**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two of six residents (Resident #1 and Resident #2) reviewed for abuse. The facility failed to ensure Resident #2, who had prior behaviors towards others, did not physically abuse Resident #1. On 08/26/25, Resident #2 had her hands around Resident #1's neck and had to be separated by facility staff. An Immediate Jeopardy (IJ) situation was identified on 08/27/25. While the IJ was removed on 08/28/25, the facility remained out of compliance at a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for abuse. Findings included: Review of Resident #1's Quarterly MDS Assessment, dated 05/02/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Her BIMS score was 05, which indicated severe cognitive impairment. Resident #1 did not have any physical or verbal behaviors towards others. Her active diagnoses included Alzheimer's Disease (a brain condition that gradually destroys memory and cognitive skills, interfering with daily life) and Depression (a mood disorder that causes persistent sadness and changes in how you think, sleep, eat, and act). Review of Resident #1's care plan, revised 11/17/24, reflected: Focus: The resident is/has potential to be physically/verbally aggressive and resistive to care r/t Dementia.Interventions/Tasks: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Review of Resident #1's skin assessment, dated 08/27/25 at 4:43 AM, reflected the resident had redness and an open spot on the right side of her neck and redness/spot on her right cheek. Review of Resident #1's Progress Notes reflected the following: LVN A wrote on 08/26/25 at 7:48 PM: The resident was attacked by an aggressive resident in the dining room. The aggressive resident was seen by the CNA putting her hand around the resident's neck [Resident #1] in the dining room. Nurse and CNA immediately ran towards them and intervened. Upon assessment, no injury noted. resident [sic] denies pain. Resident was redirected and taken to another seat away from the aggressive resident. NP and DON notified. Observation and interview on 08/27/25 at 10:40 AM with Resident #1 revealed she was sitting in a chair in the dining room. Resident #1 said she was doing great today. Resident #1 was observed to have redness to the right side of her neck that appeared to be a bruise that was about two inches long and an inch wide with a small open area. Resident #1 also appeared to have a small scratch to the right side of her cheek on her jawline that was also reddened. Resident #1 said she did not know what happened to her cheek or neck but it did not bother her. Review of Resident #2's admission MDS Assessment, dated 07/29/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Her BIMS score could not be conducted, but it was noted she had both short-term and long-term memory problems and could not make her own daily decisions. She was noted to not have any physical or verbal behaviors towards others but wandered daily that intruded on the privacy or activity of others. Her active diagnoses included Alzheimer's Disease (a brain condition that gradually destroys memory and cognitive skills, interfering with daily life) and Insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep). Review of Resident #2's Physician's Orders, dated 08/27/25, reflected the following:- Ativan Gel 0.5mg q 12 hours prn apply topically every 12 hours as needed for agitation for 14 days- Seroquel Oral Tablet 25 MG Give 1 Tablet by mouth two times a day for agitation Review of Resident #2's Treatment Administration Record reflected the following: - Resident #2 was administered the Ativan Gel (which had an order start date of 08/13/25) on the following dates: 08/14/25, 08/16/25, 08/17/25, 08/18/25, 08/19/25, 08/20/25, 08/24/25, 08/25/25, and 08/26/25. - Resident #2 was noted to have behaviors on the following dates as monitored for psychoactive behaviors: 08/02/25, 08/03/25, 08/08/25, 08/09/25, 08/14/25, 08/16/25, 08/17/25, 08/20/25, 08/21/25, 08/23/25, 08/24/25, 08/25/25, and 08/26/25. - Resident #2 was administered the Seroquel (which had a start date of 08/25/25) on the following dates: 08/25/25, 08/26/25, and 08/27/25. Review of Resident #2's Progress Notes reflected the following entries: - LVN B wrote on 07/25/25 at 2:57 PM: Resident follow up on new admit, resident continue pacing down the hallway, attempt to push fire alarm during this shift, resident continue to monitor [sic] - LVN C wrote on 07/27/25 at 1:39 AM: The resident woke up, and was very agitated, throwing around everything she could come across in her room. She was yelling out at the staff when they were offering incontinent care to her. She was calmed down and laid back to bed but still kept on waking up and coming out of her room, and re-direction was done appropriately. - LVN D wrote on 07/27/25 at 8:49 PM: Resident combative with incontinent care. She came out from the room and started pushing dining table and chairs. Resident able to redirect, sleeping in bed at this time. No s/s of acute distress noted. Bed in low position, call light within reach. - LVN C wrote on 07/28/25 at 2:14 AM: The resident woke up and was banging stuff in her room and bathroom. Staff redirected her back to bed, but she was combative, and yelling. She was brought to the dining room via wheelchair but kept standing up and pushing the tables and chairs around. She wandered through the hallway back and forth. She was redirected back to her room and agreed to lay back in bed. Right now, she is resting in bed eyes closed. - LVN B wrote on 08/07/25 at 8:47 AM: Resident going all other [sic] resident room [sic] attempting to pull them from the bed staffs [sic] continue redirecting the resident. - LVN A wrote on 08/08/25 at 1:01 AM: Resident is combative, non-compliant to care, yelling and destroying anything within her reach. Resident refused to sleep, attempting to pull roommate from the bed. All efforts to redirect resident is ineffective. NP and DON notified. - LVN C wrote on 08/10/25 at 6:29 AM: The resident pacing [sic] in the hallway entering into other patients' rooms and banging doors and throwing everything she comes across. At the dining room at the moment, throwing chairs all over and moving tables around. - LVN A wrote on 08/26/25 at 9:40 PM: Resident noted with aggressive behavior. She was seen by the CNA putting her hand around another resident's neck [Resident #1] in the dining room. Nurse and CNA immediately ran towards them and intervened. Resident was fighting and kicking staff while being redirected. PRN Ativan gel was applied with little effect. Resident also tried to pull her roommate from the bed earlier today per therapist. NP and DON notified. Resident's RP informed. Resident is currently on Q 15 mins checks for behavior. she [sic] is lying in bed in the room no behavior [sic] noted at this time. - LVN C wrote on 08/27/25 at 1:10 AM: The resident is on aggressive behavior monitoring q 15 minutes. Resident is in bed at the moment sleeping. - LVN C wrote on 08/27/25 at 5:15 AM: The resident woke up and started throwing stuff in her room. The nursing staff tried to redirect and offer incontinent care, but the resident was extremely aggressive/combative. The staff left the room. The resident kept yelling