28/25 at 10:55 AM and provided an IJ Template. Based on the facility's implementation of corrective actions on 3/25/25, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 3/26/25, prior to the SA's entrance on 3/27/25. Findings Included: A review of the facility's policy, Wanderer Management, Monitoring System & (and) Resident Elopement Protocol, reviewed 01/2023, revealed, .It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible .All staff is responsible to ensure resident safety . On 3/27/25 at 8:17 AM, an observation revealed the street where the facility was located on a two-way roadway with 18 inches of cement along the edge of both sides of the street between the asphalt. There were no crosswalks and the curbs were approximately eight (8) inches high. The speed limit was posted as 25 miles per hour (mph). There was a wooded area across from the facility and a local business comprised of two separate buildings with a fenced-in playground between the buildings that were across the street and to the right of the facility. There were three (3) vehicles observed on the roadway during a five-minute observation. The facility driveway was one-fourth (¼) mile from the facility's portico (front entrance) to the street at the lower driveway entrance. It was one-half (0.5) mile from the lower driveway entrance to the parking lot of the second building of the local business across the street from the facility. Observation included that the front entrance of the facility was locked and required a code to be entered into a wall-mounted keypad beside the door on the outside or depression of a button at the front desk in the entranceway. Record review of the admission Record revealed the facility admitted Resident #1 on 11/19/2024 and he had current diagnoses including Chronic Obstructive Pulmonary Disease (COPD). Record review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 2/21/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated he his cognition was severely impaired. Record review of the facility's investigation, dated 3/27/25, revealed on 3/22/25, Resident #1 exited through the front door and was observed by LPN #1 while she was leaving the facility at approximately 8:30 AM. LPN #1 went to the resident and tried to assist the resident back to the facility without success and had to reenter the facility for assistance. According to the Facility Investigation, LPN #1 and other staff located Resident #1 across the street in a local business parking lot, approximately one quarter mile from the facility upper driveway and assisted the resident back into the facility at 8:43 AM. Record review of the historical weather information on Wunderground.com, the local weather on 3/22/25 at 8:00 AM had zero (0) precipitation and the temperature was fifty (50) degrees Fahrenheit. On 2/27/25 at 8:35 AM, an interview with the Administrator revealed that on 3/22/25 she was notified of the elopement of Resident #1 by Registered Nurse (RN) #1 at approximately 8:30 AM. She reported that SA was notified, and thorough investigation initiated. She stated that based on security camera footage and interview with RN #1 and LPN #2 it was determined that the resident exited the facility through the front entrance, opened by the Transportation Aide (TA). She said that according to the security camera footage the resident walked down the driveway towards the lower driveway entrance. She stated that LPN #1 was driving out of the parking lot and observed Resident #1 walking up the street towards the upper driveway entrance, parked her car and walked up the street with the resident and attempted to return him to the facility. When Resident #1 refused, LPN #1 went for assistance, returned with other staff and located the resident across the street approximately 1,320 feet from the facility and assisted to return to the facility. The Administrator confirmed that the Quality Assurance (QA) committee met and determined that the root cause of the incident was that resident had been permitted to sit outside in front of the facility near the driveway and street unaccompanied and during a QA meeting on 3/24/25 made recommendations for change of procedure which was presented to the Resident Council on 3/24/25. She confirmed that the resident remained at a behavioral unit with plans for him to return to the facility following assessment and treatment. On 3/27/25 at 2:50 PM, an interview with Certified Nursing Assistant (CNA) #1 revealed she arrived at the facility at 7:00 AM on 3/22/25 and responded to request for assistance at approximately 8:30 AM outside the facility front entrance and she observed Resident #1 across the street in the (local business) parking lot and that the staff assisted the resident to return to the facility. On 3/27/25 at 2:56 PM an interview with the TA revealed that he had opened the door for Resident #1 at approximately 8:17 AM, whom he recognized as a resident who liked to sit outside. The TA said that when he was made aware of the elopement at approximately 8:30 AM he went outside and assisted nursing staff to return the