**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, staff and resident interviews the facility failed to protect a resident from further abuse when Nurse Aide #2 witnessed NA #1 striking Resident #1 when she became combative during care and did not immediately report the incident to her supervisors which resulted in NA #1 striking Resident #1 a second time, resulting in Resident #1 crying for 1 of 3 residents reviewed for abuse. The findings included: A review of the facility's policy titled Abuse Investigation and Reporting for Senior Services last revised on 01/26/23 revealed: Retaliation by staff, regardless of whether harm was intended, is also considered abuse. The policy also stated physical abuse is defined as hitting, slapping, pinching, kicking, etcetera. It also includes controlling behavior through corporal punishment, which is used as a means to correct or control behavior through such actions as pinching, spanking, slapping hands, or hitting with an object. The facility's policy stated its policy included identifying, correcting, and intervening in abusive situations. Review of facility provided reportable incidents 12/29/23 revealed a documented incident of alleged abuse directed towards Resident #1 by Nurse Aide (NA) #1. The initial 24-hour report indicated that another nurse aide (NA #2) was assisting NA #1 with providing incontinence care to Resident #1 when Resident #1 became aggressive towards the staff which resulted in NA #1 striking Resident #1 in the left should twice. Per the facility's investigation, NA #1 was immediately suspended pending the investigation. There were written statements from NA #1 and NA #2. Review of NA #2's written statement revealed the following: Today around 4:00PM I asked [NA #1] to help me change [Resident #1] in bed. Due to her being sick and deciding not to get up. We proceeded to gather the materials that were needed for her to be changed, after doing so we both went to a side of her bed so we could roll her back and forth. [NA #1] began to grab the padding under [Resident #1], on my side. [Resident #1] smacked her hand, and [NA #1] smacked her hand back and yelled you hit me first. [Resident #1] yelled back and began to sob. I told [NA #1] You can't do that, that isn't right. She replied, I can't stand this type of behavior, she is entitled. I said nothing. As I am cleaning [Resident #1], because she is rolled now, [Resident #1] begins to cry louder and yell. [NA #1] starts to yell at [Resident #1] telling her to stop and be quiet. [Resident #1] gets upset and tries to spit on her [NA #1]. [NA #1] says to her you want to spit? [Resident #1] tries to spit again and NA #1 smacks her face. I said, [NA #1], you cannot do that, that is not right. She begins to tell me how nice of a person she is and how she has had to deal with a lot so [she] can't tolerate this kind of behavior from [Resident #1]. At this point [Resident #1] is bawling her eyes out, holding my arm. I tell her It's ok senora. Then I left the room after cleaning up to figure out how and who to tell. An interview with NA #2 via telephone on 04/22/24 at 5:18 PM revealed she remembered that incident with Resident #1 and NA #1. She reported she had asked NA #1 to go and assist her in providing incontinence care to Resident #1. She reported they entered the room, notified Resident #1 of their intention to provide incontinence care with NA #1 on the left side of the bed and herself on the right side of the bed. NA #2 reported as NA #1 began to turn Resident #1 on her side, Resident #1 became angry, yelling, and swatted at NA #1. She reported NA #1 then popped Resident #1 back on her left shoulder with an open hand and told Resident #1 to stop. NA #2 reported she told NA #1 at that time that she could not do that and to stop. NA #2 stated the care continued and Resident #1 attempted to spit on NA #1 multiple times. She stated at that point, NA #1 popped Resident #1 again, either on the side of her face or left shoulder. NA #2 stated she again told NA #1 that she could not do that, and NA #1 responded that she would not deal with that kind of behavior. She stated at that point, she observed Resident #1 crying, and she told Resident #1 it was ok. NA #2 then reported she and NA #1 left at the completion of incontinence care and she went and immediately reported it to her hall nurse (Nurse #1). NA #2 reported she believed NA #1 was sent home almost immediately after she reported the interaction. NA #2 indicated Resident #1 was not physically injured but reported Resident #1 was emotionally upset following the interaction. NA #2 did not clarify why she did not stop the care when Resident #1 became aggressive or why the care was not stopped after the first time NA #1 struck Resident #1. Review of NA #1's written statement from the day of the incident with Resident #1 read: I was on my 2nd shift