from her room. Review of Resident #2's care plan, revised on 08/14/25, did not reflect anything regarding her aggressive behaviors. Review of Resident #2's Psychiatric Initial Assessment, dated 07/30/25, reflected the following: .Patient referred for medical management services for sx including Agitation, Adjustment Disorder, Noncompliance, Verbal Aggression, Physical Aggression. Patient made eye contact with provider when approached, but was unable to appropriately participate/interact. Staff report frequent periods of anxiousness/restlessness and difficulty with redirection being exhibited by patient.At this time, recommend increasing frequency of Ativan to 0.5 mg/TID per frequent symptoms of anxiety and difficulty with redirection. Review of Resident #2's Psychiatric Subsequent Assessment, dated 08/06/25, reflected the following: .During previous visit, Ativan frequency increased to TID due to reported periods of agitation and behavioral concerns. Staff states agitation decreased but continues during periods of care. Staff also report patient frequently pacing throughout secured unit and wandering into other residents rooms. Staff reports patient being aggressive and difficult to calm/redirect.At this time, due to reported continued periods of agitation and aggression during periods of care, recommend initiation of Ativan gel 0.5 mg/Q12 HR PRN X 14 days for acute agitation/aggressive behavior. Review of Resident #2's Psychiatric Subsequent Assessment, dated 08/20/25, reflected the following: .Staff reports continued behavioral concerns being exhibited by patient. Per ADON, patient reported to have ‘taken the tank off of her toilet and breaking it, as well as tearing soap dispensers off the wall.' Nursing staff within secured unit report patient often ‘easily agitated and physically aggressive. Staff states patient will attempt to hit staff during attempted periods of care. When attempting to initiate assessment, patient was found leaning over another resident within secured unit, whom was sitting on her wheelchair, and pushing her down the hall.'.At this time, due to reported symptoms of disorganized/delusional thoughts reported, Recommend [sic] initiation of Seroquel 25 mg/BID. Review of Resident #2's Psychiatric Subsequent Assessment, dated 08/27/25, reflected the following: .During previous visit, Seroquel 25 mg/BID order recommended.Staff states the day prior to exam, patient exhibited ongoing physically aggressive behaviors and ‘Choked [sic] another resident.' Per note in [EHR], on 8/26, patient was observed by the CNA ‘putting her hand around another resident's neck' in the dining room of the secured unit. During attempted intervention by nurse and CNA, patient was ‘fighting and kicking staff' during attempted redirection. Resident was placed on Q15 min safety checks, and staff denied observing physically aggressive behaviors being exhibited prior to today's assessment.Due to minimal symptom relief with currently ordered Ativan, recommend discontinuation of Ativan and initiation of clonazepam 0.5 mg/TID with consent from POA. Observation and attempted interview on 08/27/25 at 10:35 AM with Resident #2 revealed she was sitting in a chair in the dining room mumbling to herself. Resident #2 did not look the state surveyor's way or at the state surveyor until the state surveyor continued trying to talk to her. Resident #2 appeared calm but was not able to answer any questions. Phone interview on 08/28/25 at 9:32 AM with the Psych NP revealed Resident #2 was physically aggressive during moments of agitation and was difficult to redirect. The Psych NP said staff had been communicating with him about the increase in her behaviors and he added orders for a PRN Ativan gel and Seroquel more recently. The Psych NP said he noticed during his meetings with her that she was uncooperative, non-compliant, and had disorganized speech and he was not sure what was causing all of these behaviors. The Psych NP said staff also explained to him how difficult Resident #2 was to manage and control, that she had taken off the tank to the toilet and the soap dispensers from the walls, she was wheeling another unknown resident down the hall in her wheelchair in an aggressive manner, and now she had choked another resident (Resident #1). The Psych NP said Resident #2's behaviors were quite frequent and often from what he had witnessed and was told. The Psych NP said from what he was told and understood, staff were trying to minimize her behaviors the best they could and limited her interactions with others. The Psych NP said it was almost to the point that she needed 1:1 care because her behaviors were so severe. The Psych NP said he was working to get her on the right medication regiment hoping that would help to reduce her behaviors. Interview on 08/27/25 at 10:23 AM with LVN B revealed she got report from the night nurse this morning that Resident #2 attacked or scratched Resident #1 yesterday. LVN B said Resident #1 had some redness to her neck that looked like it was a scratch but she was not sure if it was from the incident with Resident #2 or not. LVN B said Resident #2 wandered a lot around the unit and was a difficult resident to handle. LVN B said Resident #2 would get mad and yell and be agitated for no reason. LVN B said staff were monitoring Resident #2 every 15 minutes right now by just keeping an eye on her in general and noting where she was or what she was doing. LVN B said Resident #2 tried to touch other residents but staff usually intervened before anything could happen because if anyone was near her anything could set her off. LVN B said when Resident #2 started to show agitation, staff would try to calm her down by singing with her, taking her for a walk outside, or getting her something to eat or drink. LVN B said Resident #2's behaviors were unpredictable and there was no trigger for it. LVN B said she was not sure if she had been trained on what to do specifically with Resident #2 in order to decrease her behaviors or reduce her agitation. LVN B said she had never seen Resident #2 be physically aggressive with another resident during her shift. Follow-up interview on 08/27/25 at 10:40 AM with LVN B revealed she saw Resident #1's reddened areas to her neck and cheek but could not recall if the reddened areas were there yesterday or not. LVN B said she did not pay much attention to Resident #1 yesterday, so she was not sure if the reddened areas were a result of the incident with Resident #2 or not. Attempted phone interview on 08/27/25 at 11:04 AM with CNA D, who worked with Residents #1 and #2 on 08/26/25, was unsuccessful as she did not answer or call back prior to exit. Attempted phone interview on 08/27/25 at 11:05 AM with LVN C, who worked with Residents #1 and #2 on 08/26/25, was unsuccessful as she did not answer or call back prior to exit. Phone interview on 08/27/25 at 11:08 AM with LVN A revealed she was at the nurses' station when she heard CNA E yelling, She's about to choke the resident. LVN A said she and CNA E ran towards Residents #1 and #2 and when they got to them, Resident #2's hand was round Resident #1's neck. LVN A said her and CNA E were able to pull Resident #2's hand away from Resident #1's neck, but Resident #2 continued to