**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, and record reviews, the facility failed to ensure the right to be free from abuse was provided for 1 of 8 residents (Resident #2) reviewed for abuse. LVN A was observed striking Resident #2 on his upper arm/shoulder after resident had grabbed LVN A's right breast. An Immediate Jeopardy (IJ) was identified on 6/13/23 at 5:00 PM and the IJ template was provided to the facility Administrator on 6/13/23 at 6/13/23 at 5:00 PM. While the immediate jeopardy was listed on 6/14/23 at 8:00 PM, the facility remained out of compliance at a scope no actual harm with potential for more than minimal harm: and a severity level of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. This failure could place resident at risk of abuse, mental anguish, injury, fear and hopelessness. Findings included: Record review of Resident #2's clinical record revealed an admission date of 11/5/19, was [AGE] years of age with the following diagnoses: dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, combined systolic (congestive) and diastolic heart failure, type 2 Diabetes mellitus with Diabetic Nephropathy, Osteoarthritis, hypertension, Nonrheumatic aortic valve stenosis (non-rheumatic aortic valve stenosis is narrowing of the valve between the left lower chamber of heart and a major blood vessel called aorta), nonrheumatic mitral valve disorder (problem with the valve located between the left heart chambers (left atrium and left ventricle)), Dementia in other diseases with other behavioral disturbance, spinal muscular atrophy, Alzheimer's disease with late onset, muscle weakness, muscle wasting and atrophy, malaise, major depressive disorder, intermittent explosive disorder, allergic rhinitis, heart-valve replacement, presence of automatic implantable cardiac defibrillator, atherosclerotic heart disease of native coronary artery, gout, personality and behavioral disorders due to known physiological condition. -A quarterly MDS resident #2 assessment dated [DATE], documented Resident #2 had a BIMS score of 08 out of 15 indicated moderately cognitively impairment. Resident's functionality requires extensive assistance with 2 person assistance with all ADL's. - Resident's care plan indicates resident #2 has a behavior problem related to being inappropriate with female resident initiated 11/23/22. Interventions to include observe behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved and situations. Document behavior and potential causes. Staff to redirect resident when having inappropriate behaviors. Record review of statement by LVN A and signed on 6/6/23 documented the following: Tuesday, June 6 @ 0635 This nurse was walking toward the 500 hall nurses stations looking for the O2 key. {Resident #2} was sitting at 500 hall nurses station window. As I approached the 500 hall nurses station window, {Resident #2} grabbed my right breast and squeezed it twice. I reacted by pushing his hand away and then slapping his left arm saying with a firm voice, 'Don't do that!' Record review of resident #2's clinical record to include progress notes and nurse's notes on the date of the incident 6/6/23 did not reveal that the resident was assessed for physical or psychosocial injuries/harm after the incident. Record review of witness statement completed and signed by RN D on 6/6/23 documented the following: 6/6/23 At approximately 0635,{LVN A} was walking in front of the 500 unit nursing station, { Resident #2} was sitting in his wheelchair. This RN D heard {LVN A} state loudly, 'you don't do that.' This RN D looked up and saw {LVN A} take his left wrist away from her body and then smacked him on his upper left arm. This RN D called out to her and told her we couldn't do that. She stated to this RN D, 'he grabbed my breast.' This RN D reminded her we can't react to the behavior and then escorted him from the area to the TV area and reminded him he can't touch staff, can't flirt with staff, etc. he stated, 'Yes, Ma'am.' During an Interview on 6/13/23 at 08:30 AM, administrator was asked if LVN A hit Resident #2. Administrator stated LVN A did push his shoulder and was immediately suspended while facility conducted an investigation. Administrator stated Resident #2 has behaviors and he yells out sexual invitations to female staff, as well as grab breasts and bottoms of female staff. During an interview with LVN B on 6/13/23 at 09:16 AM, LVN B stated she observed LVN A being grabbed by Resident #2 on the breast and she slapped him three times across chest and