Based on interviews, record review, job description review and facility policy review, the facility failed to protect the residents' right to be free from verbal abuse from a staff member for one (1) of 21 sampled residents. (Resident #17) Resident #17 was verbally abused and threatened on 2/8/25 when Certified Nursing Aide (CNA) #1 used profanity in an argument and aimed a spray bottle of chemical cleaner toward him. The facility's failure to protect Resident #17 resulted in his reporting he felt nervous and afraid. Additionally, the facility's failure to immediately remove CNA #1 from the facility placed this resident and other residents at risk for similar abuse. 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 3/12/25 at 2:15 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 02/12/25, the SA determined the IJ and SQC to be Past-Non-Compliance (PNC) and the IJ was removed on 02/13/25 prior to the SA's entrance on 03/11/25. Findings include: A review of the facility's, Abuse Prohibition Policy, dated 5/17/24, revealed, Intent .Each resident has the right to be free from abuse, mistreatment .Policy: 1. The facility will prohibit neglect, mental or physical abuse .of residents .Definitions .Verbal abuse is defined as the use of, oral, written or gestured language that willfully includes disparaging or derogatory terms to residents .within their hearing distance .Examples of verbal/mental abuse include .cursing, yelling, saying things to frighten a resident . A record review of the facility's Certified Nursing Assistant (CNA) Job Description dated March 2017, revealed, .Function: Cares for Residents under the direction and supervision of a registered nurse or a licensed practical/vocational nurse .Knows how to respond to Residents' behaviors .Demonstrates a basic understanding of behavior treats Residents with dignity and respect . A record review of the facility's investigation, dated 02/15/25, revealed On Saturday, February 8, 2025, Certified Nursing Assistant (proper name) was entering the dining room and encountered (Resident proper name) .(Resident proper name) began yelling expletives at (CNA proper name) .(CNA proper name) began arguing back with the resident using profanity .(Resident proper name) was interviewed and stated he was speaking with Licensed Practical Nurse (LPN) proper name) in the dining area when (CNA proper name) entered. He began cursing and calling CNA names and (CNA proper name) became argumentative and also used profanity. He stated that Nurse (proper name) took him back to his room and calmed him down .(CNA proper name) was interviewed. CNA stated (Resident proper name) began screaming swear words at her and then proceeded to roll his wheelchair towards her threatening to slap her in the face. Employee said this made her feel scared so she picked up a spray bottle and told him not to come any closer LPN (proper name) was interviewed. Nurse stated that her and (Resident proper name) were indeed having a conversation in the dining area when (CNA proper name) entered. Nurse stated that (Resident proper name)began cursing at (CNA proper name) and the employee began arguing back. Both (CNA proper name) and (Resident proper name) were using profanity. (CNA proper name) then picked up a spray bottle and pointed towards (Resident proper name) but did not spray the bottle. The resident was then taken back to his room .Life rounds were completed and residents with a BIMS (Brief Interview of Mental Status) of 12 or higher. One resident stated that CNA (proper name) had a smart mouth and another resident stated that he hears her being loud and using profanity in the hallway. Life rounds completed with staff with no issues noted. In services initiated with staff on Resident Rights, Vulnerable Adult, Abuse, Neglect and Customer Service. Currently, the facility decided to terminate employee (proper name) due to multiple policy violations . A record review of the time sheet for CNA #1 revealed on 2/8/25 she worked from 7:31 AM to 6:45 PM. On 2/9/25 she worked from 8:20 AM to 7:26 PM, and on 2/12/25 she worked from 7:56 AM to 11:30 AM, which was after the abuse occurred on 2/8/25. On 03/11/25 at 9:00 AM, during an interview Resident #17 confirmed that he and CNA #1 had a disagreement that occurred during the smoke break on 2/7/25. He stated that the CNA had refused to go back into the facility to get his cigarettes. The resident reported that on 2/8/25, he and LPN #1 were in the dining area talking, when CNA #1 entered the dining area. The resident stated he was still upset about the incident from the smoke break and stated to LPN #1 that CNA #1 was a lazy (expletive). CNA #1 then approached him and started using profanity toward him, and she then grabbed a bottle containing cleaning solution, that was sitting on a housekeeping cart and pointed it toward him. Resident #17 stated she did not spray it on him, but he was nervous and afraid because he thought she might spray him. On 03/11/25 at 10:03 AM, during an interview with the Risk Manager (RM) she acknowledged that she was made aware of the incident on 2/12/25 by the Administrator, which was four (4) days after the abuse occurred. The RM stated she and the Administrator called CNA #1 in for an interview, and she was then suspended. The RM stated CNA #1 fully admitted the details of the incident as reported by Resident #17 and LPN #1. On 03/11/25 at 3:40 PM, during an interview, LPN #1 stated that on 2/8/25, while walking down the hall, she encountered Resident #17, who looked toward CNA #1 and said, Go hit that (expletive) in the back of the head. LPN #1 stated she initially thought the resident was joking, as he is typically pleasant. As they continued speaking, CNA #1 approached and confronted the resident, saying, Are you talking about me? You better keep my name out of your mouth. LPN #1 stated the resident then called CNA #1 a lazy (expletive), and CNA #1 walked away, but the resident followed her and the two continued yelling at each other. CNA #1 then asked LPN #1 if she was going to intervene to de-escalate the situation. LPN #1 reported that CNA #1 grabbed a spray bottle from a housekeeping cart, pointed it at the resident, and yelled, Back the (expletive) up, back the (expletive) up! I'm going to get [another resident] to come down here to beat you in the head. LPN #1 stated the resident backed away and CNA #1 walked off. LPN #1 reported the incident to LPN #2, the Charge Nurse. Shortly afterward, LPN #3 informed LPN #1 and LPN #2 that CNA #1 had also reported the incident to her. LPN #1 stated that as LPN #3 was preparing to call the Director of Nursing (DON), CNA #1 approached them and began yelling about what should be done to Resident #17. LPN #3 escorted CNA #1 back to her unit and called the Director of Nursing (DON), who later spoke with LPN #2 and advised that he would handle the incident on Monday. LPN #1 stated she was not instructed to send CNA #1 home and did not tell CNA #1 to leave out of fear the hostility might escalate. LPN #1 acknowledged she was aware that Resident #17 was being verbally abused and threatened by CNA #1. She stated she believed reporting the incident to the Charge Nurse fulfilled her obligation but admitted she should have removed the resident once the situation escalated. LPN #1 confirmed that CNA #1 completed her shift on 2/8/25 and was still working at the facility when LPN #1 returned on 2/12/25. She also confirmed she had not been contacted by the DON for a statement prior to meeting with the Administrator on 2/12/25. LPN #1 stated that staff receive frequent in-service training on abuse prevention through computer-based modules, which include topics on de-escalation and resident safety. On 03/11/25 at 4:15 PM, during an interview, the DON stated that on 2/8/25 at approximately 10:00 AM, he received a phone call from LPN #3 reporting that Resident #17 had directed profanity toward CNA #1. The DON stated that he instructed LPN #3 to ensure that CNA #1 did not assist Resident #17 with smoke breaks moving forward. The DON further explained that around 12:00 PM that same day, he contacted LPN #2 and was informed that CNA #1 had raised her voice at Resident #17 and had been separated from the resident. The DON reported that based on the information provided at the time, he did not view the incident as abuse and, therefore, did not instruct staff to send CNA #1 home. On 03/11/25 at 4:33 PM, during an interview, LPN #2 confirmed that on 2/8/25, LPN #1 approached her at the nurse's station and informed her about the incident between Resident #17 and CNA #1. Shortly after, LPN #3 arrived from the other unit to inquire about what had occurred. LPN #2 stated that CNA #1 then came to the nurse's station, visibly agitated and upset, and said, Who the (expletive) are you sending home? LPN #2 reported that LPN #3 subsequently escorted CNA #1 back to the other unit and placed a call to the DON to report the situation. LPN #2 stated that when the DON called her later that day, she relayed what LPN #1 had reported, and suggested that the DON follow up directly with LPN #1. LPN #2 confirmed that she specifically informed the DON that CNA #1 had verbally retaliated against Resident #17, stating, Who the (expletive) are you talking to? Who the (expletive) are you calling