**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, review of video evidence, interviews, and record review, the facility failed to protect Resident (R)1 from physical and mental abuse by Certified Nursing Assistant (CNA)2. Observation of video evidence from 01/09/23-02/01/23 revealed CNA2 intentionally wrapping R1's head and face with clothing to restrict movement, pushing R1's head into her bed, and pinning R1 down with her knees to restrict movement. On 04/24/23 at 12:57 PM, an Immediate Jeopardy (IJ) template was provided to the facility's Administrator via phone with the Business Office Manager present, notifying them that an IJ existed at F600 with an effective date of 01/09/23. On 4/25/23 at 10:45 AM, the facility provided an acceptable IJ Removal Plan indicating they identified their own deficient practice and implemented a plan prior to the start of the survey. Verification of the removal plan confirmed the facility put forth good faith attempts and implemented a plan to remove the immediacy including terminating CNA2 from the facility and in services to staff, effective 02/17/23. Implementation of the removal plan for F600 included R1 being assessed by the Assistant Director of Nursing (ADON) and Minimum Data Set (MDS) Coordinator on 02/01/23 to validate that there were no signs or symptoms of abuse such as skin tears, or reddened skin areas, none were identified. On 02/01/23 the ADON identified residents that were potentially impacted by completing skin and body audits first on the residents cared for directly by CNA2 and then on all current residents. This was completed on 02/01/23; no abuse signs and symptoms were noted. On 02/02/23 current residents that are interviewable were asked if they had been abused by any staff member. This was completed by the Social Services Coordinator on 02/16/23, no additional residents were identified. On 02/15/23 -02/16/23 the Nursing Managers (DON, ADON, MDS Coordinator) interviewed all staff members to determine if they had witnessed another staff member being rough, mistreating, or abusing a resident; no additional residents were identified. On 02/09/23 the Administrator in-serviced all nursing staff (including agency staff) on abuse policies and procedures. On 02/16/23 the Nursing Managers in serviced all staff on abuse policy and procedures; competency testing was completed. This training included all current staff including agency and contract staff. The training included: recognizing physical and non-physical signs of abuse; when and how to report abuse; how to minimize the risk of abuse; what to do if a resident resists care; and how to respond to aggression. As of 02/17/23, all staff have attended the in-service, the DON will ensure that any newly identified staff who has not completed the in-service training will not be allowed to work until the training is completed. In-service and competency testing will continue once a month for three months, and then quarterly after that for one year. Abuse drills will be performed in coordination with the monthly and quarterly abuse services. The Social Services Coordinator will monitor abuse processes such as identification of abuse, reporting abuse, and identification of how to respond to care refusals weekly for two weeks; monthly for three months; then quarterly for up to one year. Reports will be presented to the Quality Assurance (QA) committee by the Administrator or DON to ensure the auditing program is reviewed at the QA meetings. The QA meetings are attended by the Administrator, DON, ADON, MDS Coordinator, Health Care Services Director, Therapy Director, Medical Director, Dietary Manager, Business Office Manager, and other supervisors. Findings include: Review of facility policy titled, Abuse Prevention, Intervention, Investigation, and Reporting Policy and Procedure last revised 9/23/19, revealed Residents are to be free from verbal, sexual physical, environmental/mental abuse; neglect; self-neglect; involuntary seclusion; at all times. Abuse: the willful infliction of injury; unreasonable confinement; intimidation; or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to; dementia without behavioral disturbances, type 2 diabetes, and major depressive disorder. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/05/23 revealed R1 has a Brief Interview of Mental Status (BIMS) score of 99, which indicates severe cognitive impairment. An observation and an attempted interview on 03/27/23 at 10:45 AM revealed R1 was non-interviewable. She showed no visual signs of injury or abuse. A phone interview on 03/27/23 at 11:37 AM with R1's Resident Representative (RR) revealed CNA2 was arrested on 02/14/23 and was charged with abuse and neglect related to R1. CNA2 is being prosecuted by the Attorney General's Office for abuse and the allegation was determined to be substantiated due to video evidence. I had concerns about R1 being abuse since back in January when they went to visit the resident and she was jumping (motioning as if she was afraid) when I tried to hug her, and she had never done that to me before. I told the Administrator and other staff about this incident and I was brushed aside and was told that R1 has dementia, so that might be the reason she is becoming fearful towards others, because she is confused and doesn't know who I am anymore. I knew this didn't sound right and I could tell something was wrong with R1. So I decided to put a camera in R1's room and I observed CNA2 put her knee on R1 to hold her down, pushing her arms into R1's chest and into the bed, spraying R1 with deodorant, and flushing R1's food over the course of a few days. When I showed the video to the local Ombudsman and Attorney General, she (CNA2) was arrested immediately. An observation of the video evidence on 03/27/23 at 11:45 AM revealed a video with a date of 01/09/23. In the video, CNA2 was observed to be intentionally