fight staff while trying to redirect her. LVN A said when she assessed Resident #1 she saw there were reddened and open areas on Resident #1's neck and cheek, but she did not think that was related to the incident, but that it was a rash. LVN A said Resident #2 had physically aggressive behaviors such as she pushed another unknown resident in the dining room on Monday, which was reported to the Abuse Coordinator, but the resident did not sustain any injuries. LVN A said she communicated with the Psych NP about Resident #2's behaviors and PRN Ativan gel was added to her orders. LVN A said when Resident #2 became agitated and unable to be redirected, she would apply the gel. Follow-up interview on 08/27/25 at 3:03 PM with LVN A revealed she did not check Resident #1's skin prior to the incident and did not know if it was due to the incident or a rash. LVN A said she only noticed the rash after the incident because she had to do a skin assessment. LVN A was unable to say how long Resident #1 had the rash to her skin and could not describe what it looked like. LVN A said Resident #2 was having an increase in her agitation and physical behaviors. LVN A said when Resident #2 first came to the facility, she was flinging chairs and tables around the dining room. LVN A said she reported this to the NP who ordered new medications, but Resident #2's behaviors did not change. LVN A said that was when the NP ordered the PRN Ativan gel but it did not work either. LVN A said she did communicate with the DON when she saw Resident #2 become physically aggressive with other residents. LVN A showed a text message exchange between her and the DON from 08/08/25 discussing Resident #2's agitation and physically aggressive behaviors regarding resisting care and destroying anything within her reach. LVN A said she knew to report any incident to the DON immediately that concerned residents. Phone interview on 08/27/25 at 11:21 AM with CNA E revealed Resident #2 was very aggressive last night and very agitated. CNA E said Resident #2 was trying to pull the table and chairs in the dining room. CNA E said she tried to move closer to Resident #2 and get her to calm down by talking to her but the resident refused. CNA E said she also tried redirecting her but again, Resident #2 refused. CNA E said when she moved closer to Resident #2, Resident #2 moved closer to Resident #1 and grabbed her neck, choking her. CNA E said she rushed towards the residents and tried to separate them and pulled Resident #2's hands off Resident #1's neck. CNA E said this behavior was normal for Resident #2 because she was always agitated and aggressive. CNA E said when Resident #2 became agitated she would try to calm her down, move close to her, and talk to her. CNA E said Resident #2 was very strong and would fight staff during care and drag staff to the ground because she was so strong. CNA E said staff would have to act fast to be near her to make sure she did not harm other residents. CNA E said she did everything she could to try and keep Resident #2 from hurting others, but nothing seemed to work. Follow-up interview on 08/27/25 at 2:42 PM with CNA E revealed Resident #2 had physically aggressive behaviors towards others ever since she arrived at the facility. CNA E said especially the last few days, Resident #2 had been showing signs of agitation and aggression. CNA E said Resident #2 pushed another resident in the dining room the other day and then had choked Resident #1 last night while she was upset. CNA E said Resident #2 would get upset and staff had to calm her down. CNA E said staff had to be alert and watch Resident #2 closely when she became agitated because when she got angry she was very strong and tried to push tables, chairs, and throw things. CNA E said staff would redirect her during these behaviors, but the redirection did not work and Resident #2 would continue her behaviors. CNA E said when these behaviors occurred, she would tell the nurse and assumed the nurse would let the ADON/DON know. Interview on 08/27/25 at 11:43 AM with CNA F revealed she cared for Resident #1 yesterday (08/26/25) and did not see any redness or scratches to her cheek or neck. CNA F said when she came to work this morning, she heard a fight happened between Residents #1 and #2. CNA F said she figured the scratches and redness to Resident #1's cheek and neck happened from the incident with Resident #2. CNA F said since the incident happened, the nurse was monitoring Resident #2 every 15 minutes, but she was not informed to do anything different regarding Resident #2. CNA F said Resident #2 was calm this morning, but she did start to yell. After going to the resident's side and talking to her, the resident calmed down. CNA F said Resident #2 was always agitated, wild, and out of control. CNA F said when Resident #2 got that way staff tried to calm her down by giving her something to drink or taking her somewhere else to calm down. CNA F said sometimes those interventions helped Resident #2 calm down, and sometimes they did not. CNA F said when redirection did not work, they would leave Resident #2 alone and just monitor her closely because she would try to go to other resident's rooms. CNA F said one day she saw Resident #2 trying to get into her roommate's bed and was trying to get the roommate out of the bed. CNA F said she rushed into the room to stop Resident #2 from hurting the roommate and nothing happened. Interview on 08/27/25 at 1:24 PM with CNA H revealed she had only been working at the facility for a month but knew Resident #2 was easily agitated. CNA H said she never seen Resident #2 be physically aggressive with another resident. CNA H said she knew to follow closely behind Resident #2 and make sure she was safe and not going to hurt anyone because she wandered around a lot. CNA H said Resident #2 was on every 15-minute checks right now because of what happened. CNA H said if she saw any resident trying to hurt another resident she would separate them and call for the nurse. CNA H said she knew when Resident #2 got upset, staff needed to help calm her down by offering her something to drink or eat. Interview on 08/27/25 at 2:49 PM with CNA I revealed Resident #2 was very erratic at times and when she got that way she would try to hurt other residents and staff. CNA I said staff would try to redirect Resident #2 to calm her down but it did not work because she did not want to be redirected. CNA I said last night specifically, Resident #2 was very upset and was behaving so badly, she was sitting at a table trying to push it away and knock residents out of their wheelchairs while hitting and swinging at them. CNA I said Resident #2 put her hands around Resident #1's neck to choke her. CNA I said when she saw Resident #1 before the incident, she did not have any marks on her cheek or neck but after the incident, Resident #1 had red spots on her cheek and neck. CNA I said Resident #2 also had a habit of wanting to get in her roommate's bed even while the resident was in the bed and if staff tried to stop her she would get more upset. CNA I said Resident #2's roommate was moved out of her room last night so she would be safe. CNA I said Resident #2's behaviors were unpredictable in that she would