back. LVN B stated LVN A was suspended for a couple of hours but feels LVN A should have been suspended longer. LVN B stated I know Resident #2 is a handful, but you don't hit them. LVN B stated the incident happened at 06:30 AM and LVN A was back to work by noon the same day. LVN B stated RN D on the floor witnessed the event. During an interview with LVN A on 6/13/23 at 09:59 AM LVN A stated Resident #2 has been inappropriate with her physically. LVN A stated her slapping Resident #2 was not retaliatory. LVN A states the first time Resident #2 physically touched her on her butt and she had a firm tone with him. LVN A stated this second incident he grabbed her breast and she smacked him on his left arm. LVN A stated she did not mean to hit Resident #2. LVN A stated she only slapped him once. LVN A stated she was suspended while the facility did their investigation. LVN A states there were several witnesses to this incident. LVN A stated witnesses for the incident were LVN B, RN D, LVN C and MA. LVN A states she was suspended for ½ a day and returned to the facility to finish her shift by approximately 1:00 PM. LVN A stated she does not know the details of the administration investigation; however she was cleared to return work. During an interview on 6/14/23 at 10:28 AM, RN D stated she heard LVN A yell stop don't do that and saw her swat Resident #2 on the left arm. RN D stated, I heard 'Don't do that' and interjected when I saw LVN A's arm swing up and make contact with the resident's arm. When asked if LVN A struck Resident #2 more than once, RN D stated LVN A did not hit Resident #2 more than one time. RN D stated LVN A was suspended but does not know length of time. RN D stated that she began the internal investigation. RN D stated she does not believe LVN A returned to work that day but honestly did not know when LVN A returned to work. During an Interview with LVN C on 6/13/23 at 11:54 AM, LVN C stated I wasn't a witness, I just heard the commotion. LVN C stated I heard what RN D told LVN A. LVN C stated RN D told LVN A You cannot hit Resident #2 like that. LVN A responded to RN D by stating well he grabbed my breast. LVN C stated RN D responded back to LVN A It doesn't matter. LVN C stated LVN A stated I'm sorry. It was a reaction. LVN C stated LVN A was crying. LVN C left interview, however came back in approximately 2 minutes later crying and stated, I just don't understand how they 'suspended' the nurse for just 2 hours. LVN C stated It's not all of Resident #2's fault. LVN C stated How can you let a nurse go for 2 hours and let her come back to the same side that Resident #2 resides on? It's not all of Resident #2's fault. Resident #2 cannot communicate well. During an interview with MA on 6/13/23 at 11:56 AM, MA stated I was on duty. I was getting started. I was cleaning off the medication cart. I heard LVN A on 6/6/23 at approximately 6:35 AM yell 'stop'. MA stated she heard all the commotion but did not actually see what happened. MA stated, I did not see Resident #2 touch her. MA stated that she saw a few nurses run towards LVN A because she was crying inconsolably. MA stated that by the time she started asking questions with LVN A, RN D had come to LVN A and was telling LVN A she needed to speak with her and console her. MA states Resident #2 is 'pretty vulgar' and requires a lot of redirecting and teaching of what is appropriate and what is not appropriate. MA states she did not see LVN A hit Resident #2. MA states the only reaction she saw from LVN A was her crying uncontrollably. MA states it wasn't surprising from what Resident #2 did. During an Interview with Resident #2 on 6/13/23 at 1:11 PM, Resident #2 stated staff treat him real good. When asked who he would go to if he had any problems, Resident #2 stated, the first person I saw. Resident #2 state, I don't have any problems. Resident #2 stated, as far as I know I'm safe here. I haven't had any incidents with anybody that I am aware of. During an interview with Admin on 6/13/23 at 1:25 PM, Admin was asked what steps the facility implements to ensure this type of incident did not occur again. Admin stated, We in serviced staff on appropriate approaches and responses and when staff have those negative behaviors. Admin stated the facility had QAPI'd the incident. During an interview with DON on 6/13/23 at 1:48 PM DON stated QAPI meeting is not scheduled until 6/22/23. DON handed what would be in the QAPI meeting titled What is a Behavior and Helping MANAGE BEHAVIORS Appropriately undated. DON states I