working on 400 hall. While I was working with [NA #2] helping [Resident #1] to change, she hit me multiple times and spit on my face. I witnessed several times she did it to other CNA's, but at that moment I hit her arm back. Later I realized I shouldn't, but somehow that moment I reacted. Sorry about it. An interview with NA #1 via telephone on 04/22/24 at 12;17 PM revealed she was working on the same hall where Resident #1 resided but was not Resident #1's assigned nurse aide. She continued, stating that she and another nurse aide (NA #2) had gone into Resident #1's room to provide incontinence care. She reported she was very familiar with Resident #1 and stated she had a history of bullying other nurse aides and would often punch, spit, and hit the nurse aides that provided her care. NA #1 stated when she and NA #2 entered Resident #1's room, they explained to her what care they planned to provide and when she rolled Resident #1 onto her right side, Resident #1 began to kick her. NA #1 stated she asked Resident #1 multiple times to please stop, don't do this but admitted she became frustrated and ended up hitting Resident #1 with her open hand on her left shoulder. She stated Resident #1 then began to spit in her face and she reacted by popping Resident #1 on the left shoulder again. She stated NA #2 asked her why she was doing that and she told her you saw what she was doing; hitting, spitting, and kicking me. NA #1 reported her strikes were not hard and did not make any sounds, leave redness, bruising, or other marks on Resident #1. She reported I never had lost my cool before that day and stated she knew after the fact that she should not have reacted that way. NA #1 stated when she and NA #2 left the room, she knew NA #2 would have to report the incident and stated she knew she would have to report it as well. NA #1 was insistent that she only struck Resident #1 on her left shoulder and that she did not use any force. NA #1 did verify that Resident #1 did begin to cry following the interaction and stated she thought her striking her surprised Resident #1 and that Resident #1 probably did not believe that a nurse aide would stand up to her behavior. NA #1 reported she did not feel as though her actions were abusive and when asked why she did not just stop the care and come back later, NA #1 reported if they would have left and come back, Resident #1 would have acted the same way and both she and NA #2 though they needed to just get it done. NA #1 stated I don't know why I was so frustrated that day. She stated I worked on the dementia hall several months with no issues, I'm usually so very patient and treat the residents good. I don't think what I did was wrong, I make no apology to that resident for what I did, I'm sorry I surprised the other NA. I don't think it was abusive in nature, If they didn't lay me off, I was planning on quitting because the whole interaction was traumatizing. NA #1 reported she was approached almost immediately by the Assistant Administrator and was told she needed to go home. NA #1 stated she was suspended pending an investigation and ultimately terminated. Multiple attempts to reach Nurse #1 by telephone on 04/22/24 and 04/23/24 were unsuccessful. Nurse #1 never returned any telephone calls. Review of Nurse #1's written statement dated 12/29/23 revealed the following: I was sitting in charting room when [NA #2] asked to speak to me in private. She reported what she had just seen [NA #1] had done to [Resident #1]. I immediately reported to [Assistant Administrator] who immediately spoke with [the nurse aides]. An interview with the Director of Nursing at the time of the incident on 04/22/24 at 4:11 PM revealed she felt that the facility's policies and procedures were followed at the time and that NA #2 intervened when she told NA #1 to stop. She indicated that NA #1 should have removed herself from the situation when she became frustrated. The Director of Nursing reported ibn response to the incident, the facility educated all staff on the policies and procedures for abuse prohibition that included intervention. An interview with the Administrator on 04/22/24 at 2:18 PM, who was serving as the Assistant Administrator the day of the incident revealed she was approached by Nurse #1 who informed her that NA #2 had alleged that NA #1 had struck Resident #1 twice during incontinence care. The Administrator stated she went and spoke with NA #2 who recounted the incident to her. The Administrator stated she then immediately went to NA #1 and informed her of the allegations and sent her home. The Administrator stated she believed less than 10 minutes passed between her being notified and NA #1 being sent home. She stated she assigned a unit manager to escort NA #1 from the building to ensure she had no other interactions with other residents. The Administrator stated she then notified the Director of Nursing and began a full investigation into the allegations. She reported her investigation determined that due to the statements that alluded Resident #1 was tearful following the interaction, she ended up substantiating the allegation and subsequently terminated the employment of NA #1. She stated immediately after the incident, Nurse #1 completed skin checks of Resident #1 and all other cognitively impaired residents, while cognitively intact residents were interviewed with no concerns noted. She also reported assigning abuse, neglect, and exploitation training to all her staff that had to be completed before their next shift, along with training regarding employee burnout. The Administrator stated when she went to interview Resident #1 shortly after being informed of the incident, she was observed to be in her room, resting comfortably and did not appear to be upset. She stated when she questioned Resident #1, Resident #1 could only respond with yes/no answers but reported someone had been mean to her but was unable to tell her where she was hit. The Administrator stated Resident #1 did not appear tearful or fearful during questioning. She also stated a skin check was performed with no injury, redness, or swelling being observed. The Administrator stated with the statement of Resident #1 being emotional after the incident, they reached out to Resident #1's psych provider who stated they did not currently have a provider they could send to the facility to speak with Resident #1 so she reached out to the medical director who followed up a day or two later. The Administrator reported at the time of the investigation, NA #1 only ever reported to them that she struck Resident # 1 once and that she felt that NA #2 had intervened when she told NA #1 she should not be striking the resident. The Administrator also reported she felt that [NAME] Administrator reported that all staff were trained on abuse policies and procedures at the time of hire and then on an annual basis. The Administrator also reported the facility had placed the incident in their quality assurance program which included audits of staff interactions and on-going, current monitoring. The facility provided the following corrective action plan: 1. Corrective action for residents found to be affected: A. What are we going to do for the resident affected? Immediate skin check, physical assessment for injuries performed by nurse #1. Abuse Allegation was reported to the resident's family (RR), Administrator, DON, Provider, the Admin Office, Adult Protective Services, and the local police department. Accused NA was immediately suspended pending investigation results. Accused NA was advised to not return to the facility or the facility's property until further notice. NA was terminated once the investigation was completed. 2-hour abuse reporting to state completed on 12/29/23. Resident was assessed by the provider on 01/02/24 and new order for medication to decrease behaviors received however RR refused to allow the new medication. Alleged Abuse Incident report was completed by hall nurse on 12/29/23. Administrator observed four different employee interactions on 12/29/23 with residents to ensure that staff interactions were appropriate. Reviewed resident's care plan and added intervention for staff to leave and reapproach resident when she is combative with care on 12/29/23. B. Who is going to do it? Hall nurse performed assessment on resident and completed the incident report for alleged abuse on 12/29/23. Nurse notified Administrator and Administrator completed 2-hour abuse reporting form and sent in on 12/29/23. Nursing Supervisor notified provider on call on 12/29/23. Administrator notified resident's family(RR) and DON on 12/29/23. Hall nurse completed incident report on 12/29/23. Administrator met immediately with accused NA and suspended her immediately on 12/29/23. DON and Administrator met with NA #1 and terminated her employment once the allegation was substantiated on 12/30/23. Administrator and DON reviewed resident's care plan and added appropriate interventions. C. How will the corrective action be communicated to staff? The NA involved was suspended immediately and then terminated. Reporting NA intervened and then reported immediately to supervisor. She received education regarding intervening, stopping what she is doing and reporting immediately via Abuse Reporting policy education and Relias online learning education. All staff in facility educated on Abuse, intervening, stopping what you are doing, reporting immediately, and investigations on 12/29/23. All additional staff will be educated prior to their next working shift. D. Is action clearly documented and care planned? Documented in statements and in with the NA involved. Resident #1's care plan was reviewed and appropriate new interventions added. 