be walking around and then walk up to a resident and start trying to be physical towards them. CNA I said there was not a trigger causing Resident #2's behaviors that she could identify. CNA I said Resident #2 acted this way ever since she got to the facility, but her behavior was getting worse. CNA I said she had not talked to anyone in management about Resident #2's behaviors because she was told to just redirect her even though she refused the redirection. CNA I said the nurse on shift knew about Resident #2's behaviors and she thought the nurse would report everything to management. CNA I said before Resident #2 choked Resident #1, she had not harmed or hurt any other resident. Follow-up interview on 08/27/25 at 4:08 PM with CNA I revealed after Resident #2 had choked Resident #1, Resident #1 was very upset and scared. CNA I said she herself was also scared after the incident, and Resident #1 seemed very emotional afterwards asking why someone would do that to her. CNA I said she tried to calm her down and assured her she was safe. Interview on 08/27/25 at 2:37 PM with the MDS Coordinator revealed she was ultimately responsible for updating the resident's care plans, but all nurses could update them as well. The MDS Coordinator said she had not heard Resident #2 had behaviors towards others so she did not know to update her care plan to address them. The MDS Coordinator said she attended all the clinical morning meetings where staff would discuss such behaviors and then she would update the resident's care plan then. Interview on 08/27/25 at 1:10 PM with ADON G revealed she understood Resident #2 had sporadic behaviors at times, like when she went towards Resident #1 and grabbed her neck. ADON G said staff were able to separate the two residents during the incident. ADON G said they were dealing with Resident #2 because she got agitated but they thought it was because she was in a new environment since she was a newer admit and needed time to adjust. ADON G said Resident #2 had these sporadic moments where staff did not know what was going to happen, so they closely monitored her. ADON G said she was not sure if the redness and scratches to Resident #1's cheek and neck were from the incident with Resident #2 or not, because she had not seen them for herself yet. Follow-up interview on 08/27/25 at 1:41 PM with ADON G revealed she saw Resident #1 and noticed she had 4 dots, two of which were prominent but dried up and closed now. ADON G said she thought the redness to Resident #1's skin was from a scratch but she could not be sure. ADON G said Resident #2 was physically aggressive with staff before the incident with Resident #1 but she had swung towards other residents before, just never made contact with them. ADON G said Resident #2 had also pushed another resident on Monday (08/25/25) in the dining room but the resident did not sustain any injuries. ADON G said she was not sure what interventions were put in place to keep other residents safe from Resident #2's physically aggressive behaviors but she would have the Psych NP review her medications again. ADON G said she knew the Psych NP already ordered PRN Ativan gel and Seroquel to help with Resident #2's behaviors but staff reported the medications were not working. ADON G said she was going to have to meet with the IDT to see what the next steps were for Resident #2. ADON G said she also received a report that Resident #2 tried to get in her roommate's bed and move the roommate out of the bed but the CNA intervened and stopped it from happening. ADON G said right now, Resident #2 was being monitored every 15 minutes by the nurse until the facility could decide what next steps to take with her regarding her behaviors. ADON G said what happened between Residents #1 and #2 was considered physical abuse. ADON G said all residents had the right to be free from abuse. ADON G said staff were in-serviced regarding abuse as they went over who the abuse coordinator was for the facility, the types of abuse, and what to do when someone abused someone and how quickly to report abuse. Interview on 08/27/25 at 2:06 PM with the DON revealed she was told last night Resident #2 tried to choke Resident #1 but staff were able to separate the two residents. The DON said Resident #2 was placed on every 15-minute checks by the nurse and then she, herself, came to the building. The DON said Resident #2 had a roommate at the time who was moved out of the room for her safety. The DON said staff also gave Resident #2 a shower and she fought during that, which was normal behavior for her. The DON said after Resident #2 went to bed. The DON said the NP was contacted and responded a psychiatric evaluation needed to be completed. The DON said the Psych NP came today (08/27/25) to meet and evaluate Resident #2. The DON said Resident #2 was just ordered Seroquel a few days ago and had not had the chance to become effective. The DON said she looked at Resident #1 and she was upset but calmed down and sat at the nurse's station. The DON said she noticed two spots on Resident #1's neck and cheek but she was not sure if they were caused by the incident with Resident #2 or not. The DON said the two spots looked dry and scabbed over. The DON said she knew about Resident #2's behaviors because she was told on Monday the resident pushed another resident. The DON said she was told by staff Resident #2 was resistive to care and would fight with staff but never tried to attack residents. The DON said if the staff did not tell her what was happening with Resident #2, she could not fix anything or address her behaviors. The DON said sometimes she reviewed staff's charting and the 24-hour report but it was not a regular occurrence for her. The DON said the plan to address Resident #2's behaviors now were that the Psych NP was going to adjust her medications after his evaluation. The DON said she knew to help clam Resident #2 down, she liked to go outside when she was agitated so that was an intervention staff could use. The DON said Resident #2's care plan did not address her behaviors because before this incident she was not aware of them. The DON said the ADON and the MDS Coordinator were responsible for updating a resident's care plan if they knew what to update it with. The DON said the purpose of the care plan was to know what interventions should be used to address the situation or behavior. The DON said if the care plan was not updated for a resident, then staff would not know how to manage the resident's behavior and things could escalate. The DON said what happened between Residents #1 and #2 was considered physical abuse. The DON said all residents should be free from abuse. The DON said all staff were responsible for ensuring all residents were free from abuse. The DON said if residents were not free from abuse, they were at risk of potential injury, death, and being harmed. The DON said all staff were trained on the facility's policy regarding abuse, specifically going over who to report abuse to, the types of abuse, and the timeliness to report abuse. Interview on 08/27/25 at 3:15 PM with the Administrator revealed she was told by the DON Resident #2 had put her hands around Resident #1's neck. The Administrator said she and