a (expletive)? LPN #2 also reported that she told the DON about the allegation that CNA #1 had aimed a chemical-filled spray bottle at the resident and threatened to recruit another resident to physically harm him. LPN #2 stated that the DON responded that he would handle the situation on Monday. LPN #2 explained that she did not send CNA #1 home that day, as she was waiting for direct instructions from the DON. On 3/12/25 at 10:02 AM, during a phone interview, CNA #1 stated that on 2/8/25, she was in the dining area when she noticed Resident #17 speaking with his nurse (LPN#1). CNA #1 reported that she approached them and asked, Is there something you need to tell me? According to CNA #1, Resident #17 began using profanity toward her. CNA #1 stated she turned to the nurse and asked, Are you going to intervene with your resident? CNA #1 reported that Resident #17 then threatened to slap her. In response, she stated that she grabbed a spray bottle of cleaning solution from a nearby cart, aimed it at the resident, and told him not to put his hands on her. CNA #1 said she did not view pointing the spray bottle at the resident as a threatening act but rather as a defensive measure. CNA #1 acknowledged that the facility regularly provides abuse prevention training, which includes guidance on appropriate responses to escalating situations. On 03/12/25 at 12:15 PM, during an interview, LPN #3 stated that she did not personally witness the incident involving CNA #1 and Resident #17 on 2/8/25. She reported that CNA #1 informed her that Resident #17 had cursed at her, and in response, she cursed back and aimed a spray bottle of cleaning fluid at him. LPN #3 stated that CNA #1 was frustrated because LPN #1 had been standing next to the resident during the incident and did not intervene. LPN #3 explained that she went to the Unit 2 nurse's station to discuss the matter with LPN #1 and LPN #2. According to LPN #3, LPN #2 instructed her to notify the DON. LPN #3 stated that she contacted the DON and informed him that CNA #1 admitted to cursing at Resident #17 and pointing a spray bottle of cleaner at him. LPN #3 reported that the DON instructed her to document a statement and assured her that he would address the issue on Monday. LPN #3 added that she also reminded the DON about CNA #1's responsibility for taking residents to their scheduled smoke breaks. On 03/12/25 at 12:51 PM, during an interview, the Administrator stated she became aware of the incident from 2/8/25 when CNA #4 approached her on 2/12/25 and asked if she had been made aware of what had occurred. The Administrator explained that, following this, she immediately spoke with Resident #17, the DON, the involved nurses, and CNA #1. The Administrator reported that CNA #1 admitted to the incident as described and was subsequently sent home on 2/12/25. She further stated that in-services were held with all staff to reinforce how to identify and report abuse, which included drills and refresher training. The Administrator confirmed that all staff are regularly trained on appropriate actions in response to allegations or incidents of abuse. She acknowledged that the nursing staff did not follow the facility's abuse policy and protocol, specifically stating that CNA #1 should have been removed from duty immediately. A record review of the admission Record revealed the facility admitted Resident #17 on 7/15/24 with diagnoses including Anxiety Disorder. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/16/25 revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. A review of Section E revealed the resident had not exhibited any verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). Facility Corrective Action Plan: On 03/12/2025 at 3:15 PM State Agency (SA) notified facility Administrator of Immediate Jeopardy (IJ). State Agency Surveyor provided the facility with the Immediate Jeopardy (IJ) templates. Facility respectfully submits this corrective action plan. Brief Summary of Events On 02/12/2025 at 10:45AM the Administrator was notified of allegation of verbal abuse involving Resident #17 and CNA (Certified Nursing Assistant) #1. On 02/08/2025 CNA #1 was delivering a resident tray when she overheard Resident #17 and staff member laughing. The CNA #1 questioned the contents of their conversation. Resident #17 started using profanity directed at her. CNA #1 picked up a spray bottle pointing it in the direction of Resident # 17. CNA # I was using profanity as she was walking away from Resident # 17. CNA #1continued to work in facility in separate care area until allegation was reported to administration on 2/12/2025. Corrective Actions 1. On 02/12/2025 at 9:30am. The Treatment Nurse conducted a routine head-to-toe body assessment on Resident #17 to review for any skin abnormalities or concerns. Resident #17 had no negative skin issues or concerns. 