resident to the facility. On 3/27/25 at 4:30 PM an interview with CNA #2 revealed that she was working from 7:00 AM to 7:00 PM on 3/22/25 and was made aware of the elopement per intercom announcement at approximately 8:30 AM and went outside and assisted in returning the resident to the facility. On 3/28/25 at 11:00 AM, during a telephone interview with LPN #2, she reported that she was on duty 7:00 AM through 3:00 PM on 3/22/25 and assigned to the care of Resident #1, with whom she was familiar. At approximately 8:30 AM, she heard an overhead announcement and reported to the Unit 1 Nurses Station where she was notified by LPN #1 that the resident was outside and refused to return to the facility. She confirmed that she and other staff went to assist the resident who had walked a little way up the street and crossed over into the parking lot of a local business that was closed due to it being Saturday. She said following return to his room, Resident #1 refused a body audit but allowed incontinent care during which she was able to observe for signs of injury and observed none. On 3/28/25 at 2:00 PM, an interview with the Director of Nursing (DON) revealed she reported that LPN #1 made her aware of the elopement via telephone on 3/22/25 at approximately 8:30 AM. She stated she was responsible for referrals to behavioral units and securing placement with Resident #1's Representative (RR) consent at a behavioral unit for assessment and treatment due to behavioral chances. She confirmed that she conducted a new Wander/Elopement Assessment and reviewed and updated the resident's care plan and facility elopement binders on 3/22/25. She said that Resident #1 had never exhibited exit seeking or aggressive behaviors prior to 3/22/25. On 3/28/25 at 2:30 PM an interview with the Administrator revealed she stated, The facility could not anticipate that the resident's normal behavior would change. She said that Resident #1's BIMS score indicated cognitive impairment, but he had never exhibited exit seeking or aggressive behaviors prior to 3/22/25. The Administrator confirmed that all steps on the facility's Corrective Action Plan had been completed as of 3/24/25. The facility submitted a corrective action plan as follows: On March 28, 2025, at 10:55 AM -State Agency (SA) notified facility Administrator of Immediate Jeopardy (IJ). The State Agency Surveyor provided the facility with the Immediate Jeopardy (IJ) templates. Facility respectfully submits this corrective action plan. Brief Summary of Events On 03/22/2025 at approximately 8:17 AM it was discovered that Resident #1 exited the building through the front entrance with assistance by the facility Transportation Aide #1. Resident #1 was not deemed a wander risk on wander assessment completed 02/2l/2025 and never exhibited wandering behaviors while in the facility. The facility failed to provide supervision to prevent the elopement of Resident# 1, who left the facility unattended. This failure allowed Resident# I to be away from the facility unnoticed and unsupervised on 03/22/2025 from 08:17 AM until 08:30 AM, when the facility nurse noted resident outside in front of the facility. This was approximately 13 minutes after Resident# l was last observed in the facility by Van Driver #1. Corrective Actions On 03/22/2025 at 8:30 AM, LPN (Licensed Practical Nurse) #1 was exiting the facility grounds when she noticed resident#1 pushing his wheelchair and at 8:36 A.M. along with additional staff assisted the resident to return to the facility On 03/22/2025, at approximately 08:40 AM, the Administrator was notified by RN (Registered Nurse)#1 of Resident#1 exited the building without supervision and was back in the building. On 03/22/2025 at approximately 08:45 AM, resident#1 was placed on 1:1 monitoring. On 03/22/2025 at approximately 08:50 AM, Resident#1 Responsible Party was notified by the DON that Resident#1 exited and had been returned to the facility. On 03/22/2025 Nurse Practitioner (NP)#1 was notified by the Director of Nursing of Resident#1 exit of facility and return along with behaviors. NP#1 placed an order for behavioral unit evaluation of Resident#1 for inpatient stay. On 03/22/2025 at approximately 8:55 AM DON contacted Behavior facility with a referral for resident#1 for further evaluation. On 03/22/2025 at approximately 9 AM, Resident# 1 refused a head-to- toe assessment but LPN #2 was able to visually inspect resident#1 during incontinence care. No injuries were noted. On 03/22/2025 at approximately 2:43 PM Resident#1 exited the facility with Behavioral Unit for inpatient stay. On 03/23/2025 at 8:14 PM the State Agency (SA) was notified by the Director of Nurses of the incident. On 03/24/2025 at approximately 9:30 AM, the SOC initiated a 100%, mandatory In-service Training which was completed on 03/25/2025 for elopement (including facility policy review) and the care of residents with difficult behaviors, to be continued for all new hires going forward. No staff are allowed to work until in service completed. On 03/24/2025 at 4:53 PM, the DON completed a post Elopement