the DON got to the facility to get the statements from the nurse and CNA about what happened. The Administrator said the CNA told her she was nearby Resident #2 who walked towards Resident #1 and started grabbing her neck. The Administrator said the CNA quickly removed Resident #2's hands from Resident #1 and then separated the residents. The Administrator said Resident #2 was placed on every 15-minute checks by the nurse after everything was settled. The Administrator said the DON started an abuse in-service with staff that went over who to report abuse to, the types of abuse, and how quickly staff were supposed to report abuse. The Administrator said she did not look to see if Resident #1 had any injuries from Resident #2 or not. The Administrator said the 6 AM to 2 PM nurse, LVN B, came to the morning clinical meetings and would explain the resident got agitated with staff and she would be redirected and kept away from other residents. The Administrator said no other shift nurses reported to the clinical meetings, it was only the 6 AM to 2 PM shift nurses. The Administrator said other shift nurses reported things on the 24-hour report or would call the DON to let her know what was going on, such as if a resident began to have behaviors. The Administrator said she knew CNA's were told to redirect Resident #2 and get her involved in some type of activity, take her outside, or play some music. The Administrator said she heard Resident #2 pushed another resident a few days ago but the resident did not have any injuries from the situation. The Administrator said she was not told Resident #2 had been swinging at or trying to hit other residents. The Administrator said she could only intervene if she knew what was happening and since she did not know about Resident #2's behaviors, she could not put things in place. The Administrator said she expected staff to communicate with her when a resident showed signs of increased agitation and behaviors. The Administrator said if she knew about the extent of Resident #2's behaviors she could have taken other steps to ensure the residents' safety, such as transferring her to be evaluated. The Administrator said Resident #2's care plan was not updated either to reflect her behaviors because the management staff did not know about it. The Administrator said she was the abuse coordinator for the facility, and this situation was considered physical abuse. The Administrator said all residents had the right to be free from abuse and all staff were responsible for making sure they were. The Administrator said if residents were not free from abuse they would be harmed or have some type of trauma happen to them up to and including death. Review of the facility's policy, revised 06/24/24, and titled Abuse, Neglect and Exploitation reflected: Definitions: ‘Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #2) reviewed for care plan accuracy. The facility failed to develop and implement a care plan revised on 08/14/25 for Resident #2, which addressed her physically aggressive behaviors towards others between 08/02/25 to 08/26/25. LVN A and CNA E were able to pull Resident #2's hand away from Resident #1's neck on 08/26/2025. An IJ was identified on 08/27/25. The IJ template was provided to the facility on [DATE] at 5:18 PM. While the IJ was removed on 08/28/25, the facility remained out of compliance at a scope of pattern and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems. This failure placed residents at risk of not receiving needed services due to inaccurate comprehensive care plans. Findings included: Review of Resident #2's admission MDS Assessment, dated 07/29/25, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her BIMS score could not be conducted, but it was noted she had both short-term and long-term memory problems and could not make her own daily decisions. She was noted to not have any physical or verbal behaviors towards others, but did wander daily that intruded on the privacy or activity of others. Her active diagnoses included Alzheimer's Disease (a brain condition that gradually destroys memory and cognitive skills, interfering with daily life) and Insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep). Review of Resident #2's care plan, revised on 08/14/25, revealed it did not reflect anything regarding her aggressive behaviors. Review of Resident #2's Physician's Orders reflected the following:- Ativan Gel 0.5mg q 12 hours prn apply topically every 12 hours as needed for agitation for 14 days- Seroquel Oral Tablet 25 MG Give 1 Tablet by mouth two times a day for agitation Review of Resident #2's Treatment Administration Record reflected the following:- She was administered the Ativan Gel on the following dates: 08/14/25, 08/16/25, 08/17/25, 08/18/25, 08/19/25, 08/20/25, 08/24/25, 08/25/25, and 08/26/25. - She was noted to have behaviors on the following dates as monitored for psychoactive behaviors: 08/02/25, 08/03/25, 08/08/25, 08/09/25, 08/14/25, 08/16/25, 08/17/25, 08/20/25, 08/21/25, 08/23/25, 08/24/25, 08/25/25, and 08/26/25.- She was administered the Seroquel on the following dates: 08/25/25, 08/26/25, and 08/27/25. Review of Resident #2's Progress Notes reflected the following:- LVN B wrote on 07/25/25 at 2:57 PM: Resident follow up on new admit, resident continue pacing down the hallway, attempt to push fire alarm during this shift, resident continue to monitor [sic]- LVN C wrote on 07/27/25 at 1:39 AM: The resident woke up, and was very agitated, throwing around everything she could come across in her room. She was yelling out at the staff when they were offering incontinent care to her. She was calmed down and laid back to bed but still kept on waking up and coming out of her room, and re-direction was done appropriately.- LVN D wrote on 07/27/25 at 8:49 PM: Resident combative with incontinent care. She came out from the room and started pushing dining table and chairs. Resident able to redirect, sleeping in bed at this time. No s/s of acute distress noted. Bed in low position, call light within reach.- LVN C wrote on 07/28/25 at 2:14 AM: The resident woke up and was banging stuff in her room and bathroom. Staff redirected her back to bed, but she was combative, and yelling. She was brought to the dining room via wheelchair but kept standing up and pushing the tables and chairs around. She wandered through the hallway back and forth. She was redirected back to her room and agreed to lay back in bed. Right now, she is resting in bed eyes closed.- LVN B wrote on 08/07/25 at 8:47 AM: Resident going all other [sic] resident room [sic] attempting to pull them from the bed staffs [sic] continue redirecting the resident.- LVN A wrote on 08/08/25 at 1:01 AM: Resident is combative, non-compliant to care, yelling and destroying anything within her reach. Resident refused to sleep, attempting to pull roommate from the bed. All efforts to redirect resident is ineffective. NP and DON notified.- LVN C wrote on 08/10/25 at 6:29 AM: The resident pacing [sic] in the hallway entering into other patients' rooms and banging doors and throwing everything she comes across. At the dining room at the moment, throwing chairs all over and moving tables around.