will get every resource in here to protect Resident #2, especially when his behaviors effect his quality of life. I want Resident #2 to have the best quality of life. During the interview, a record review of Resident #2's care plan was reviewed with DON, RN D changed Resident #2's care plan to include: The resident has a behavior problem TOUCHING STAFF INAPPROPROIATELY date initiated 6/6/23 revised 6/13/23. DON stated LVN A has been moved to the memory care unit or the 800 hall to give her and Resident #2 a break from each other. DON stated she failed to obtain LVN A's signature on sign in sheet for in service as they did a 1:1 education in her office dated 6/6/23. DON states that Admin and DON counselled LVN A while educating her as they felt LVN A had no intent of harming resident and LVN A needed assistance with dealing and developing coping skills. DON states You're my patient regardless of your past and I put a blanket of protection over all of them. That also goes to my nurses. Record review on 6/13/23 of the facility's internal investigation revealed the incident occurred on 6/5/23 with corrective action notice and written counseling held with LVN A for 'failure to demonstrate a respectful, and cooperative demeanor in all interactions with patients.' The corrective action notice was signed by LVN A, DON and Admin on 6/5/23. Record review on 6/13/23 of internal investigation reveals letter written by Admin dated 6/7/23, documented the following: This administrator met with Resident #2 today in his room to discuss his continued inappropriate behavior with staff. Upon approach Resident #2 was alert and oriented. Informed Resident #2 why and what I was there to discuss. Resident #2 stated again. Informed Resident #2 that any form of sexual behavior such as making sexual comments, touching or grabbing is unacceptable and that it will not be tolerated. Informed Resident #2 that his increase in this sexual behavior had been discussed with his daughter in the special care plan last week and consideration for other placement had been discussed if the behavior did not cease. Resident #2 stated I'll behave. Asked Resident #2 if he was aware of his behavior as being inappropriate. He reported that that he just likes to have fun. Allowed Resident #2 to repeat his understanding of the importance of this conversation and the immediate need for this behavior to cease. He verbally acknowledged he understood. Will continue to follow up with staff in regard to Resident #2 behavior. Interview with LVN A on 6/14/23 at 1:26 PM to clarify what date incident occurred. Corrective Action Notice (written counseling) was signed and dated 6/5/23. Witness statements from LVN A and RN D both indicate incident occurred on 6/6/23. LVN A pulled up her timesheet while on phone with surveyor and stated she worked a full day on 6/5/23 and this incident occurred on 6/6/23. Based on this information the Corrective Action Notice (Written counseling) was signed and dated incorrectly with incorrect date on 6/5/23 and should have been dated 6/6/23. Record review of internal investigation reveals a facility copy of Resident Abuse Policy dated 2020, documented the following: Policy Statement: It is the responsibility of our facility employees/associates, consultants, attendings physicians, family members, visitors, etc., to promptly report any incident of suspected neglect or resident abuse, including injuries of an unknown source, and theft or misappropriate of resident property to facility management. POLICY INTERPRETATION AND IMPLEMENTATION 1. Our facility will not condone resident abuse by anyone, including associates (associates herein refer to covered individuals), staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends or other individuals. The Facility will not employ persons who have been found guilty of abuse, neglect or mistreatment or have had a finding entered into a state registry or licensing authority concerning such behaviors. 