2. On 02/12/2025 at 10:55am The Director of Nursing and Administrator interviewed Resident #17 regarding the allegation of abuse. Resident #17 provided statement of events. 3. On 2/12/2025 at 1130am, CNA (Certified Nursing Assistant) #1 was interviewed, statement obtained and suspended pending investigation by the Administrator. CNA #1 was subsequently terminated. 4. On 02/12/2025 at approximately 11:30am an allegation of abuse involving Resident #17 was reported to the State Agency (SA) by the Facility Risk Manager. 5. On 02/12/2025 at approximately 1140am an allegation of abuse involving Resident #17 was submitted to the Attorney General (AG) complaint website by the Risk Manager regarding allegation of abuse. 6. On 2/12/2025 at 11:40am, Referral was sent to Psychologist Nurse Practitioner by the Director of Nursing for evaluation and follow up. 7. On 2/12/2025 at 11:40am, The Medical Director was notified of the allegation by the Administrator. 8. 02/12/2025 at 12:00pm The Administrator notified ombudsman with no answer and left message. 9. On 2/12/2025 at 12:14pm, The DON conducted Trauma Assessment on Resident #17 with no negative findings. 10. On 2/12/2025 at 12:30pm, The Risk Manager initiated Life satisfaction rounds on with residents with BIMS (Brief Interview of Mental Status} of 12 or higher regarding Abuse and Safety in the facility. two negative findings on unprofessional behavior resulted with a report of being rude and loud. No allegations of abuse resulted. 11. On 2/12/2025 at 1:30pm, Peer reviews initiated by Risk Manager regarding Abuse and Safety in the facility involving CNA #1. One finding resulted in witnessing the allegation involving Resident #17. On 2/12/2025 at 1:30-1:45pm, An Abuse Drill Evaluation completed with Station I and II by the DON and Administrator as part of an ongoing monitoring plan. Life satisfaction rounds with two residents having a BIMS of twelve or higher will be completed by the Administrator/DON or Risk Manager weekly times four weeks, every other week times eight and monthly thereafter for three months. The QAPI committee will evaluate additional action based on results. The DON will conduct two random interviews on residents with BIMS of twelve or higher for any allegations of abuse or neglect weekly times four weeks, every other week times eight weeks and monthly times three months thereafter. The DON, Assistant Director of Nursing, or Risk Manager will conduct two random body audits on residents with BIMS below twelve for any indicators of abuse or neglect weekly times four weeks, every other week for eight weeks and monthly times three months thereafter. The QAPI committee will evaluate additional action based on results. The QAPI Committee will review potential trends and patterns and provide recommendations as needed. 12. On 2/12/2025 at 2:30pm, an in-service initiated by Risk Manager/ DON/ADM on Abuse and Neglect, Resident Rights, Vulnerable Adult, along with the reporting guidelines including how to address if abuse is noted. No staff was allowed to return to work prior to completion. 13. On 2/12/2025 at 3:00pm, QAPI Committee held a Quality Assurance Meeting to include Medical Director, Director of Nursing, Assistant Director of Nursing, Risk Manager/Infection Preventionist, Medical Records, Director of Rehabilitation, [NAME] Office Manager, Activity Director and Minimum Data Set Nurse to discuss allegations of abuse along with corrective action and monitoring in place. Policies were reviewed with no revisions needed. 14. On 3/12/2025 at 3:15pm. State Agency (SA) notified the Administrator of Immediate Jeopardy with past noncompliance of 02/12/2025. The State Agency (SA) provided the facility with the Immediate Jeopardy templates. 15. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 02/12/2025 and the Immediate Jeopardy was removed 02/13/2025. Validation: The SA validated on 3/13/2025, through interview and record review that all corrective actions had been implemented as of 2/12/25, and the facility was in compliance as of 2/13/25, prior to the SA's entrance on 3/11/2025.

