Based on record review, review of facility self-reported incidents, review of the facility policy and procedure related to Abuse and staff interview the facility failed to ensure allegations of staff to resident physical and verbal abuse that occurred on 02/22/23 were reported timely to ensure all facility residents were protected. This resulted in Immediate Jeopardy on 02/22/23 at approximately 1:30 A.M. when State Tested Nursing Assistant (STNA) #374 witnessed STNA #370 potentially physically and verbally abuse Resident #26, a resident who resided in a facility licensed only bed but failed to immediately report the incident. On 02/22/23 at approximately 4:45 A.M. STNA #374 witnessed STNA #370 potentially verbally abuse a second resident, Resident #36, who also resided in a facility licensed only bed but failed to immediately report the incident. The lack of timely reporting placed all facility residents at risk for physical, verbal, emotional, psychosocial harm as STNA #370 continued to work additional shifts before the incidents were ultimately reported and the STNA was suspended on 02/24/23. This had the potential to affect all 18 residents (#2, #4, #5, #6, #9, #10, #11, #12, #15, #16, #17, ##19, #20, #30, #31, #33, #34 and #40) who resided in facility certified beds and for whom STNA #370 could have potential contact with as the building the facility was located in had certified and licensed only beds assigned to the same staff. The facility certified bed census was 18. On 03/01/23 at 5:25 P.M. the Administrator and Human Resources #429 were notified Immediate Jeopardy began on 02/22/23 at approximately 1:30 A.M. when STNA #374 witnessed an incident of potential staff to resident physical and verbal abuse and failed to immediately report the abuse to a supervisor. The Immediate Jeopardy continued 02/22/23 at approximately 4:45 A.M. when STNA #374 witnessed another potential incident of staff to resident verbal abuse and failed to immediately report the abuse to a supervisor resulting in the perpetrator, STNA #370 remaining on the schedule and working for additional shifts placing all residents at risk for situations of abuse by the STNA. The Immediate Jeopardy was removed on 03/03/23 when the facility implemented the following corrective action: • On 02/24/23 and 10:41 P.M., the facility suspended STNA #370 upon report of the allegations of staff to resident verbal and physical abuse involving Resident #26 and Resident #36, residents who resided in licensed only beds in the same facility. • Beginning on 02/24/23 and 10:41 P.M. and ending on 02/25/23 at 11:45 A.M. the Administrator began an investigation of the allegations of verbal and physical abuse when STNA #374 reported the abuse to Registered Nurse (RN) #395. RN #395, LPN #349, and the Director of Nursing (DON) took STNA #370 off the schedule and did skin sweeps to see to see if non-interviewable residents (#20 and #33) had any signs of abuse and interviewed (#2, #5, #6, #9, #11, #12, #15, #17, #30, #34, #40, and #42) who had a Brief Interview for Mental Status (BIMS) of eight or higher for any concerns related to abuse. No new evidence of abuse was identified. • On 02/26/23 between 8:00 A.M. and 8:30 A.M. the DON notified facility Medical Director #430 of the staff to resident physical and verbal abuse • On 03/01/23 and 5:39 P.M., the facility terminated STNA #370 upon determining there was potential that the allegations of verbal and physical abuse occurred to safeguard the residents affected as well as the other residents in the facility. • On 03/01/23 and 5:45 P.M., the facility terminated STNA #374 and LPN #319 for failing to timely report the alleged staff to resident verbal and physical abuse to protect all residents in the facility. • On 03/03/23 the Administrator began staff training for all staff related to Abuse, Neglect, and Misappropriation with additional information to highlight for all staff the reporting requirements which also addressed the failures to report that occurred and the repercussions thereof. A plan for any staff unable to attend the in-service revealed they would have to complete an online in-service prior to working their next shift. As of 03/06/23 four administrative staff, the DON, the Assistant Director of Nursing (ADON), five activities staff, four maintenance staff, four medical secretary/reception staff, Human Resources, 61 nursing staff, seven housekeeping staff, 30 dietary staff, and the beautician had completed the in-service. • Beginning on 03/03/23 a plan for all new hires to receive education during orientation by Medical Secretary #301 and Human Resources Director #429, on Abuse, Neglect, and Misappropriation and annually thereafter during the facility wide Abuse, Neglect, and Misappropriation in-service. • On 03/03/23 a plan for the Administrator, DON, and Director of Human Resources #429, or their designees to audit staff knowledge utilizing quizzes administered quarterly for one year then resume annual in-service training with quizzes and also quizzes during the annual competency training held in November was implemented. • On 03/03/23 a plan for Human Resources #429 or designee to audit four staff members weekly times four weeks via a quiz regarding when to report allegations of abuse and who to report the allegations of abuse to. Human Resources continue random quizzes quarterly this year, and then the quizzes will be completed after annual abuse and competency training. • The facility identified all grievances and concerns would be forwarded to the Quality Assurance and Performance Improvement (QAPI) committee for further review and recommendations. There was no change to the grievance systems or the QAPI review process during the review of these incidents of abuse. All staff were responsible to identify and report abuse in a timely manner. A concern would be put on a concern form. The residents get information on filing grievances upon admission and are invited to resident council. Family members are educated on how to file a grievance upon admission, and they are also invited to come to the resident council. These systems are being maintained and are in place. • Interviews completed on 03/06/23 from 8:10 A.M. to 8:27 A.M. with Receptionist #31, RNs #373 and #394, STNAs #336, #345, and #378, Hospitality Aides #357 and #417, Housekeeping #313, and Environmental Services #418 revealed staff had been recently educated in person on 03/03/23 or had taken an online course prior to starting shift on abuse. All staff interviewed knew what abuse was, what to do when abuse occurs, and to report abuse immediately. Although the Immediate Jeopardy was removed on 03/03/23, the deficiency remained at 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 continued compliance. Findings include: Review of the facility SRI, tracking number 232428 dated Saturday 02/25/23 and timed 9:03 A.M. revealed it was discovered on 02/24/23 STNA #374 had witnessed STNA #370 slap Resident #26 on Wednesday morning (02/22/23). The facility initiated an investigation of the incident at that time. Resident #26 was noted to reside in a facility bed that was licensed only. Review of the facility SRI, tracking number 232429 dated Saturday 02/25/23 and timed 9:15 A.M. revealed it was discovered on 02/24/23 STNA #374 had witnessed STNA #370 make disparaging comments about Resident #36 on Wednesday morning (02/22/23). The facility initiated an investigation of the incident at that time. Resident #36 was noted to reside in a facility bed that was licensed only. Review of schedule dated 02/21/23 to 02/23/23 revealed STNAs #370 and #374 were the two direct care staff scheduled from 10:00 P.M. to 6:00 A.M. to provide care to all 41 residents in the nursing facility, which included 18 residents who resided in certified nursing home beds. Interview with the Administrator on 03/01/23 at 11:11 A.M. confirmed STNA #374 did not report the observations of abuse timely, and STNA #370 remained on the schedule and provided care to nursing facility residents until she punched out in the morning on Friday 02/24/23. When the Administrator was notified of the alleged abuse on 02/24/23 at 10:41 P.M., STNA #370 was taken off the schedule until an investigation could be completed. The Administrator revealed facility staff were last in serviced on the facility abuse policy in June of 2022 and STNA #374 attended that in service. During the abuse in service, staff were educated that any observation of abuse should be reported immediately. The Administrator confirmed the notification from STNA #374 was not timely, and if the abuse had been reported timely by STNA #374, STNA #370 would have been taken off the schedule and not have worked two full shifts after the observation. Observation on 03/01/23 at 12:15 P.M. revealed the facility certified beds and licensure beds were intermingled throughout the facility and not divided into distinct parts. Interviews on 03/01/23 at 11:42 A.M. and 1:34 P.M. with STNA #374 revealed when there were two STNAs scheduled from 10:00 P.M. to 6:00 A.M. and they found it easier to tag team (care of residents), so both STNAs provided care to all facility residents, those 18 residents who resided in beds that were certified and the additional residents who resided in licensed only beds. The STNA revealed on 02/22/22 at approximately 1:30 A.M. STNA #374 witnessed STNA #370 say disparaging words and hit Resident #26. On 02/22/23 at approximately 4:45 A.M. STNA #374 witnessed STNA #370 say disparaging words to Resident #36 during care. STNA #374 stated she didn ' t say anything to anyone regarding what she witnessed that day because she had to take STNA #370 home from work, and she was afraid of what would happen to her. On the night of 02/22/23, STNA #374 stated she tried to tell LPN #319, who stated, Oh you know how [STNA #370] is. STNA #374 felt LPN #319 was not taking it seriously. On Thursday 02/23/23 STNA #374 stated she did not work. On Friday 02/24/23 STNA #374 reported the incident to RN #395 at the beginning of her shift when she got to work. STNA #374 confirmed the notification of the observed abuse was not immediate and any observation of abuse should be reported immediately. Review of the punch detail report for STNA #370 revealed STNA #370 punched in at 9:54 P.M. on Tuesday 02/21/23 and punched out at 6:04 A.M. on Wednesday 02/22/23, punched in at 9:54 P.M. on Wednesday 02/22/23 and punched out on Thursday 02/23/23 at 6:09 A.M., punched in at 9:53 P.M. on Thursday 02/23/23 at 9:53 P.M. and punched out on Friday 02/24/23 at 6:03 A.M. STNA #370 did not work since after she punched out on Friday 02/24/23 at 6:03 A.M. Review of facility policy titled Abuse/Neglect/Mistreatment/Misappropriation, revised 02/22/23, revealed all alleged incidents or suspicions involving abuse, neglect, mistreatment, or misappropriation of property would be immediately reported to the employee ' s immediate supervisor, Director of Nursing (DON) and/or the Administrator. This deficiency represents non-compliance investigated under Self-Reported Incident, Control Number OH00140682 and Control Number OH00140677.