- LVN A wrote on 08/26/25 at 9:40 PM: Resident noted with aggressive behavior. She was seen by the CNA putting her hand around another resident's neck (Resident #1) in the dining room. Nurse and CNA immediately ran towards them and intervened. Resident was fighting and kicking staff while being redirected. PRN Ativan gel was applied with little effect. Resident also tried to pull her roommate from the bed earlier today per therapist. NP and DON notified. Resident's RP informed. Resident is currently on Q 15 mins checks for behavior. she [sic] is lying in bed in the room no behavior [sic] noted at this time.- LVN C wrote on 08/27/25 at 1:10 AM: The resident is on aggressive behavior monitoring q 15 minutes. Resident is in bed at the moment sleeping.- LVN C wrote on 08/27/25 at 5:15 AM: The resident woke up and started throwing stuff in her room. The nursing staff tried to redirect and offer incontinent care, but the resident was extremely aggressive/combative. The staff left the room. The resident kept yelling from her room. Review of Resident #2's Psychiatric Initial Assessment, dated 07/30/25, reflected the following: .Patient referred for medical management services for sx including Agitation, Adjustment Disorder, Noncompliance, Verbal Aggression, Physical Aggression. Patient made eye contact with provider when approached, but was unable to appropriately participate/interact. Staff report frequent periods of anxiousness/restlessness and difficulty with redirection being exhibited by patient.At this time, recommend increasing frequency of Ativan to 0.5 mg/TID per frequent symptoms of anxiety and difficulty with redirection. Review of Resident #2's Psychiatric Subsequent Assessment, dated 08/06/25, reflected the following: .During previous visit, Ativan frequency increased to TID due to reported periods of agitation and behavioral concerns. Staff states agitation decreased but continues during periods of care. Staff also report patient frequently pacing throughout secured unit and wandering into other residents rooms. Staff reports patient being aggressive and difficult to calm/redirect.At this time, due to reported continued periods of agitation and aggression during periods of care, recommend initiation of Ativan gel 0.5 mg/Q12 HR PRN X 14 days for acute agitation/aggressive behavior. Review of Resident #2's Psychiatric Subsequent Assessment, dated 08/20/25, reflected the following: .Staff reports continued behavioral concerns being exhibited by patient. Per ADON, patient reported to have ‘taken the tank off of her toilet and breaking it, as well as tearing soap dispensers off the wall.' Nursing staff within secured unit report patient often ‘easily agitated and physically aggressive. Staff states patient will attempt to hit staff during attempted periods of care. When attempting to initiate assessment, patient was found leaning over another resident within secured unit, whom was sitting on her wheelchair, and pushing her down the hall.'.At this time, due to reported symptoms of disorganized/delusional thoughts reported, Recommend [sic] initiation of Seroquel 25 mg/BID. Review of Resident #2's Psychiatric Subsequent Assessment, dated 08/27/25, reflected the following: .During previous visit, Seroquel 25 mg/BID order recommended.Staff states the day prior to exam, patient exhibited ongoing physically aggressive behaviors and ‘Choked [sic] another resident.' Per note in [EHR], on 8/26, patient was observed by the CNA ‘putting her hand around another resident's neck' in the dining room of the secured unit. During attempted intervention by nurse and CNA, patient was ‘fighting and kicking staff' during attempted redirection. Resident was placed on Q15 min safety checks, and staff denied observing physically aggressive behaviors being exhibited prior to today's assessment.Due to minimal symptom relief with currently ordered Ativan, recommend discontinuation of Ativan and initiation of clonazepam 0.5 mg/TID with consent from POA. Observation and attempted interview on 08/27/25 at 10:35 AM with Resident #2 revealed she was sitting in a chair in the dining room mumbling to herself. Resident #2 did not look the surveyor's way or at the surveyor until the surveyor continued trying to talk to her. Resident #2 appeared calm but was not able to answer any questions. Review of Resident #1's Quarterly MDS Assessment, dated 05/02/25, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her BIMS score was 05, indicating severe cognitive impairment. Her MDS indicated she did not have any physical or verbal behaviors towards others. Her active diagnoses included Alzheimer's Disease (a brain condition that gradually destroys memory and cognitive skills, interfering with daily life) and Depression (a mood disorder that causes persistent sadness and changes in how you think, sleep, eat, and act). Review of Resident #1's care plan, revised 11/17/24, reflected: Focus: The resident is/has potential to be physically/verbally aggressive and resistive to care r/t Dementia.Interventions/Tasks: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Review of Resident #1's Progress Notes reflected the following:- LVN A wrote on 08/26/25 at 7:48 PM: The resident was attacked by an aggressive resident in the dining room. The aggressive resident was seen by the CNA putting her hand around the resident's neck (Resident #1) in the dining room. Nurse and CNA immediately ran towards them and intervened. Upon assessment, no injury noted. resident [sic] denies pain. Resident was redirected and taken to another seat away from the aggressive resident. NP and DON notified. Review of Resident #1's skin assessment, dated 08/27/25, reflected she had redness and an open spot on the right side of her neck and redness/spot to her right cheek. Observation and interview on 08/27/25 at 10:40 AM with Resident #1 revealed she was sitting in a chair in the dining room. Resident #1 said she was doing great today. Resident #1 was observed to have redness to the right side of her neck that appeared to be a bruise that was about two inches long and an inch wide with a small open area. Resident #1 also appeared to have a small scratch to the right side of her cheek on her jawline that was also reddened. Resident #1 said she did not know what happened to her cheek or neck but it did not bother her. Interview on 08/27/25 at 10:23 AM with LVN B revealed she got report from the night nurse this morning that Resident #2 attacked or scratched Resident #1 yesterday. LVN B said Resident #1 had some redness to her neck that looked like it was a scratch but she was not sure if it was from the incident with Resident #2 or not. LVN B said Resident #2 had wandered a lot around the unit and was a difficult resident to handle. LVN B said Resident #2 would get mad and yell and be agitated for no reason. LVN B said staff were monitoring Resident #2 every 15 minutes right now by just keeping an eye on her. LVN B said Resident #2 tried to touch other residents but staff usually intervened before anything could happen because if anyone was near her anything could set her off. LVN B said when Resident #2 started to show agitation, staff would try to calm her down by singing with her, taking her for a walk outside, or getting her something to eat or drink. LVN B said Resident #2's behaviors were unpredictable and there was no trigger for it. LVN B said she was not sure if she had been trained on what to do specifically with Resident #2 in order to decrease her behaviors or reduce her agitation. LVN B said she had never seen Resident #2 be physically aggressive with another resident during her shift. Follow-up interview on 08/27/25 at 10:40 AM with LVN B revealed she saw Resident #1's reddened areas to her neck and cheek but could not recall if they were there yesterday or not. LVN B said she did not pay much attention to Resident #1 yesterday so she was not sure if the reddened areas were a result of the incident with Resident #2 or not. Phone interview on 08/27/25 at 11:04 AM with CNA D, who worked with Residents #1 and #2 on 08/26/25, was unsuccessful as she did not answer or call back prior to exit. Phone interview on 08/27/25 at 11:05 AM with LVN C, who worked with Residents #1 and #2 on 08/26/25, was unsuccessful as she did not answer or call back prior to exit. Phone interview on 08/27/25 at 11:08 AM with LVN A revealed she was at the nurses' station when she heard CNA E yelling, She's about to choke the resident. LVN A said she and CNA E ran towards Residents #1 and #2 and when they got to them, Resident #2's hand was round Resident #1's neck. LVN A said her and CNA E were able to pull Resident #2's hand away from Resident #1's neck, but Resident #2 continued to fight staff while trying to redirect her. LVN A said that when she assessed Resident #1 she saw there was a reddened and opened areas to her neck and cheek but she did not think that was related to the incident, but that it was a rash. LVN A said that Resident #2 had physically aggressive behaviors such as she pushed another resident in the dining room on Monday, which was reported to the Abuse Coordinator but the resident did not sustain any injuries. LVN A said she communicated with the Psych NP about Resident #2's behaviors and PRN Ativan gel was added to her orders. LVN A said Resident #2 became agitated and unable to be redirected, she would apply the gel. Follow-up interview on 08/27/25 at 3:03 PM with LVN A revealed she did not check Resident #1's skin prior to the incident and did not know if it was due to the incident or a rash. LVN A said she only noticed the rash after the incident because she had to do a skin assessment. LVN A was unable to say how long Resident #1 had the rash to her skin and could not describe what it looked like. LVN A said that Resident #2 had been having an increase in her agitation and physical behaviors. LVN A said when Resident #2 first came to the facility, she was flinging chairs and tables around the dining room. LVN A said she reported this to the NP who ordered new medications but Resident #2's behaviors did not change. LVN A said that was when the NP ordered the PRN Ativan gel but it did not work either. LVN A said she did communicate with the DON when she saw Resident #2 become physically aggressive with other residents. LVN A showed a text message exchange between her and the DON from 08/08/25 discussing Resident #2's agitation and physically aggressive behaviors regarding resisting care and destroying anything within her reach. LVN A said she knew to report any incident to the DON immediately that concerned residents. Phone interview on 08/27/25 at 11:21 AM with CNA E revealed Resident #2 was very aggressive last night and very agitated. CNA E said Resident #2 was trying to pull the table and chairs in the dining room. CNA E said she tried to move closer to Resident #2 and get her to calm down by talking to her but the resident refused. CNA E said she also tried redirecting her but again, Resident #2 refused. CNA E said when she moved closer to Resident #2, Resident #2 moved close to Resident #1 and grabbed her neck choking her. CNA E said she rushed towards the residents and tried to separate them and pull Resident #2's hands off Resident #1's neck. CNA E said this behavior was normal for Resident #2 because she was always agitated and aggressive. CNA E said when Resident #2 became agitated she would try to calm her down, move close to her, and talk to her. CNA E said Resident #2 was very strong and would fight staff during care and drag staff to the ground because she was so strong. CNA E said staff would have to act fast to be near her to make sure she did not harm other residents. CNA E said she did everything she could to try and keep Resident #2 from hurting others but nothing seemed to work. Follow-up interview on 08/27/25 at 2:42 PM with CNA E revealed Resident #2 had physically aggressive behaviors towards others ever since she arrived to the facility. CNA E said especially the last few days, Resident #2 had been showing signs of agitation and aggression. CNA E said Resident #2 pushed another resident in the dining room the other day and then had choked Resident #1 last night while she was upset. CNA E said Resident #2 would get upset and staff had to calm her down. CNA E said staff had to be alert and watch Resident #2 closely when she became agitated because when she got angry she was very strong in trying to push tables, chairs, and throw things. CNA E said staff would redirect her during these behaviors but the redirection did not work and Resident #2 would continue her behaviors. CNA E said when these behaviors occurred, she would tell the nurse and assumed the nurse would let the ADON/DON know. CNA E said she had not been trained on anything specific to do with Resident #2 regarding her behaviors. Interview on 08/27/25 at 11:43 AM with CNA F revealed she cared for Resident #1 yesterday and did not see any redness or scratches to her cheek or neck. CNA F said when she came to work this morning, she heard that a fight happened between Residents #1 and #2. CNA F said she figured the scratches and redness to Resident #1's cheek and neck happened from the incident with Resident #2. CNA F said that since the incident happened, the nurse was monitoring Resident #2 every 15 minutes, but she was not informed to do anything different regarding Resident #2. CNA F said Resident #2 had been calm this morning but did start to yell and after going to her side and talking to her, the resident calmed down. CNA F said Resident #2 was always agitated, wild, and out of control. CNA F said when Resident #2 got that way staff tried to calm her down by giving her something to drink or taking her somewhere else to calm down. CNA F said sometimes those interventions helped Resident #2 to calm down, and sometimes they did not. CNA F said when redirection did not work, they would leave Resident #2 alone and just monitor her closely because she would try to go to other resident's rooms. CNA F said one day she saw Resident #2 trying to get into her roommate's bed and was trying to get the roommate out of the bed. CNA F said she rushed into the room to stop Resident #2 from hurting the roommate and nothing happened. Interview on 08/27/25 at 1:24 PM with CNA H revealed she had only been working at the facility for a month but knew Resident #2 was easily agitated. CNA H said she had never seen Resident #2 be physically aggressive with another resident. CNA H said she knew to follow closely behind Resident #2 and make sure she was