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 21 sampled residents. Resident #17. Resident #17 was verbally abused and threatened on 2/8/25 when Certified Nurse Aide (CNA) #1 used profanity in an argument and aimed a spray bottle of chemical cleaner toward him. This was witnessed by Licensed Practical Nurse (LPN) #1. This occurred on 02/08/25, however, the facility did not report it to the State Agency (SA) until 02/12/25, delaying the facility's ability to protect the resident from further mistreatment. The facility's failure to ensure immediate reporting increased the risk of harm which left Resident #17 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 03/12/25 at 2:15 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 02/12/25, the SA determined the IJ and SQC to be Past-Non-Compliance (PNC) and the IJ was removed on 02/13/25 prior to the SA's entrance on 03/11/25. Findings include: A review of the facility's, Abuse Prohibition Policy, dated 5/17/24, revealed, Intent .Each resident has the right to be free from abuse, mistreatment .Policy: 1. The facility will prohibit neglect, mental or physical abuse .of residents .Definitions .Verbal abuse is defined as the use of, oral, written or gestured language that willfully includes disparaging or derogatory terms to residents .within their hearing distance .Examples of verbal/mental abuse include .cursing, yelling, saying things to frighten a resident . 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 2 hours of the allegation . A record review of the facility's investigation, dated 02/15/25, revealed On Saturday, February 8, 2025, Certified Nursing Assistant (proper name) was entering the dining room and encountered Resident (proper name) .(Resident proper name) began yelling expletives at (CNA proper name) .(CNA proper name) began arguing back with the resident using profanity .(Resident proper name was interviewed and stated he was speaking with (Licensed Practical Nurse (LPN) (proper name) in the dining area when (CNA proper name) entered. He began cussing and calling CNA names and (CNA proper name) became argumentative and also used profanity. He stated that Nurse (proper name) took him back to his room and calmed him down .CNA (proper name was interviewed. CNA stated (Resident proper name) began screaming swear words at her and then proceeded to roll his wheelchair towards her threatening to slap her in the face. Employee said this made her feel scared so she picked up a spray bottle and told him not to come any closer LPN, (proper name) was interviewed. Nurse stated that her and (Resident proper name) were indeed having a conversation in the dining area when (CNA proper name) entered. Nurse stated that (Resident proper name began cursing at (CNA proper name) and the employee began arguing back. Both (CNA proper name) and (Resident proper name) were using profanity. (CNA proper name) then picked up a spray bottle and pointed towards (Resident proper name) but did not spray the bottle. The resident was then taken back to his room .Life rounds were completed and residents with a BIMS of 12 or higher. One resident stated that CNA (proper name) had a smart mouth and another resident stated that he hears her being loud and using profanity in the hallway. Life rounds completed with staff with no issues noted. In services initiated with staff on Resident Rights, Vulnerable Adult, Abuse, Neglect and Customer Service. Currently, the facility decided to terminate employee (proper name) due to multiple policy violations . During an interview on 03/11/25 at 9:00 AM, an interview with Resident #17 revealed that he and CNA #1 got into an argument on 2/8/25 when he was in the dining area talking to LPN #1. Resident #17 admitted that he called CNA #1 a lazy (expletive) and then CNA #1 approached him, using profanity, and grabbed a bottle of cleaning spray and pointed it toward him. He stated he was nervous and afraid that the CNA was going to spray him. He confirmed that LPN #1 witnessed the altercation. During an interview on 03/11/25 at 10:03 AM, the Risk Manager (RM) revealed she was made aware of the incident on 2/12/25 by the Administrator. The RM stated she and the Administrator called CNA #1 in for an interview on 2/12/25 and she was then suspended. The RM stated CNA #1 fully admitted the details of the incident as reported by the resident and LPN #1. During an interview on 03/11/25 at 3:40 PM, Licensed Practical Nurse (LPN) #1 explained that on 2/8/25 she witnessed a verbal altercation between Resident #17 and CNA #1. LPN #1 reported the incident to LPN #2, who was the Charge Nurse at the time. Shortly after, LPN #3 approached both LPN #1 and LPN #2 to inform them that CNA #1 had also reported the incident to her. LPN #1 stated that LPN #3 was the one who contacted the Director of Nursing (DON) regarding the situation. LPN #1 confirmed she was not given instructions to send CNA #1 home and admitted that she did not direct CNA #1 to leave because she was concerned the