Based on medical record review, review of a Self-Reported Incident (SRI), staff interviews, review of the local police report, review of the facility investigation, review of email and policy review, the facility failed to ensure one resident (Resident #28) was free from physical abuse by facility staff. This resulted in Immediate Jeopardy and serious negative psychosocial harm, based on a reasonable person's response of fear and anxiety, for Resident #28, who has severe cognitive impairment, when Licensed Practical Nurse (LPN) #431 physically walked Resident #28 back a couple steps to a wall, held her against the wall with her right forearm, and placed her left hand on the resident's throat in response to behaviors Resident #28 was exhibiting, causing Resident #28 to start screaming and crying. This affected one (#28) of four residents (#10, #20, #28, and #30) reviewed for abuse. There was a total of 17 residents (#28, #38, #20, #293, #143, #39, #8, #30, #10, #14, #1, #26, #27, #15, #25, #19, and #36) screened for abuse during the annual survey. The facility census was 44. On 01/09/23 at 4:01 P.M., the Licensed Nursing Home Administrator (LNHA), Regional Director of Clinical Operations (RDCO) #503, and Regional Director of Operations (RDO) #510 were notified Immediate Jeopardy began on 12/29/22 at approximately 9:20 A.M. when Resident #28 was at LPN #431's nurse's medication cart and attempted to take the narcotic book. LPN #431 attempted to direct Resident #28 away from the cart by telling her no and pushing her hand away from the book. Resident #28 became agitated and grabbed LPN #431's face, neck, and face mask. LPN #431 responded by raising her forearm and walking Resident #28 back a couple steps to the wall then holding the resident against the wall with her right forearm across Resident #28's chest and her left hand on Resident #28's throat. State Tested Nursing Assistant (STNA) #422 witnessed the interaction from the point of Resident #28 grabbing the narcotic book, observing LPN #431 raise her right forearm and backing Resident #28 into the wall, placing her forearm on the resident's chest and her hand on Resident #28's neck to hold her there. The thud sound from Resident #28 being backed against the wall caused STNA #420 to turn around and she also witnessed LPN #431 pinning Resident #28 to the wall with her right forearm and left hand on her neck. The Immediate Jeopardy was removed on 01/10/23 when the facility implemented the following corrective actions: • On 12/29/22 at 9:23 A.M., Resident #28 and LPN #431 were immediately separated by STNA #422 and Activities Director (AD) #442. Resident #28 was placed on a one-on-one supervision level by nursing staff. • On 12/29/22 at 9:25 A.M., the Director of Nursing (DON) was alerted of the situation and notified RDCO #503. LPN #431 was removed from patient care area and went with RDCO #503 to the DON's office. • On 12/29/22 at 9:30 A.M., Medical Director #600 was notified by the DON and a new order was placed for Resident #28 to be placed on a one-on-one supervision level. • On 12/29/22 at 9:45 A.M., Resident #28 had skin assessments and pain assessments completed by the DON with no findings of any injuries. Neurological checks were initiated by the DON. • On 12/29/22 at 10:04 A.M., RDCO #503 began an investigation, obtaining LPN #431's statement. LPN #431 was suspended from duty pending investigation by the Administrator, RDCO #503, the DON and Human Resources Manager (HRM) #446. The DON escorted LPN #431 to the time clock and to the exit door. • On 12/29/22 at 10:30 A.M., Social Services Director (SSD) #435 and the Administrator notified Resident #28's representative/husband, of the altercation that took place with LPN #431. • On 12/29/22 at 11:00 A.M., the Administrator and STNA #422 attempted to obtain a statement from Resident #28. • On 12/29/22 at 11:28 A.M., the initial SRI was submitted to the Ohio Department of Health by the Administrator. • On 12/29/22 at 1:00 P.M., all residents on the North and South halls, where LPN #431 was assigned, were asked the abuse questionnaire by the Administrator. No negative findings were discovered. • On 12/29/22 at 2:30 P.M., employee statements were obtained by the Administrator. • On 12/29/22 at 3:00 P.M., the DON completed skin assessments for all residents on the North and South halls for residents who were not able to be interviewed. No negative findings were