4. When an alleged or suspected case of exploitation, mistreatment, neglect, injuries of an unknown source, or abuse is reported, the Facility Administrator, or his/her designee, will notify the following persons or agencies per the current state/federal reporting requirements of such incident, if appropriate: a) The State licensing/certification agency responsible for surveying/licensing the Facility. b) The Resident's Representative (Sponsor) of Record. c) Law Enforcement Officials d) The Resident's Attending Physician, and e) The Facility Medical Director 6.Definitions of abuse . a) Abuse is defined as 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 well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Any act, failure to act, or incitement to act done willfully, knowingly or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This it includes verbal abuse, sexual abuse, mental/psychological, or physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflect injury or harm. Including corporal punishment, involuntary seclusion or any other actions within this definition. ABUSE INVESTIGATIONS POLICY STATEMENT All reports of resident abuse, neglect and injuries which have an unknown source (defined per state regulations) shall be promptly and thoroughly investigated by the Facility management. POLICY INTERPRETATION AND IMPLEMENTATION 6. Associates/Employees of this facility who have an allegation against them of resident abuse may be reassigned to non-resident care duties or suspended from duty until the results of the investigation have been reviewed by the Administrator/designee. On 6/13/23 at 5:00 PM, The Administrator was notified that an Immediate Jeopardy had been identified, IJ template provided, and a Plan of Removal was requested. The Facility's Plan of Removal (as follows) was accepted 6/14/23 at 3:45 PM. The Facility's Plan of Removal F600 - 6/13/2023 Facility failed to protect the veteran from physical abuse. Resident grabbed LVN breast. In response the LVN physically removed his hand, then slapped the resident on the shoulder/upper arm. 1. Administrator/ DON/Designee to give Abuse and Neglect education/in-service to all staff on 6/6/2023. 2. Administrator/DON/ Designee Abuse and Neglect education/in-service to be provided to staff again beginning on 6/13/2023 and ongoing until all current staff are obtained. To include who is the abuse coordinator, what constitutes abuse, and to always report when in doubt. 3. DON/ Designee Education and Training to all staff provided on difficult/inappropriate behaviors and redirection interventions beginning 6/13/2023 and ongoing on how to deal with redirection/difficult and inappropriate behaviors. 4. DON/ Administrator to perform weekly random Q&A validation audits during rounds to include who is the abuse coordinator, how to deal with difficult behaviors, examples of abuse and neglect. 5. Director of Resident Care Services and Education (regional) provided education to Facility Management team on Regulatory Reporting on 06/13/2023. Facility staff member slapped a resident which has the potential to cause physical or psychosocial harm. 1. Staff member was suspended pending investigation. Prior to return to work on 6/6 employee received a write up to include how to respond to respond when a resident exhibits an inappropriate behavior. Staff member was not put on schedule to work and provide care to this resident. 2. Dir of Resident Care & Services (regional) to follow-up with staff member to validate understanding of how to respond appropriately to inappropriate behaviors (6/14/2023) 3. Administrator/DON/Social Worker to immediately assess and document all investigations of abuse. 4. DON/ADON/Designee to educate/in-service Nursing staff to assess and document in the veterans/residents record a head to toe skin assessment and in a progress note document veterans/residents' psychosocial wellbeing. 5. Psych Services to be notified and ask to visit veteran/resident if currently being seen or SW to ask resident/RR if would agree to psych consult visit request if necessary. 6. Resident Care Plan updated 6/6 and 6/13/2023 and again 6/14/2023 to include interventions to assist staff in helping resident with his inappropriate behavior. Updated C.N.A. POC [NAME] with helpful interventions for staff when interacting with resident. Facility had the responsibility to protect residents from abuse that could cause serious injury or harm. 1. If an abuse allegation is made the Administrator/DON/SW will address the allegation immediately by: a. Protecting the resident(s) immediately involved in the allegation and protecting other residents from the alleged perpetrator(s) b. Immediately reporting all allegations of A/N/E to the State per current regulatory requirements, c. Initiate a thorough investigation as to the allegation(s), including but not limited to assessing the resident(s) involved, obtaining statements of those allegedly involved, interviews with witnesses, suspending staff, re-enactments if needed. d. Follow the facility A/N/E policy. 2. If abuse involves an employee, an employee will be suspended based upon pending investigation. 