situation could escalate further. LPN #1 acknowledged that she was aware CNA #1 verbally abused and threatened Resident #17 and believed she followed protocol by reporting the incident to the Charge Nurse. LPN #1 also stated she should have immediately removed the resident from the escalating situation. She further noted that she was not contacted by the DON to provide a statement about the incident until 2/12/25. During an interview on 03/11/25 at 4:15 PM, the DON revealed he received a phone call from LPN #3 at 10:00 AM on 2/8/25 to inform him that Resident #17 has cursed the CNA. The DON stated he instructed LPN #3 to not have CNA #1 assist the resident with smoke breaks. The DON stated that at 12:00 PM on 2/8/25 he called LPN #2 and was told that CNA #1 got loud with Resident #17 and was separated from Resident #17. The DON stated he did not report the incident to the State Agency on 2/8/25 because he did not feel the incident was an abuse situation from the information he had been told by the nurses. During an interview on 03/11/25 at 4:33 PM, LPN #2 explained that on 2/8/25, LPN #1 approached her at the nursing station and reported the incident involving Resident #17 and CNA #1. LPN #2 stated that CNA #1 then came to the nursing station, visibly aggravated and upset, and stated, Who the (expletive) are you sending home? LPN #2 reported that LPN #3 then escorted CNA #1 back to the other unit and called the DON to report the incident. LPN #2 explained that when the DON called her directly, she relayed what LPN #1 had reported and recommended that the DON speak directly with LPN #1 for further details. LPN #2 stated she specifically informed the DON that CNA #1 had retaliated against the resident by yelling, Who the (expletive) are you talking to? Who the (expletive) are you calling a (expletive)? LPN #2 further reported that she told the DON about CNA #1 aiming a spray bottle containing cleaning chemicals at Resident #17 and threatening to enlist another resident to physically harm him. LPN #2 stated the DON informed her that he would address the situation on Monday. LPN #2 acknowledged that she did not send CNA #1 home because she was waiting for direction from the DON. She stated that during a meeting with the Administrator on the following Wednesday, she was asked why she had not contacted the Administrator directly. LPN #2 explained that she believed notifying the DON was the appropriate course of action. During an interview on 03/12/25 at 12:15 PM, LPN #3 stated that she did not personally witness the incident involving CNA #1 and Resident #17 on 2/8/25. LPN #3 stated that she contacted the DON and informed him that CNA #1 admitted to cursing at Resident #17 and pointing a spray bottle of cleaner at him. LPN #3 reported that the DON instructed her to document a statement and assured her that he would address the issue on Monday. During an interview on 03/12/25 at 12:30 PM, in a follow up interview with the RM she explained the DON was questioned as to why he did not report the incident on 2/8/25, the day he was informed about the verbal abuse and threats made to Resident #17 by CNA #1. The RM reported the DON stated he felt the incident was downplayed when it was reported to him and the resident was safe. During an interview on 03/12/25 at 12:51 PM, the Administrator stated she became aware of the incident that occurred on 2/8/25 when CNA #4 approached her on 2/12/25 and asked if she had been made aware of the incident. The Administrator explained that, following this, she immediately spoke with Resident #17, the DON, the involved nurses, and CNA #1. The Administrator reported that CNA #1 admitted to the incident as described and was subsequently sent home on 2/12/25. She acknowledged that the nursing staff did not follow the facility's abuse policy and protocol, specifically stating that CNA #1 should have been removed from duty immediately. A record review of the admission Record revealed the facility admitted Resident #17 on 7/15/24 with diagnoses including Anxiety Disorder. Facility Corrective Action Plan: On 03/12/2025 at 3:15PM State Agency (SA) notified facility Administrator of Immediate Jeopardy (IJ). State Agency Surveyor provided the facility with the Immediate Jeopardy (IJ} templates. Facility respectfully submits this corrective action plan. Brief Summary of Events On 02/12/2025 at 10:45AM the Administrator was notified of allegation of verbal abuse involving Resident #17 and CNA(Certified Nursing Assistant) #1. On 02/08/2025 CNA #1 was delivering a resident tray when she overheard Resident #17 and staff member laughing. The CNA #1 questioned the contents of their conversation. Resident #17 started using profanity directed at her. CNA #1 picked up a spray bottle pointing it in the direction of Resident # 17. CNA # 1 was using profanity as she was walking away from Resident # 17. CNA #1 continued to work in facility in separate care area until allegation was reported to administration on 2/12/2025. Corrective Actions 1. On 02/12/2025 at 9:30am. The Treatment Nurse conducted a routine head-to-toe body assessment on Resident #17 to review for any skin abnormalities or concerns. Resident #17 had no negative skin issues or concerns. 