discovered. • On 12/29/22 at 3:00 P.M., the Administrator completed education for all facility staff on the facility's Abuse, Neglect, and Misappropriation policy and the de-escalation of Alzheimer's and dementia residents. • On 01/03/23 at 10:00 A.M., the Administrator notified the Montpelier Police Department of the incident. • On 01/04/23, the final SRI was submitted to the Ohio Department of Health by the Administrator at 6:31 P.M. • On 01/09/23 at 2:22 P.M., LPN #431 was terminated from the facility by the Administrator, DON, and HRM #446. • On 01/09/23, the facility-initiated audits to be completed for abuse and de-escalation practices of Alzheimer's and dementia residents. Three staff will be questioned about their knowledge, three times weekly, for four weeks to be completed by the DON. • On 01/10/23, the residents on the East Hall were interviewed for abuse by the Administrator and skin assessments were performed by the DON. No negative findings were discovered. • On 01/13/23, a Quality Assurance meeting was scheduled to be held to review the audit findings and adjust as needed. • Starting 12/27/22 through 01/10/23, the records of three additional residents (#10, #20, and #23) were reviewed for abuse. Sixteen additional residents (#38, #20, #293, #143, #39, #8, #30, #10, #14, #1, #26, #27, #15, #25, #19, and #36) were screened for abuse during the annual survey. There were no additional concerns noted. Although the Immediate Jeopardy was removed on 01/10/22, the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure on-going compliance. Findings include: Review of Resident #28's medical record revealed an admission date of 11/12/22. Diagnoses included Alzheimer's disease, dementia with behavioral disturbance, type II diabetes, anxiety disorder, depression, and insomnia. Review of Resident #28's Minimum Data Set (MDS) assessment, dated 11/19/22, revealed a Brief Interview for Mental Status (BIMS) score of two indicating Resident #28 had severe cognitive impairment. Resident #28 had delusions and displayed physical behavioral and verbal symptoms directed toward others, behavioral symptoms not directed toward others, and wandering behaviors one to three days during the review period. It was noted Resident #28's wandering behaviors significantly intruded on the privacy and activities of others. Review of Resident #28's care plan, revised 12/29/22, revealed supports and interventions for behavioral problems. Interventions included one-on-one staffing, fifteen minute checks as ordered, approach and speak in a calm manor, behavioral consult as needed, encourage resident to express her feelings, consult with psychiatric services, encourage to participate in activities, honor resident's choice, intervene as necessary to protect the rights and safety of others, minimize potential for disruptive behaviors by offering tasks to divert attention, monitor behavioral episodes and attempt to determine underlying cause, observe and anticipate needs, and praise any indication of progress in behaviors. Review of Resident #28's progress notes revealed a late entry was completed on 01/05/23 that noted on 12/29/22 at 9:20 A.M. it was alleged Resident #28 was in the hallway with LPN #431, when Resident #28 reached for narcotic book. LPN #431 stated to Resident #28 that was her narcotic book and removed Resident #28's hand from the book. Resident #28 then became agitated, reached for LPN #431's facemask ripping the mask, and then attempted to aggressively grab LPN #431 on the neck. LPN #431 used her forearm to push the resident back, however, there was a wall behind the resident, which stopped the motion. It was alleged at this time that LPN #431 utilized her other hand and placed it on the resident's chest/throat area. At this time, Resident #28 yelled out, STNA and activities director immediately separated Resident #28 and LPN #431. Resident #28 was assessed for injury by nursing staff. Neurological checks were initiated as the resident would allow/tolerate related to advanced dementia, behaviors and agitation. Resident #28 was immediately placed on one-on-one supervision by staff and assisted to a calm environment to participate in one-on-one activity. Resident #28's physician was notified of the incident. Resident #28's husband was notified of the incident. Review of the facility SRI, dated 12/29/22, revealed LPN #431 reported Resident #28 attempted to touch her face and ripped her