3. Based upon results of investigation, the employee may be terminated. 4. If unfounded, facility will determine need for alternative staffing assignment. 5. DON/Administrator/Designee to provide 1:1 education/in-service how to respond/ Appropriate interventions and received a write up prior to returning to a floor assignment. 6. Will report and review Failure to protect to QAPI monthly for compliance for 6 months, plan to be modified as needed based upon audit results. Monitoring of the Plan of Removal included: During an interview on 6/14/23 at 4:29 PM with ADM would obtain copies of all education/in-services listed on Plan of Removal for surveyor. ADM stated facility had Q&A cards with questions about abuse, neglect and behavior interventions and each manager would ask random residents and staff weekly, log it and report this information to the ADM and DON. ADM clarified Corrective Action Notice date was incorrect. ADM stated the Corrective Action Notice (written counseling) date was in error and would be corrected. Copy of crossed-out date of 6/5/23 with corrected date of 6/6/23 and initials from admin was written on Corrective Action Notice. ADM stated once abuse had been reported, there would be a protocol for ADM, social worker and DON to know our part to take action. During interviews on 6/14/23 from 5:11 PM to 5:42 PM with staff members (listed below) regarding receiving in-service training on Abuse, Neglect and Exploitation, Redirecting Difficult Behaviors, Regulatory Reporting and Nursing Skin Assessment. Out of 10 CNA's interviewed, 7 stated they had received and signed in-service training on 6/14/23. One CNA stated she was agency, did not sign the in-service training, but did receive the training. One CNA stated she was 'too busy' working and had not received it. One CNA, who was working, stated she had received verbal information about the incident but not about the in-service training. Four LVN's, all stated signed and received the in-service training. Two RN's, all stated signed and received the in-service training. Five office staff, all stated signed and received the in-service training. One Maintenance Director stated he had signed and received the in-service training. During an observation on 6/14/23 at 5:12 PM one RN was educating night supervisor RN regarding in-service training of Abuse, Neglect and Exploitation, Redirecting Difficult Behaviors, Regulatory Reporting and Nursing Skin Assessment. Record review of the facility provided in-service sign in sheet revealed staff were trained on Validation of Education Managing Inappropriate Behaviors on 6/14/23, Abuse and Neglect Inservice Education dated 6/13/23, Regulatory Reports dated 6/14/23, Nursing Skin assessment, Nursing Notes to include psychosocial wellbeing dated 6/14/23, ANE (Resident #2. Incident) dated 6/6/23, How to Re-direct and Deal with Difficult Behaviors - Resident #2 dated 6/7/23, Q&A index Cards - Abuse, Neglect and Behavior Interventions An Immediate Jeopardy (IJ) was identified on 6/13/23 at 5:00 PM and the IJ template was provided to the facility Administrator at 6/13/23 at 5:00 PM. While the immediate jeopardy was lifted on 6/14/23 at 8:00 PM the facility remained out of compliance at a scope potential for more than minimal harm: and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. The Immediate Jeopardy was re-opened on 7/5/23 at 10:00 AM due to the facility failed to follow their Plan of Removal. Based on the Plan of Removal, if abuse involves an employee, an employee will be suspended based upon pending investigation. LVN A was allowed to continue to work with residents. Interview on 7/5/23 at 10:56 AM with Administrator and DON, administrator stated she and the DON felt that LVN A was capable of working with dementia residents and was very familiar with their behaviors and confused state of minds. Administrator and DON were notified that Immediate Jeopardy was re-opened until further investigation evidence was determined. Administrator stated that LVN A's personnel file had not been updated since 6/14/23, as their had not been any issues or concerns. Admin stated all personnel that worked in the vicinity of the incident had been interviewed and 2 witness statements (LVN A and RN D) were the only statements that had been in the investigation file. Interview on 7/5/23 at 11:20 AM DON stated LVN A had been suspended until investigation was thoroughly completed. Interview on 7/5/23 at 2:00 PM, DON stated the list of employees that