2. How will corrective action be accomplished for those residents having the potential to be affected? A. How will we identify other residents at risk? All residents in the facility have the potential to be at risk. B. After identifying at risk residents, what are we going to do for them? The hall nurse performed skin assessments on all residents that accused NA cared for on this day that were unable to be interviewed on 12/29/23. No further injuries noted. The Administrator interviewed residents and asked if they felt safe and if they had any concerns of any staff member being mean to them or rough with them. All other residents stated they felt safe and no one had been mean or rough with them. LSC Employee Interaction Audit Form for Substantiated Abuse Allegation was started immediately. That audit will be completed by Central Nurse Manager who will observe 4 different employees' interactions with residents 3 times per week for 4 weeks to ensure that staff interactions are appropriate. Staff education started immediately regarding Abuse, Intervening and Caregiver burnout. Education completed 12/29/23 for all staff in facility and all staff will be educated prior to working their next shift. Two extra Relias courses were assigned by the Staff Development Coordinator for the month of January related to Abuse and Caregiver burnout. C. Are we taking credit for interventions in the chart and on the care plan? The Resident's care plan was reviewed and updated to reflect additional interventions for staff. 3. What measures will be put into place to ensure that the deficient practice will not occur? A. What system(s) will we adapt/change/implement to keep the problem from reoccurring? Abuse Investigating and Reporting education materials from Lutheran Services University that includes information on caregiver burnout along with a wallet card with signs and symptoms of staff burnout added to facility orientation and will remain part of orientation moving forward. Abuse Reporting has always been included in orientation however more focus on caregiver burnout will be added effective 12/30/23. Staff education completed on LSC Policy of Abuse Investigation and Reporting; this policy includes education on intervening, stopping what you are doing, reporting immediately, for Senior Services as well as Lutheran Services University education related to caregiver burnout. Staff will be educated prior to their next working shift. Staff Development Coordinator assigned Relias courses on Abuse, intervening, stopping what you are doing, reporting immediately and on Caregiver burnout to all staff for the month of January. B. How will we educate/communicate any system changes to the staff? Printed Staff Education on LSC Policy of Abuse Investigation and Reporting for Senior Services and Lutheran Services University information on caregiver burnout as well as the two new Relias courses assigned to January agenda. Provided Staff Education on WHATSAPP messaging system to nursing department, and on PCC Bulletin Board to all departments on importance of recognizing caregiver burnout and importance of walking away when frustrated, importance of reporting potential abuse immediately to supervisor, and being familiar with LSC Policy on Abuse Investigation and Reporting which includes intervening, stopping what you are doing and reporting immediately. Added additional education materials to facility orientation related to caregiver burnout, how to recognize and importance of reporting to supervisor when caregiver burnout is suspected. Wallet card will also be provided to all new employees during facility orientation that contains symptoms of staff burnout. 4. How does the facility plan to monitor its performance to make sure that solutions are sustained? A. Are we evaluating actual staff practices? Yes. Administrator determined audits were needed at time of initial investigation report on 12/29/23. Audits were initiated and completed 4 audits 12/29/2023 by Administrator. Central Nurse Manager will observe 4 different employees' interactions with residents 3 times per week for 4 weeks to ensure that staff interactions are appropriate starting 12/29/23. B. Are we performing regular audits to ensure the corrective action/system/change is being implemented and are working? Yes. Audits were initiated on 12/29/23. Observation of employee's interactions with residents has been started and will continue monthly x3 beginning immediately and continuing February and March 2024, and then quarterly for Q2, Q3, and Q4 in 2024. These observations will end 12/31/2024. C. Are we sharing audit results in the monthly QAPI meetings? Yes. All POCs are shared in QAPI. The next QAPI meeting is scheduled for February 1, 2024. Date of compliance: January 3, 2024 The facility's corrective action plan was validated on 04/23/24. Review of facility provided monitoring