mask off. Resident #28 then placed her hands around LPN #431's neck. LPN #431 attempted to separate and loosen her grip by using her forearm to move her back towards the wall. Resident #28's head made contact with the wall. The DON heard a yell from the incident and came out to help separate the two parties. LPN #431 was escorted to an office to get her statement. Her statement was obtained, and she was walked to the nurse's station to count off medications and then walked out of the facility. LPN #431 was suspended pending investigation. Resident #28 was separated from LPN #431 and had a skin assessment completed immediately with no injuries noted. Resident #28 was placed on a one-on-one with a staff member. The Interdisciplinary Team consulted with Resident #28's family to make a referral to an older adult psychiatric unit to help adjust her medications and assist with her behavior. All interviews and skin assessments to be completed as necessary. Further review of the SRI investigation found on 12/29/22 at approximately 9:30 A.M., it was reported that LPN #431 had moved Resident #28 against the wall with her forearm. The incident occurred on North Hall and was partially witnessed by some of the nursing staff. The incident occurred as Resident #28 attempted to take LPN #431's narcotic book. LPN #431 stated she put her hand on the book to attempt to stop the resident from taking it. This upset Resident #28 and Resident #28 ripped LPN #431's mask off and placed her hand on LPN #431's neck. LPN #431 stated she then used her forearm to move Resident #28 towards the wall to keep Resident #28 from choking her. LPN #431 stated she did not at any point use her other arm to touch Resident #28. Staff statements showed LPN #431 had used her forearm to move Resident #28 towards the wall. One employee, STNA #422, stated she had seen this occur and also stated LPN #431 had placed other her hand on Resident #28's neck. Other staff witnesses did not see LPN #431 place her hand on Resident 28's neck. Upon interview with Resident #28, it was noted that she was very pleasant and did not have any complaints of pain. The incident was reported to the local Police Department and the officer obtained information to create a report and notified the Administrator she would contact her with an update and a copy of the report. The SRI revealed as a result of the investigation, the facility cannot substantiate the allegation of abuse stating staff interviews showed contradicting stories on how LPN #431 separated Resident #28 from herself. Review of the STNA #420's witness statement, dated 12/29/22, revealed STNA #420 was witness to the interaction between Resident #28 and LPN #431. STNA #420 reported she heard LPN #431 say, Please stop hitting staff and Resident #28 laughing. She heard a thud and turned to see LPN #431 use her forearm to pin Resident #28 against the wall and her other hand was on Resident #28's throat. STNA #420 reported she saw STNA #422, and other staff separate them. Resident #28 was crying and screaming. Review of STNA #422's witness statement, dated 12/29/22, revealed she rounded the corner because she heard LPN #431 yelling. Resident #28 was observed grabbing the narcotic book. LPN #431 told Resident #28 No and slapped her hand away. Resident #28 then reached toward LPN #431's face. LPN #431 then choked Resident #28 with one hand and used her other arm to push Resident #28 against the wall. STNA #422 reported other staff heard the thud and yelling and ran toward them. LPN #431 then dropped her hand from Resident #28's neck but continued to pin Resident #28 against the wall. Review of the statement from LPN #431, dated 12/29/22, revealed at approximately 9:20 A.M. LPN #431 reported Resident #28 was trying to take her narcotic book. LPN #431 told Resident #28 No and She could not have it. Resident #28 had a washcloth in her hand and attempted to reach in her face and tore her mask off. LPN #431 reported Resident #28 placed her hand on LPN #431's neck and in order to loosen her grip LPN #431 moved her back with my forearm. The wall was behind her, and Resident #28 hit her head on the wall and yelled out. The DON came out to assist and immediately intervened and asked other staff members to assist with Resident #28. The DON and regional nurse then asked LPN #431 for her statement and took her to the office. LPN #431 was informed a formal investigation would be completed and