wrapping R1's head and face with clothing to restrict movement. CNA2 was observed pushing R1's head into her bed and pinning R1 down with her knees to also restrict R1's movement. Additional observation of video evidence on 03/27/23 revealed additional videos dated 01/09/23 - 02/01/23. These videos revealed CNA2 spraying R1's head, face, and body with an aerosol deodorant, in order to control R1's movement. Further observation of the videos revealed R1's head being pushed into her bed and CNA2 holding R1 down to restrict movement. A phone interview on 03/27/23 at 12:43 PM with the Director of the Ombudsman Program for South Carolina revealed On 01/23/23, R1's RR contacted our office because they had concerns of R1 suddenly becoming fearful of family members when they attempted to hug her, which was a new behavior. R1's RR put cameras in R1's room and over the course of a few days, videos showed CNA2 abusing R1. We were in contact with R1's RR on the following dates beginning on 01/23/23 and continued contact regarding this incident on the following days: 01/25/23; 01/26/23; 01/27/23; 01/31/23; and 02/06/23. After R1's RR showed us the videos of CNA2 abusing R1, we immediately reported this incident to law enforcement and the Attorney General's Office, so criminal charges could be taken against CNA2 and both agencies went onsite to investigate this matter. During the on-site investigation, Administration revealed that R1's RR had spoken to the facility about concerns related to R1 suddenly becoming fearful of others on (01/16/23) and had conducted their own internal investigation, but could not substantiate any abuse allegations at the time. CNA2 was arrested on 02/14/23 and a press release to the public by law enforcement was on 02/22/23. Record review of an internal investigation by the facility dated 01/16/23 revealed R1's RR was visiting the resident and she had concerns she addressed with the Administrator, which he spoke with other abuse coordinating staff about their concern. R1's RR stated that R1 was very jumpy today when she would move around her, when she went to hug R1 she jumped, almost as if she was afraid of being hit. R1's RR never accused anyone of any abuse, she was just concerned. A body audit was done and staff went to speak with R1. She was sitting in the hallway in her wheelchair with something in her hand that she was fidgeting with and was mumbling. When I spoke to her, she didn't acknowledge me, when I stooped down, she didn't look at me but she did rub my arm. I continued talking to her, she laughed as I talked to her, she continued mumbling something regarding smoking and a job. R1 didn't show any signs of distress, anxiousness or being nervous. R1 has been known to resist care (push staff away from her) and she will push off staff when they have tried to hug her in the past. She hasn't shown any signs of affection toward staff or her husband, that also resides at the facility since admission. Staff will continue to monitor for any changes in R1 and will address them accordingly. A phone interview on 03/27/23 at 4:06 PM with CNA2 revealed she denied all accusations of abusing R1. She further stated and denied being arrested and charged with elder abuse by law enforcement or the Attorney General's Office and denied any pending criminal charges as well. CNA2 stated that she retired from the facility by choice and was not terminated by the facility due to abusing R1. An interview with the Social Services Director (SSD) on 03/27/23 at 4:30 PM revealed that they had written the internal investigation concern related to this incident and interviewed R1 on 01/16/23 (date where RR had 1st concerns related to R1). The SSD further stated that she interviewed R1's roommate and other interviewable residents that were in the care of CNA2 and had no other concerns with abuse or neglect with other residents. An interview with the Administrator on 03/27/23 at 4:39 PM revealed that they were informed about CNA2's physical, mental, and involuntary seclusion of R1 by law enforcement/the Attorney General's Office on 02/01/23. When the facility was made aware of the abuse by law enforcement, they reported the abuse to the state agency in a timely manner. We spoke with R1's RR in mid-January (01/16/23), but were unable to substantiate abuse allegation at that time, due to no signs of harm in an interview and body audits. We were unaware that R1's RR had put a camera in R1's room after they reported their concerns until law enforcement and the Ombudsman Office arrived at the facility for their investigation. R1 and CNA2 previously worked together here at the facility before R1 was diagnosed with dementia and was admitted as a resident. We never suspected any abuse with CNA2 with other residents at the facility. When R1's RR spoke with us about her concerns she never alleged abuse against anyone at the facility, at the time. When law enforcement arrived at the facility for the investigation, CNA2 was still employed at the facility because we had no reason to believe that she harmed any residents, but after their investigation we terminated CNA2 on 02/05/23 and she was later charged by law enforcement on 2/14/23. Review on 03/27/23 at 4:45 PM of an Employee Termination Record dated 02/06/23 revealed CNA2 was terminated from the facility due to violations of resident rights and the care they provided was not in consistent expectations of the facility in a way that could have resulted in harm to the resident. A phone interview on 04/12/23 at 9:30 AM with the Attorney General Investigator revealed that CNA2 was still employed at the facility when they went onsite to complete their investigation. CNA2 was terminated from the facility after the completion of their investigation and has been charged with elder abuse. Under the terms of CNA2's bond, they are not allowed to be employed at any healthcare facility type.