tools revealed the facility had completed a 24 hour and 5 working day report upon notification of the incident and completion of their investigation. The investigation revealed written statements from all parties involved, a termination notification for NA #1, education with sign-in sheets for all staff in the facility, skin checks and interviews with alert and oriented residents, and finally monitoring tools for ongoing monitoring to ensure the issue was resolved. The completion of the self-imposed corrective action plan was verified on-site through staff interviews and record review. The compliance date of 01/03/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to ensure a resident's lower extremities were secured in the mechanical lift during incontinence care which resulted in a fall to the floor for 1 of 3 residents reviewed for falls (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and dementia with behavioral disturbances. A facility policy revised 7/4/19 indicated in addition to orientation training on use of the mechanical lifts, manufacturer manuals would be used to assist in the education and ensure proper usage of the lift equipment. An activity of daily living (ADL) care plan dated 6/30/22 revealed Resident #1 was to be transferred with the standup lift, a yellow medium lift sling, and 1 staff person assistance. A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was cognitively impaired, was always incontinent of bowel and bladder, and required extensive assistance of 2 staff for transfers. A fall care plan dated 9/8/22 revealed Resident #1 was at risk for falls due to confusion and balance problems, and unaware of safety needs. An incident report dated 11/22/22 indicated Resident #1 was lying in the floor with her head in Nurse Aide (NA) #1's lap when Nurse #1 arrived after being summoned for assistance by an unidentified nurse aide student. The report detailed Resident #1 let go of the handlebars during a transfer and had to be lowered to the floor by NA #1. The incident report indicated Resident #1 was only oriented to person but reported no pain when Nurse #1 arrived. A disciplinary action report dated 11/22/22 reflected NA #1 was counseled and re-educated on the use of the mechanical lift secondary to a fall encountered by Resident #1 on 11/22/22 due to NA #1 not securing the buckles on the leg straps of the mechanical lift. Activity of Daily Living (ADL) documentation by NA #1 dated 11/22/22 at 4:07 PM reflected Resident #1 was dependent for transfers. A Physical Therapy Evaluation and Plan of Treatment completed by Physical Therapist (PT) #1 dated 11/22/22 reflected Resident #1 was to use the sit to stand mechanical lift with a yellow lift sling for transfers and that staff were educated on proper transfer status to maintain the safety of Resident #1 and staff. The evaluation reflected Resident #1 had a goal of improving lower extremity strength to be able to stand for greater than 10 minutes to improve transfer and sit to stand skills. An interview with NA #1 on 1/19/23 at 3:27PM revealed she was the NA assigned to provide care for Resident #1 on 11/22/22 from 7 AM to 3 PM. NA #1 indicated shortly before the end of her schedule shift; she placed Resident #1 into the mechanical sit to stand lift in to provide incontinence care. NA #1 stated she got in a hurry and did not retrieve the leg straps and attach them to the lift before attempting to stand Resident #1. NA #1 further elaborated she secured a green lift sling around Resident #1 and lifted her from her wheelchair. NA #1 stated there was a student who was observing her care but was too young to assist in the care of Resident #1 on 11/22/22. NA #1 stated she lifted Resident #1 to a standing position and began providing incontinence care. After about 8-10 minutes, she said Resident #1 started saying she needed to sit down, but NA #1 told Resident #1 she was almost finished with her care and would sit her as soon as the incontinence care was completed. NA #1 stated around 12-15 minutes into care, Resident #1 let go of the handlebars on the lift and had to be caught before she hit the floor from falling out through the lift sling. She could not recall who the student nurse aide present at the time of the fall but indicated she did not recall Resident #1 being injured when the fall occurred. A telephone interview with Nurse #1 on 1/19/23 at 3:42 PM revealed she was the nurse assigned to the unit where Resident #1 resided and was called to the room on 11/22/22 where she found Resident #1 in the floor with her head in NA #1's lap. Nurse #1 indicated she assessed Resident #1 while in the floor to have no visible injuries and she assisted NA #1 to stand her and place her back to her wheelchair with the use of a gait belt. Nurse #1 stated she was not made aware at the time of the fall that NA #1 had performed incontinence care on Resident #1 using the mechanical sit to stand lift without the use of the lower extremity straps to secure her in place. Nurse #1 stated she did not recall any complaints of pain or discomfort by Resident #1 throughout the reminder of her shift on 11/22/22. An interview with PT #1 on 1/19/23 at 4:00 PM revealed she evaluated Resident #1 on 11/22/22 for safe transfer techniques and felt she remained safe to continue use of the sit to stand lift with the use of a yellow medium lift sling for all transfers. An interview with the Director of Nursing (DON) on 1/19/23 at 4:27 PM revealed she was made aware of the fall by Nurse #1 and had reprimanded NA #1 and provided re-education following the fall on 11/22/22. The DON had not discovered during the investigation that Resident #1 was lifted using the mechanical sit to stand lift by NA #1 without the use of lower extremity lift straps being present in the room. The DON stated NA #1 was a very honest employee but did not believe that the lift straps were not attached to the lift during the transfer. She had also not been made aware Resident #1 had remained in the lift for 10-15 minutes while providing incontinence care on 11/22/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview the facility failed to provide twice daily treatments to a pressure ulcer as ordered by the physician. This was evident for 1 of 2 residents reviewed for pressure ulcers (Resident #51). Findings Included: Resident #51 was admitted to the facility on [DATE] and diagnoses included stage 3 pressure ulcer. A quarterly minimum data set (MDS) dated [DATE] for Resident #51 identified she had a stage 3 pressure ulcer. Review of a wound assessment dated [DATE] for Resident #51 identified a stage 3 pressure ulcer to coccyx. Review of the physician ' s orders revealed an order dated 3/7/22 to cleanse open area to coccyx with normal saline and pat dry. Apply silver alginate and super absorbent pad. Change twice daily. The treatment order was changed on 4/11/22 to clean open area to coccyx with Dakin ' s 0.125% solution and pat dry. Apply Mycolog cream to peri wound. Apply silver alginate and super absorbent pad. Change twice daily and as needed. Review of the April 2022 treatment administration record (TAR) for Resident #51 revealed the treatment was scheduled to be completed on the AM and PM shift. The wound treatment was not documented as completed on 4/2/22, 4/6/22 and 4/12/22 on the AM shift. The wound treatment was not documented as completed on 4/6/22, 4/7/22, 4/12/22, 4/15/22, 4/16/22, 4/18/22, 4/20/22, 4/22/22 and 4/25/22 on the PM shift. An observation on 4/27/22 at 10:50 am of Resident #51 ' s wound revealed there was moderate drainage with bright red blood present. An interview on 4/28/22 at 8:33 am with the wound physician revealed he had been treating Resident #51 ' s coccyx wound. He stated the treatment was ordered to be done twice daily because of the moisture associated with incontinence and the impact of moisture on the wound. He explained his preference was for the dressing to be changed twice daily because with less moisture the wound had a better change of healing. The wound physician indicated he expeceted his orders for twice daily dressing changes to be followed. An interview on 4/28/22 at 9:04 am with the Director of Nursing (DON) revealed the facility had a wound nurse who did some of the treatments, but she had recently been re-assigned to some additional nurse management duties. She stated the wound physician came weekly and the wound nurse would round with him. The DON added the hall nurses were responsible to complete the wound treatments. An interview on 4/28/22 at 10:00 am with Nurse #1 revealed Resident #51 had an order to treat her pressure ulcer twice daily and as needed. She stated on 4/6/22 she was the nurse for Resident #51, but she couldn ' t recall if she had completed the treatment to her pressure ulcer; adding sometimes the wound nurse would complete the treatment is she was rounding with the wound doctor. Nurse #1 indicated she had also worked with Resident #51 on 4/18/22 and 4/20/22 and she thought she had completed the AM treatment but was unsure about the PM treatment. An interview on 4/28/22 at 10:15 am with Nurse #2 revealed she worked routinely with Resident #51. She stated on 4/7/22 and 4/12/22 she could not remember if she had completed the treatments. She explained she would routinely get the AM treatment done and if she didn ' t ' have time to get the PM treatment done she would notify the nurse that relieved her. Nurse #2 stated the resident had a lot of drainage from her wound at times and that was why there was an order to change the dressing twice daily. An interview on 4/28/22 at 11:35 am with the DON revealed she expected Resident ' #51 ' s pressure ulcer to be treated twice daily and as needed as ordered by the wound physician.