asked her to not discuss this investigation outside of the interview. The facility told LPN #431 they would notify her with an outcome as soon as possible. Review of the statement from the DON revealed she was in her office when she heard yelling. She ran into the hallway and saw LPN #431 standing in front of Resident #28, who was pinned against the wall by LPN #431. LPN #431 had her right arm against Resident #28's chest and her left hand was coming down from the area of Resident #28's neck. As the DON got closer, STNA #420 stated, She can't hold her against the wall like that! LPN #431 stepped away from Resident #28 who was yelling Oh Lord just take me. Why? Why me? Resident #28 was observed holding her head and her throat as she walked. STNA #422 was walking with Resident #28 attempting to calm her and assisted her back to her room. Notification was made to RDCO #503. LPN #431 was immediately brought into the DON's office and her statement was taken. The DON then walked LPN #431 out of the facility. Review of the statement from RDCO #503 revealed she was in the DON's office when yelling was heard. The DON went out and came back in indicating she needed RDCO #503's help. The DON explained Resident #28 had been experiencing increased behaviors related to dementia aggravated by a urinary tract infection. Resident #28 had ripped LPN #431's facemask off and had tried to choke her. LPN #431 then pinned Resident #28 against the wall. LPN #431 was directed to the DON's office and the Unit Manager was directed to complete a skin assessment on Resident #28 and initiate one-on-one supervision for the resident. LPN #431's statement was taken, and LPN #431 had no observed scratches or redness. RDCO #503 explained to LPN #431 she would be suspended pending the investigation. The DON then escorted LPN #431 to gather her things, to the timeclock, and out of the facility. Statements were gathered from employees and residents who were able to be interviewed on the hallway. Residents who were not able to complete an interview had skin checks completed. Social Services interviewed Resident #28 for any adverse psychosocial effects, and none were noted. Review of the investigation revealed statements were taken from Activities Director (AD) #442, Registered Nurse (RN) #447, Activities Staff (AS) #479, and STNA #500. None reported witnessing the incident between Resident #28 and LPN #431. Review of the investigation's follow up interview with STNA #422, dated 01/04/23, revealed STNA #422 was asked if she saw Resident #28 put her hands around LPN #431's neck. STNA #422 stated she did not. STNA #422 was not asked about LPN #431 having her hands around Resident #28's neck. Review of the investigation's follow up interview with LPN #431 on 01/04/23 revealed LPN #431 reported Resident #28 had ripped her mask off and put her hands around her neck. LPN #431 denied putting her hands around Resident #28's neck. LPN #431 also denied slapping Resident #28's hand away from the narcotic books. Review of an email correspondence between the Administrator and the Corporate Office revealed on 01/03/23 the Administrator requested approval for termination of LPN #431. The email request revealed during the SRI investigation two employees stated they saw LPN #431's hand on Resident #28's neck. The Administrator stated she and the DON did not feel comfortable keeping LPN #431 employed. Approval was granted 01/08/23. Interview on 01/09/22 at 7:23 A.M. with the Administrator verified the allegation of staff to resident abuse between LPN #431 and Resident #28 occurred on 12/29/22. The Administrator reported at the time of the investigation there was only one witness to LPN #431 holding Resident #28 to the wall with her hand on the resident's neck. The SRI was unsubstantiated based on LPN #431 denying the allegation and only having one witness. The Administrator reported LPN #431 had not been back in the facility and they had just received approval from the corporate office to terminate her. The reason for termination was due to her customer service not being in line with the facility's standards. They did not feel comfortable having her back in the facility. During an interview on 01/09/23 at 8:07 A.M. with the Administrator, during a review of the SRI investigation witness statements, the Administrator verified there were two STNAs who witnessed LPN #431 pinning Resident #28 to the wall with her right forearm and having her left hand on Resident #28's neck. The Administrator verified the SRI for the abuse allegation should have been substantiated based on there being two witnesses to the interaction between LPN #431 and Resident #28. Interview on 01/09/23 at 8:08 A.M. with STNA #420 verified she was witness to the interaction between LPN #431 and Resident #28. STNA #420 reported she was approximately halfway down the hallway when she heard a thud and turned around. When she turned, she saw LPN #431 had pushed Resident #28 up against the wall and was holding her there with her right forearm across Resident #28's chest and her left hand on Resident #28's throat to restrain her. STNA #420 reported she was shocked because she had never seen LPN #431 react that way before. STNA #420 stated she went right away down to the Unit Manager's office and told her to get down to the hall quickly. When the Unit Manager and the DON got to the hall, LPN #431 had removed her hand from Resident #28's throat and was still holding Resident #28 against the wall with her forearm. Interview on 01/09/23 at 8:16 A.M. with STNA #422 verified she was witness to the interaction between LPN #431 and Resident #28. STNA #422 reported she heard a disagreement and rounded the corner of the hallway to see Resident #28 at LPN #431's medication cart grabbing LPN #431's narcotic logbook. STNA #422 reported LPN #431 told Resident #28 No and smacked Resident #28's hand away from the logbook. STNA #422 reported Resident #28 then grabbed LPN #431's face, her face mask, and her throat area. LPN #431 then grabbed Resident #28 by the throat, pushed her back into the wall, and held Resident #28 against the wall with her left hand on her throat and her right forearm across Resident #28's chest. STNA #422 reported everyone started running toward them and LPN #431 quickly dropped her hand from Resident #28's neck. STNA #422 reported LPN #431 continued to hold Resident #28 against the wall with her right arm. STNA #422 reported she and another staff took Resident #28 back down to her room and were trying to help her calm down. LPN #431 was taken to the DON's office. Resident #28 was assessed by another nurse and as far as STNA #422 was aware Resident #28 had no physical injuries from the situation. Interview on 01/12/23 at 4:09 P.M. with LPN #431 verified she had already provided statements to the facility and to the police department. LPN #431 denied putting her hands on Resident #28. LPN #431 stated Resident #28 came at her face scratching and hitting. LPN #431 reported she had marks on her neck and face from Resident #28. LPN #431 reported she knocked Resident #28's arms away from her face and pushed her back away from her to stop Resident #28 from injuring her. LPN #431 verified she held Resident #28 against the wall for a few seconds but released her when Resident #28 started screaming and hitting her head on the wall. LPN #431 stated everyone came running when Resident #28 started to scream. Review of the employee file for LPN #431 revealed a hire date of 07/15/22. Review of the Employee Corrective Action Form Dated 01/09/23 revealed LPN #431 was provided a verbal termination notice on 01/09/23. The termination notice was requested 01/03/23 and approved by the Human Resources Division Director. The reason for the termination was listed as other: a result of SRI 230588. Review of the Time Punch Card for LPN #431 revealed on 12/29/22 she clocked in at 7:00 A.M. and clocked out at 10:04 A.M. Review of the Police Report, dated 01/04/22, revealed the police department was notified on Wednesday January 4, 2023, of a physical altercation between a nurse to a patient with severe dementia which occurred 12/29/22. The report was still under investigation. Review of the facility policy titled, Ohio Abuse, Neglect, and Misappropriation, revised 09/20/22, revealed abuse was considered a willful infliction of an injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The definition of willful means the individual acted deliberately not that the individual intended to inflict injury or harm. It was the policy of the facility to provide resident centered care that met the psychosocial, physical, and emotional needs and concerns of the residents. It was the intent of the facility to prevent the abuse, mistreatment, or neglect of residents. This deficiency demonstrates non-compliance related to Master Complaint Number OH00138604.