wander evaluation on Resident #1 and changed to high risk for Elopement, and the care plan was updated to reflect this. On 03/24/2025 at approximately 12:00 PM, DON reviewed the wander and elopement binders to ensure all were up to date. On 03/24/2025 at approximately 2:00 PM, a Quality Assurance Committee Meeting was held with the Medical Director, Administrator, Director of Nursing/Infection Preventionist, and the Assistant Director of Nursing to discuss Resident #1 elopement along with plan of correction; policies were reviewed with no revisions. The facility procedure for residents sitting outdoors was updated. On 03/24/2025 at approximately 5:00 PM, the Director of Nursing audited current high-risk wander patients to review orders and care plans for accuracy. There was currently one (1) wander patient. And the Administrator performed an elopement drill on 03/25/2025 at 6:30 AM. On 03/24/2025 at 2:48 PM and 03/24/2025 at 5:40 PM the Maintenance director performed elopement drills with staff to review and educate on policies and procedures on elopement. On 03/24/2025 at approximately 9 am a Staff quiz was initiated by the CNA # 2 with all staff on knowledge of the elopement policy. On 03/25/2025 at approximately 10 am Resident council meeting was held by the Administrator to include the President and 19 members to notify of current events and procedure changes to outdoor sitting with supervision in ungated areas. On 03/25/25 at 10 am new procedures were implemented by the Administrator related to residents prohibited from sitting in ungated areas without supervision. On 03/25/25 at approximately 10:10 am new procedures were placed in the new hire orientation package by the Administrator for implementation of the procedure change of residents prohibited from sitting in ungated areas without supervision. On 03/25/25 at approximately PM Wander evaluations were audited by the Director of Nursing on all current residents reveals six residents requiring schedule adjustments. The Director of Nursing will monitor current residents for potential risks through incident report reviews, observation and communication with staff for three (3) months; the Maintenance Director will conduct elopement drills monthly (with rotating shifts until all shifts completed) for three (3) months. The Administrator will present incident report reviews and documentation of drills for review to QA team weekly to monitor compliance with the plan for three (3) months then quarterly. The facility alleges that all corrective actions were completed as of 3/25/25 and the IJ removed 3/26/25 prior to the SA entry on 3/27/25. Validation: The SA validated through interview and record review view, that all corrective actions had been implemented as of 3/25/25, and the facility was in compliance as of 3/26/25, prior to the SA's entrance on 3/27/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to protect the residents' right to be free from physical abuse from a staff member for one (1) of five (5) sampled residents. Resident #1 Resident #1 was physically and emotionally abused on 12/25/24 when Certified Nursing Aide (CNA) #1 handled him roughly, sprayed cold water on his face, and turned out the lights in the shower room, while laughing. The facility's failure to protect resulted in Resident #1 reporting he felt sad, taken advantage of, and a little afraid. Additionally, the facility's failure to immediately remove CNA #1 from the facility placed this resident and other residents in a situation that was likely to result in ongoing serious injury, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The State Agency (SA) notified the Administrator of the IJ and SQC on 2/3/25 at 2:40 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 12/31/24, the SA determined the IJ and SQC to be Past-Non-Compliance (PNC) and the IJ was removed on 1/1/25 prior to the SA's entrance on 1/23/25. Findings include: A review of the facility's, Abuse Prohibition Policy dated 5/17/24, revealed, Intent: This protocol was intended to assist in the prevention of abuse .Policy:1. The facility will prohibit neglect, mental or physical abuse . A record review of the admission Record revealed the facility admitted Resident #1 on 8/22/24 with diagnoses including Hypertension and Depression. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/29/24 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated he was cognitively intact. A record review of the facility's investigation, dated 1/2/25, revealed that on 12/30/24, the Director of Nursing (DON) received notification that a CNA had handled a resident roughly during activities of daily living (ADL) care, which included spraying a resident in the face with cold water and turning the light off in the shower room prior to exiting the room, leaving another employee and the resident in darkness. The incident occurred on 12/25/24. A review of the corrective actions revealed the facility put immediate actions in place including suspending and terminating the perpetrator and the facility's Administrator. The resident was provided support and reassurance, a body audit was conducted, and the allegation was reported, and appropriate notifications, including law enforcement were made. Life Satisfactions Rounds and Peer reviews were initiated, and Trauma Assessment was performed on Resident #1. A Quality Assurance Performance Improvement (QAPI) committee meeting was held on 12/31/24. In-services were completed on abuse, resident rights, and vulnerable the adult act. A record review of the Witness Statement, completed by Licensed Practical Nurse (LPN) #1 and signed on 12/26/24, revealed, I, (Proper Name of LPN #1), witnessed CNA (name not provided) cause emotional abuse to resident (Proper Name of Resident #1). While giving the resident a shower, CNA turned on the shower and sprayed the resident in the face with the water. Resident hollered out loudly, telling CNA to stop. Writer also told CNA not to do it anymore. CNA roughly wiped the resident's body parts. Resident started crying for CNA to stop and please let her (writer) do my shower. Writer told CNA she would take over with the shower. Writer asked CNA to just spray the soap off. CNA then turned the water from warm to cold and began spraying the resident. Resident began to scream, telling CNA the water is too cold. CNA only laughed and told the resident he will be ok. CNA began to shake the resident's bed side to side roughly. Resident began to scream 'stop.' Writer also told CNA to stop and that the resident could fall off the shower bed. CNA replied, 'it's your wheels screeching.' Also, while writer was drying the resident off, CNA went and turned the lights off, causing darkness. Both writer and the resident screamed, telling CNA to stop. CNA just laughed it off. When writer got done dressing the resident, I asked CNA how he would transfer the resident back to bed without a sling because he wet the previously one up, he replied, 'watch this, he's going to roll and go for a ride.' CNA put the shower bed beside the resident's bed and told resident, 'your about to roll on your stomach then to your back' and proceeded to push the resident from the shower bed to his bed. Writer walked out. A record review of the timecard for CNA #1 revealed he worked at the facility from 6:30 AM to 7:00 PM on 12/25/24 and 12/26/24. He also worked from 6:30 AM to 4:45 PM on 12/30/24, which was after the abuse occurred on 12/25/24. On 1/23/25 at 9:46 AM, during an interview with Resident #1, he recalled the incident in the shower and explained CNA #1 roughly handled him roughly and sprayed cold water on his face. He stated that he told CNA #1 it was cold, and CNA #1 laughed in response. Later, when CNA #1 began drying him off, it hurt and at that point, the nurse intervened and took over, which felt much better to him. He expressed that he was not afraid or upset, but the incident did make him feel sad that he was taken advantage of. CNA #1 did not take care of him anymore after that. At 11:18 AM on 1/23/25, during a phone interview with LPN #1, she recalled the incident involving CNA #1, where she witnessed as he began to get the resident from the bed. As he did so, he placed both his hands on the sides of the bed and shook it from side to side. She told him to stop because the resident could fall off the bed. He complied, but in response, CNA #1 thought it was funny and stated, He will be alright. After that, CNA #1 wheeled the resident out to the shower room and into the stall and she was there to assist as well. At that time, he took off the resident's gown, turned on the water, and sprayed the resident in the face with the shower sprayer. LPN#1 yelled, What are you doing? The water is still cold! She observed Resident #1's face grimace as if he was in pain, and he then stated, It's cold, it's cold. She asked CNA #1 why he did that, but he shrugged her off and waited until the water warmed up. LPN#1 began to lather the resident's body with body wash while CNA #1 sprayed him down with warm water. After CNA #1 finished, he grabbed a towel and began to wipe the resident down roughly. The resident said, It hurts, so she commanded CNA#1 to stop, and let her handle it. She then took the towel and began to wipe the resident gently. She indicated that CNA #1 continued to laugh it off, and turned the lights off, she and the resident screamed, and he turned them back on. On 1/23/25 at 12:02 PM in an interview with the current Administrator, she revealed the incident occurred with the previous Administrator, but she was aware of the situation. During the investigation, the facility determined that the event occurred and terminated CNA #1 and the Administrator. On 1/23/25 at 1:12 PM, during a phone interview, CNA #1 revealed that he has worked at the facility for the past two years. He explained that he is aware but does not know the source of the allegations regarding Resident #1. He confirmed that a nurse he does not know and claims to have never seen before assisted him while he was showering the resident. He stated that he does not recall spraying cold water on the resident's face, adding that all he remembers is the resident saying the water was too hot. He reiterated, I did not do anything to the resident. CNA #1 further explains that the Administrator never spoke with him about anything. All he knows is that on 12/30/24, he was told to go home because an investigation had been opened regarding him. He stated that he did not ask what it was about nor was he informed, and a few days later, someone from Human Resources called him and told him he was fired. On 1/23/25, at 1:36 PM, during an interview with the DON, she revealed that the incident occurred on 12/25/24, however, she did not learn about it until Monday, 12/30/24. She immediately suspended CNA#1 and began inservicing staff as the they were not allowed to work until in serviced on abuse and neglect. The Administrator was on vacation at the time. She indicated that she could not readily remember if CNA #1 had been written up for similar actions and was surprised that he would be accused of such behavior. She noted that he had been working with the same group of men for at least three (3) or four (4) months and that during her interviews after the event, the men spoke fondly of him, although she did add that he plays a lot. On 1/23/25 at 2:57 PM, in a phone interview with the previous Administrator, she explained that she worked on 12/26/24 and 12/27/24, which were on Thursday and Friday, and then she was off for vacation. During that time, LPN #1 came to talk with her and informed her about the incident with CNA #1 and Resident #1, mentioning that the CNA had the water set too cold during the shower. The former Administrator explained that was all LPN #1 said about the situation, so she instructed the nurse to write a statement and put it in her box. Afterward, she went to interview Resident #1 while he was sitting outside his door, and he denied that anything had happened to him other than the shower being cold. She asked him if someone had hurt him, and he specifically said No. She then told the resident that she would speak with the CNA anyway, and the resident seemed concerned, asking, What are you going to talk with him about? She reassured the resident that there was nothing to worry about. The Administrator stated she then attempted to interview CNA #1 by calling him on the phone, but he did not answer and was not scheduled to work that day. She noted that the written statement by LPN #1 was completely different from what she had verbally reported. She stated she was surprised to be suspended and later terminated regarding this event. On 2/3/25 at 10:00 AM, in a follow up interview with Resident #1, he recalled being a little afraid when CNA #1 was shaking the shower bed because he could have fallen. He acknowledged that he was sprayed in the face but was most upset about being wiped and handled roughly. Resident #1 confirmed that he did cry out during the shower for CNA #1 to stop and that it was several days before anyone at the facility asked him any questions about it. On 2/3/25 at 10:18 AM in a follow-up interview with LPN #1, she stated that the event occurred on 12/25/24 in the afternoon, and she thought it may have been after 3:00 PM. She explained both she and CNA #1 were working a 12 hour shift that day. She stated that CNA #1's behavior in the shower room scared her because it seemed odd to her. LPN #1 could not recall if CNA#1 was in the resident's room after the shower when she left the room, but she immediately reported what had happened to Registered Nurse (RN) #1 who was the charge nurse. She explained RN #1 was at the nurses station when she reported the abuse and there were other staff members that were there and may have heard her report. She reported everything that happened in the shower room to the charge nurse. LPN #1 further explained that on the following day, 12/26/24, she was working at the facility and the Administrator was there. She reported the CNA's abusive behavior to the Administrator at that time, who instructed her to write a statement. She wrote the statement and handed it directly to the Administrator and did not put it in a box. She said the Administrator did not ask her any questions about it. On 2/3/25 at 10:53 AM, in a phone interview with LPN #2, she stated that on 12/25/24, she walked up on RN #1 and LPN #1 as they were discussing the incident that occurred in the shower room with Resident #1 and CNA #1. She explained that LPN #1 was upset, but she was not sure of everything that was said because she was passing by and just heard part of the conversation. LPN #2 was unsure of how many days CNA #1 worked after 12/25/24. On 2/3/25 at 11:33 AM, in a phone interview with CNA #2, she stated that she was working on 12/25/24. She explained that she worked close to the shower room and recalled hearing noises and hollering from the shower room. She described it as kind of unusual but that CNA #1 always talked loudly. She stated that she saw LPN #1 and RN #1 talking but did not hear much of the conversation. She said that LPN #1 was upset and was saying she couldn't believe what was happening. On 2/3/25 at 11:45 AM, in an interview with RN #1, she stated that she left the faciity on [DATE] around 1:30 PM to 2:00 PM and denied being at the facility when the event occurred. She stated she did not hear about it until the next day (12/26/24) when LPN #1 told her about it and said she was going to report it to the Administrator. She said that the nurse did not go in detail, but said she was uncomfortable with what had happened. On 2/3/25 at 1:00 PM, in an interview with the current Administrator and the DON, they confirmed the CNA continued to work his shift on 12/25/24 and he also worked on 12/26/24 and until around 4:00 PM on 12/30/24. The DON stated she received the call from corporate around 4:00 PM inquiring if the allegation was reported to the SA. She was unaware of the incident because she was off the week of Christmas. The DON and Administrator stated that as part of their investigation they conducted interviews regarding the nurse's inaction. The nurse (LPN #1) said that she reported the incident immediately, but when they interviewed the charge nurse, she denied this. They felt like it was a she said, she said situation and was unable to find out where the breakdown occurred. They said they interviewed the staff that worked on 12/25/24, but none of them stated they heard LPN #1 telling the charge nurse about the abuse. Based on the implementation of the facility's corrective actions on 12/31/2024, the deficient practice was determined to be past noncompliance, and the facility was found in compliance effective 1/1/25. Validation: The SA validated on 1/23/2025, through interview and record review that all corrective actions had been implemented as of 12/31/24, and the facility was in compliance as of 1/1/25, prior to the SA's entrance on 1/23/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to report an allegation of abuse within the required two (2) hour timeframe for one (1) of five (5) sampled residents. Resident #1 Licensed Practical Nurse (LPN) #1 witnessed physical and emotional abuse of Resident #1 on 12/25/24, however, the facility did not report it to the State Agency (SA) until 12/30/24, delaying the facility's ability to protect the resident from further harm. The facility's failure to ensure immediate reporting increased the risk of further harm which left Resident #1 and other residents in a situation that was likely to cause serious injury, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The State Agency (SA) notified the Administrator of the IJ and SQC on 2/3/25 at 2:40 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 12/31/24, the SA determined the IJ and SQC to be Past-Non-Compliance (PNC) and the IJ was removed on 1/1/25 prior to the SA's entrance on 1/23/25. Findings include: A review of the facility policy, Abuse Prohibition revised 5/17/24, reveals on page 7 .2. The facility will report all allegations and substantiated occurrences of abuse .to the state agency and to all other agencies as required by law .The Abuse Coordinator will report all allegations of abuse .immediately or within two hours of the allegation . A record review of the admission Record revealed the facility admitted Resident #1 on 8/22/24 with diagnoses including Hypertension and Depression. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/29/24 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated he was cognitively intact. A record review of the facility's investigation, dated 1/2/25, revealed that on 12/30/24, the Director of Nursing (DON) received notification that a Certified Nursing Assistant (CNA) had handled a resident roughly during activities of daily living (ADL) care, which included spraying a resident in the face with cold water and turning the light off in the shower room prior to exiting the room, leaving another employee and the resident in darkness. The incident occurred on 12/25/24. A review of the corrective actions revealed the facility put immediate actions in place including suspending and terminating the perpetrator and the facility's Administrator. The resident was provided support and reassurance, a body audit was conducted, and the allegation was reported, and appropriate notifications were made, including law enforcement. Life Satisfactions Rounds and Peer reviews were initiated, and Trauma Assessment was performed on Resident #1. A Quality Assurance Performance Improvement (QAPI) committee meeting was held on 12/31/24. In-services were completed on abuse, resident rights, and vulnerable the adult act. A record review of the Witness Statement, completed by Licensed Practical Nurse (LPN) #1 and signed on 12/26/24, revealed, I, (Proper Name of LPN #1), witnessed CNA (name not provided) cause emotional abuse to resident (Proper Name of Resident #1). While giving the resident a shower, CNA turned on the shower and sprayed the resident in the face with the water. Resident hollered out loudly, telling CNA to stop. Writer also told CNA not to do it anymore. CNA roughly wiped the resident's body parts. Resident started crying for CNA to stop and please let her (writer) do my shower. Writer told CNA she would take over with the shower. Writer asked CNA to just spray the soap off. CNA then turned the water from warm to cold and began spraying the resident. Resident began to scream, telling CNA the water is too cold. CNA only laughed and told the resident he will be ok. CNA began to shake the resident's bed side to side roughly. Resident began to scream 'stop.' Writer also told CNA to stop and that the resident could fall off the shower bed. CNA replied, 'it's your wheels screeching.' Also, while writer was drying the resident off, CNA went and turned the lights off, causing darkness. Both writer and the resident screamed, telling CNA to stop. CNA just laughed it off. When writer got done dressing the resident, I asked CNA how he would transfer the resident back to bed without a sling because he wet the previously one up, he replied, 'watch this, he's going to roll and go for a ride.' CNA put the shower bed beside the resident's bed and told resident, 'you're about to roll on your stomach then to your back' and proceeded to push the resident from the shower bed to his bed. Writer walked out. During an interview on 1/23/25, at 1:36 PM, the DON revealed that the incident occurred on 12/25/24, however, she did not learn about it until Monday, 12/30/24. She immediately suspended the CNA and began educating staff as the they were not allowed to work until in-serviced on abuse and neglect. The Administrator was on vacation at the time. During a phone interview on 1/23/25 at 2:57 PM, the previous Administrator explained that she worked on 12/26/24 and 12/27/24, which were on Thursday and Friday, and then she was off for vacation. During that time, LPN #1 came to talk with her and informed her about the incident with CNA #1 and Resident #1, mentioning that the CNA had the water set too cold during the shower. The former Administrator explained that was all LPN #1 said about the situation, so she instructed the nurse to write a statement and put it in her box. She noted that the written statement by LPN #1 was completely different from what she had verbally reported. During a follow-up interview on 2/3/25 at 10:18 AM, LPN #1 she stated that the event occurred on 12/25/24 in the afternoon, and she thought it may have been after 3:00 PM. She explained she immediately reported what had happened to Registered Nurse (RN) #1 who was the charge nurse on 12/25/24. She explained RN #1 was at the nurses' station when she reported the abuse and there were other staff members that were there and may have heard her report. She reported everything that happened in the shower room to the charge nurse. LPN #1 further explained that on the following day, 12/26/24, she was working at the facility and the Administrator was there. She reported CNA #1's abusive behavior to the Administrator at that time, who instructed her to write a statement. She wrote the statement and handed it directly to the Administrator and did not put it in a box. She said the Administrator did not ask her any questions about it. During a phone interview on 2/3/25 at 10:53 AM, LPN #2 stated that on 12/25/24, she walked up on RN #1 and LPN #1 as they were discussing the incident that occurred in the shower room with Resident #1 and the CNA #1. She explained that LPN #1 was upset, but she was not sure of everything that was said because she was passing by and just heard part of the conversation. During a phone interview on 2/3/25 at 11:33 AM, CNA #2 stated that she was working on 12/25/24. She stated that she saw LPN #1 and RN #1 talking but did not hear much of the conversation. She said that LPN #1 was upset and was saying she couldn't believe what was happening. During an interview on 2/3/25 at 11:45 AM, RN #1 stated that she left the faciity on [DATE] around 1:30 PM to 2:00 PM and denied being at the facility when the event occurred. She stated she did not hear about it until the next day (12/26/24) when LPN #1 told her about it and said she was going to report it to the Administrator. She said that LPN#1 did not go in detail, but said she was uncomfortable with what had happened. During an interview on 2/3/25 at 1:00 PM, with the current Administrator and the DON, the DON stated she received the call from corporate around 4:00 PM on 12/30/24 inquiring if the allegation was reported to the state agency. She was unaware of the incident because she was off the week of Christmas. The nurse (LPN #1) said that she reported the incident immediately, but when they interviewed the charge nurse, she denied this. They also reported they had interviewed the staff that worked on 12/25/24, but none of them stated they heard LPN #1 telling the charge nurse about the abuse. Based on the implementation of the facility's corrective actions on 12/31/2024, the deficient practice was determined to be past noncompliance, and the facility was found in compliance effective 1/1/25. Validation: The SA validated on 1/23/2025, through interview and record review that all corrective actions had been implemented as of 12/31/24, and the facility was in compliance as of 1/1/25, prior to the SA's entrance on 1/23/2025.