2. On 02/12/2025 at 10:55am The Director of Nursing and Administrator interviewed Resident #17 regarding the allegation of abuse. Resident #17 provided statement of events. 3. On 2/12/2025 at 1130am, CNA (Certified Nursing Assistant) #1 was interviewed, statement obtained and suspended pending investigation by the Administrator. CNA #1 was subsequently terminated. 4. On 02/12/2025 at approximately 11:30am an allegation of abuse involving Resident #17 was reported to the State Agency (SA) by the Facility Risk Manager. 5. On 02/12/2025 at approximately 1140am an allegation of abuse involving Resident #17 was submitted to the Attorney General (AG) complaint website by the Risk Manager regarding allegation of abuse. 6. On 2/12/2025 at 11:40am, Referral was sent to Psychologist Nurse Practitioner by the Director of Nursing for evaluation and follow up. 7. On 2/12/2025 at 11:40am, The Medical Director was notified of the allegation by the Administrator. 8. 02/12/2025 at 12:00pm The Administrator notified ombudsman with no answer and left message. 9. On 2/12/2025 at 12:14pm, The DON conducted Trauma Assessment on Resident #17 with no negative findings. 10. On 2/12/2025 at 12:30pm, The Risk Manager initiated Life satisfaction rounds on with residents with BIMS (Brief Interview of Mental Status) of 12 or higher regarding Abuse and Safety in the facility. two negative findings on unprofessional behavior resulted with a report of being rude and loud. No allegations of abuse resulted. 11. On 2/12/2025 at 1:30pm, Peer reviews initiated by Risk Manager regarding Abuse and Safety in the facility involving CNA #1. One finding resulted in witnessing the allegation involving Resident #17. On 2/12/2025 at 1:30-1:45pm, An Abuse Drill Evaluation completed with Station I and II by the DON and Administrator as part of an ongoing monitoring plan. Life satisfaction rounds with two residents having a BIMS of twelve or higher will be completed by the Administrator/DON or Risk Manager weekly times four weeks, every other week times eight and monthly thereafter for three months. The QAPI committee will evaluate additional action based on results. The DON will conduct two random interviews on residents with BIMS of twelve or higher for any allegations of abuse or neglect weekly times four weeks, every other week times eight weeks and monthly times three months thereafter. The DON, Assistant Director of Nursing, or Risk Manager will conduct two random body audits on residents with BIMS below twelve for any indicators of abuse or neglect weekly times four weeks, every other week for eight weeks and monthly times three months thereafter. The QAPI committee will evaluate additional action based on results. The QAPI Committee will review potential trends and patterns and provide recommendations as needed. 12. On 2/12/2025 at 2:30pm, an in-service initiated by Risk Manager/ DON/ADM on Abuse and Neglect, Resident Rights, Vulnerable Adult, along with the reporting guidelines including how to address if abuse is noted. No staff was allowed to return to work prior to completion. 13. On 2/12/2025 at 3:00pm, QAPI Committee held a Quality Assurance Meeting to include Medical Director, Director of Nursing, Assistant Director of Nursing, Risk Manager/Infection Preventionist, Medical Records, Director of Rehabilitation, [NAME] Office Manager, Activity Director and Minimum Data Set Nurse to discuss allegations of abuse along with corrective action and monitoring in place. Policies were reviewed with no revisions needed. 14. On 3/12/2025 at 3:15pm. State Agency (SA) notified the Administrator of Immediate Jeopardy with past noncompliance of 02/12/2025. The State Agency (SA) provided the facility with the Immediate Jeopardy templates. 15. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 02/12/2025 and the Immediate Jeopardy was removed 02/13/2025. Validation: The SA validated on 3/13/2025, through interview and record review that all corrective actions had been implemented as of 2/12/25, and the facility was in compliance as of 2/13/25, prior to the SA's entrance on 3/11/2025.