completed in-service trainings on Abuse, Neglect and Exploitation, Redirecting Difficult Behaviors, Regulatory Reporting and Nursing Skin Assessment were color coded and all staff had been trained. The one CNA that had reported to surveyor that she was too busy working had signed the in-service trainings, but no longer works at the facility. DON stated that LVN A has been removed from the schedule effective 7/6/23 through 7/15/23 as proactive measures since facility does not know what is going to happen with this investigation. DON stated schedule has not been posted and this was just for staffing coordinator and DON at this time. Interview on 7/5/23 at 2:15, LVN B stated that administrator or any upper management interviewed her about the incident. LVN B stated that her immediate supervisor (care coordinator previous ADON) was standing directly beside her and saw the entire incident occur. LVN B stated immediate supervisor told LVN B that she would take care of everything. LVN B stated she was told she did not have to document the incident. LVN B stated she was told to call the family and LVN B asked if she was supposed to tell the family that Resident #2 had been slapped she was told no. LVN B stated she yelled at LVN A You can't do that. LVN A stated RN D also yelled You can't do that upon seeing LVN A strike Resident #2. Interview on 7/5/23 at 2:32 PM, RN D stated no on was standing beside her. RN D believes LVN B was standing behind her at her medication cart and that there was someone at the computer but does not recall who this person was. RN D stated she was the only person that yelled You can't do that when she saw LVN A strike Resident #2. RN D stated she took LVN A to her office and had LVN A write up her statement and then sent her home. RN D stated later that day she told LVN B to complete a skin assessment on Resident #2, which was not completed. RN D stated she told LVN B to call Resident #2's family to notify them of the incident. RN D stated LVN B asked what she was supposed to tell the family and RN D stated to LVN B to follow the incident report questions. Interview on 7/5/23 at 3:22 PM, DON stated social worker completed safety rounds with all residents asking resident if they felt safe. DON stated psychiatrist saw Resident #2 on 6/6/23 and on 6/16/23. DON stated resident was placed in a behavioral facility for 2 weeks due to another incident. DON stated she was unaware of LVN B witnessing incident. DON stated she does not know where LVN B was at the time of the incident and that LVN B did not report to her or administrator that she was a witness to the incident. Interview on 7/5/23 at 3:43 PM, Administrator stated she did not interview LVN B and was unaware that LVN B was a witness to the incident. Administrator stated she had just started working on her investigation when she called corporate and was told this was not a reportable offense and did not need to be investigated. Administrator states the investigation file she has only has the two witnesses (LVN A and RN D) as witnessing the incident. Interview on 7/5/23 at 4:25 PM, Admin interviewed regarding plan of removal to protect all residents from abuse, neglect and exploitation. Plan of Removal reviewed for assurances that employee will be suspended until investigation is completely resolved of deficiencies, plan of care and board of nursing action. Record review of the facility provided in-service sign in sheets revealed all staff were trained on How to Re-direct and Deal with Difficult Behaviors - Resident #2, Abuse and Neglect, Nursing Skin Assessment Nursing Notes to include psychosocial wellbeing, Regulatory Reporting. Record review of the facility provided in-service sign in sheets revealed all residents were interviewed for safety rounds. Record review of the facility Provider Investigation Report dated 6/15/23 with no intake number. Record review of the facility schedule for LVN A for June 2023 and July 2023. LVN A worked 10 days after IJ was lifted and was removed from the facility on 7/5/23 at 11:15 AM. LVN A worked on the following dates: 6/14/23, 6/16/23, 6/19/23, 6/2023, 6/23/23, 6/24/23, 6/25/23, 7/1/23, 7/2/23 and 7/5/23. The Immediate Jeopardy (IJ) that was lifted on 6/14/23 at 8:00 PM was re-opened on 7/5/23 at 10:00 AM due to the facility failing to follow their plan of removal. While the immediate jeopardy was lifted on 7/5/23 at 5:30 PM, the facility remained out of compliance at a scope potential for more than minimal harm: and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns.