**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to protect 1 of 3 residents from physical abuse. On 04/02/23 at approximately lunchtime, Resident (R)24 was slapped by Certified Nursing Aide (CNA)2 after a combative incident. This was witnessed by CNA3 and the Activities Director. Because a wheelchair-bound resident was struck by a nursing aide, the resident was placed at increased risk for severe harm and mental anguish. On 06/13/23 at approximately 3 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 06/13/23 at 5:30 PM the Administrator was notified that the physical abuse of R24 by CNA2 constituted immediate jeopardy at F600. The facility presented an acceptable plan of removal of the immediate jeopardy on 06/14/23 at 10 AM. The survey team validated that the immediate jeopardy was removed on 06/14/23 at 12 PM following the facility's implementation of the plan of removal of the immediate jeopardy. The facility's presented plan revealed the facility had identified its own deficiencies and corrected prior to the start date, warranting F600 at past noncompliance. The IJ began on 04/02/23 and was removed on 04/09/23. Findings include: Review of the facility policy titled, Resident Abuse and Neglect and revised on 09/27/22 revealed that It is the policy of [NAME] Healthcare and Rehab to ensure that residents are free from any form of abuse or neglect. The policy defined physical abuse as hitting, slapping, pinching, kicking, and includes controlling resident behavior through corporal punishment. R24 was admitted to the facility on [DATE] with diagnoses including, but not limited to, hemiplegia and hemiparesis following cerebral brain infarction affecting left nondominant side, frontal lobe and executive function deficit following cerebral infarction. She scored 04/15 on her Brief Interview for Mental Status (BIMS) during her admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) 03/03/23 indicating severe cognitive impairment. Review of CNA3's statement written to the facility on [DATE] revealed R24 knocked a phone out of the possession of CNA2. After the incident, CNA2 slapped the resident and continued to pick up her phone. CNA2 also said that the resident knocked her new phone from her and that's the reason she slapped the resident. Interview with CNA3 on 06/13/23 at approximately 2:42 PM revealed that she and three other CNAs were standing by the nurse's station. R24 tried to stand from her chair. CNA2 went to the resident to seat her down when R24 pushed the phone from CNA2's hand. CNA2 picked it up and slapped the resident. This happened after lunch. Review of Activities Director statement to the facility written on 04/02/23 revealed that she witnessed CNA2 slap R24. The Activities Director was trying to help the resident in the wheelchair, but the resident was resistant. She called CNA2 to assist. During the struggle, the resident knocked CNA2's phone from her possession. The CNA gave the resident a slap across the face and stated, she slapped my new phone out of my hand. Afterward the resident was quiet. Activities reported the incident to Licensed Practicing Nurse (LPN)3. Multiple unsuccessful attempts were made to contact the Activities Director for interview during the course of the survey. Review of LPN3's statement to the facility, written on 04/02/23, revealed she was informed of the abuse incident by the Activities Director. She notified LPN2, who was the nurse for R24. Multiple unsuccessful attempts were made to contact LPN3 for interview during the course of the survey. Review of LPN2's statement to the facility, written on 04/02/23, revealed she was in her car during her lunch break when LPN3 informed her of the abuse incident. She performed a body audit for R24 and found no abnormal findings or apparent injury. She notified the abuse coordinator. Multiple unsuccessful attempts were made to contact LPN2 for interview during the course of the survey. Review of CNA2's undated statement to the facility, and her follow-up statement conducted by phone by Registered Nurse (RN)1 on 04/04/23 revealed she denied slapping R24. Interview with CNA2 on 06/13/23 at approximately 11:27 AM revealed she denied the abuse allegation. Interview with daughter of R24 on 06/13/23 at approximately 4:30 PM revealed, when asked regarding changes in the resident after the abuse incident, that R24 gets scared. The facility followed up on the resident for psychosocial harm. Review of R24 progress notes revealed a 04/03/23 social services note indicating that the resident was calm with no signs or symptoms of distress. Review of R24's Care Plan revealed that the facility care planned for Alleged incident occurring 04/02/23, and that interventions included 14-day monitoring for victim for mental and physical signs of distress or anger as well as psychosocial support. Interview with the Director of Nursing (DON) on 06/13/23 at 4:40 PM revealed that she had repeatedly instructed CNA2 to not have their phones out in resident care areas. The DON had educated staff on this over and over. Interview with the Social Services Director (SSD) on 06/13/23 at approximately 5:30 PM revealed she monitored R24 in the days after the incident as well as updating the care plan for the resident. There were no psychosocial or behavioral changes or concerns in the days following the incident or the months since the investigation. Multiple observations of R24 during the course of the survey revealed no concerns, physical or psychosocial, regarding the abuse incident that occurred on 04/02/23. The facility's removal plan included: R24 was assessed by the charge nurse and found to be without injury. The resident has continued to receive body audits for a total of 2 more days to monitor for any signs of injury. These were completed on 04/03/23 and 04/04/23 with no injuries noted. Social Services began following R24 for any negative psychosocial outcomes related to the incident and none had been observed. Nurses monitored R24 for 14 days for any negative effects regarding the incident and none have been noted. R24 was assessed by the facility Nurse Practitioner on 04/03/23 with no negative outcomes noted. R24's medical doctor was notified of the incident on 04/02/23. The Administrator and Director of Nursing were notified of the incident on 04/02/23. The alleged perpetrator was suspended pending outcome of investigation on 04/02/23 and was terminated on 04/05/23. All interviewable residents in the facility were interviewed / assessed to identify if they felt safe and if they had ever experienced abuse while living at the facility. There were no further allegations or issues noted. Abuse policies were reviewed, and no revisions were made. All staff received education on facility abuse policies by the administrator starting on 04/03/23. All staff will receive abuse training, reporting and protecting residents, including agency staff prior to their assigned duties. All newly hired staff will receive proper abuse training, reporting, and protecting residents during orientation. New agency staff will be in-serviced by the DON or charge nurse prior to working regarding resident abuse, reporting, protecting the residents, and abuse policy. All staff received training regarding how to deal with residents who are resistive or combative during care provided by the Administrator starting 04/06/23. All newly hired staff will receive this training during orientation. All new agency staff will be in-serviced by the DON or charge nurse prior to starting work regarding dealing with resistant or combative residents. Abuse investigation procedures and documentation process were reviewed and revised. The Administrator implemented a new reportable incident procedure to ensure investigations were initiated and completed thoroughly on 04/06/23. The IDT staff were educated on changes starting on 04/06/23. The Administrator, DON, and Social Services Director will conduct random interviews and observations of residents and staff regarding any signs, complaints of abuse, timely reporting, and timely protection of resident and following policy and providing proper care of residents who are aggressive and resistive to care. This will be done weekly x 4, then monthly x 3, then quarterly. Root cause analysis was conducted and presented to IDT on 04/06/23 by the nurse consultant.