safe and not going to hurt anyone because she wandered around a lot. CNA H said Resident #2 was on every 15-minute checks right now because of what happened. CNA H said if she saw any resident trying to hurt another resident she would separate them and call for the nurse. CNA H said she knew when Resident #2 got upset, staff needed to help calm her down by offering her something to drink or eat. Interview on 08/27/25 at 2:49 PM with CNA I revealed Resident #2 was very erratic at times and when she got that way she would try to hurt other residents and staff. CNA I said staff would try to redirect Resident #2 to calm her down but it did not work because she did not want to be redirected. CNA I said last night specifically, Resident #2 was very upset and was behaving so badly that she was sitting at a table trying to push it away and knock residents out of their wheelchairs while hitting and swinging at them. CNA I said Resident #2 put her hands around Resident #1's neck to choke her. CNA I said when she saw Resident #1 before the incident, she did not have any marks on her cheek or neck but after the incident, Resident #1 had red spots on her cheek and neck. CNA I said Resident #2 also had a habit of wanting to get in her roommate's bed even while the resident was in the bed and if staff tried to stop her she would get more upset. CNA I said Resident #2's roommate was moved out of her room last night so that she would be safe. CNA I said Resident #2's behaviors were unpredictable in that she would be walking around and then walk up to a resident and start trying to be physical towards them. CNA I said there was not a trigger causing Resident #2's behaviors that she could identify. CNA I said Resident #2 had acted this way ever since she got to the facility, but her behavior was getting worse. CNA I said she had not talked to anyone in management about Resident #2's behaviors because she was told to just redirect her even though she refused the redirection. CNA I said the nurse on shift knew about Resident #2's behaviors and she thought the nurse would report everything to management. CNA I said before Resident #2 choked Resident #1, she had not harmed or hurt any other resident. Follow-up interview on 08/27/25 at 4:08 PM with CNA I revealed after Resident #2 had choked Resident #1, Resident #1 was very upset and scared. CNA I said she herself was also scared after the incident, and Resident #1 seemed very emotional afterwards asking why someone would do that to her. CNA I said she tried to calm her down and assure her she was safe. Interview on 08/27/25 at 2:37 PM with the MDS Coordinator revealed she was ultimately responsible for updating resident's care plans, but all nurses could update them as well. The MDS Coordinator said she had not heard that Resident #2 had behaviors towards others so she did not know to update her care plan to address them. The MDS Coordinator said she attended all the clinical morning meetings where staff would discuss such behaviors and then she would update the resident's care plan then. Interview on 08/27/25 at 1:10 PM with ADON G revealed she understood that Resident #2 had sporadic behaviors at times, like when she went towards Resident #1 and grabbed her neck. ADON G said staff were able to separate the two residents during the incident. ADON G said they have been dealing with Resident #2 because she gets agitated but they thought it was because she was in a new environment since she was a newer admit and needed time to adjust. ADON G said Resident #2 has these sporadic moments where staff did not know what was going to happen so they closely monitored her. ADON G said she was not sure if the redness and scratches to Resident #1's cheek and neck were from the incident with Resident #2 or not because she had not seen them for herself yet. Follow-up interview on 08/27/25 at 1:41 PM with ADON G revealed she saw Resident #1 and noticed she had 4 dots, 2 of which were prominent but dried up and closed now. ADON G said she thought the redness to Resident #1's skin was from a scratch but she could not be sure. ADON G said Resident #2 had been physically aggressive with staff before the incident with Resident #1 but she had swung towards other residents before, just never made contact with them. ADON G said Resident #2 had also pushed another resident on Monday (08/25/25) in the dining room but that resident did not sustain any injuries. ADON G said she was not sure what interventions were put in place to keep other residents safe from Resident #2's physically aggressive behaviors but she would have the Psych NP review her medications again. ADON G said she knew the Psych NP already ordered PRN Ativan gel and Seroquel to help with Resident #2's behaviors but staff were reporting that the medications were not working. ADON G said she was going to have to meet with the IDT to see what the next steps were for Resident #2. ADON G said she also received a report that Resident #2 tried to get in her roommate's bed and move the roommate out of the bed but the CNA intervened and stopped it from happening. ADON G said right now, Resident #2 was being monitored every 15 minutes by the nurse until the facility could decide what next steps to take with her regarding her behaviors. ADON G said what happened between Residents #1 and #2 was considered physical abuse. ADON G said that all residents had the right to be free from abuse. ADON G said that staff had been in-serviced regarding abuse as they went over who the AC was for the facility, the types of abuse, and what to do when someone abuses someone and how quickly to report abuse. ADON G said she did Interview on 08/27/25 at 2:06 PM with the DON revealed she was told last night that Resident #2 had tried to choke Resident #1 but staff were able to separate the two residents. The DON said Resident #2 was placed on every 15-minute checks by the nurse and then she herself came to the building. The DON said Resident #2 had a roommate at the time who was moved out of the room for her safety. The DON said staff also gave Resident #2 a shower and she fought during that which was normal behavior for her. The DON said after that Resident #2 went to bed. The DON said the NP was contacted and responded that a psychiatric evaluation needed to be completed. The DON said the Psych NP came today (08/27/25) to meet and evaluate Resident #2. The DON said Resident #2 was just ordered Seroquel a few days ago and had not had the chance to become effective. The DON said she looked at Resident #1 while she was here and she was upset but calmed down and sat at the nurse's station. The DON said she noticed two spots on Resident #1's neck and cheek but she was not sure if they were caused by the incident with Resident #2 or not. The DON said the two spots looked dry and scabbed over. The DON said she knew about Resident #2's behaviors because she was told on Monday that the resident had pushed another resident. The DON said she was told by staff that Resident #2 was resistive to care and would fight with staff but never tried to attack residents. The DON said if the staff did not tell her what was happening with Resident #2, she could not fix anything or address her behaviors. The DON said sometimes she reviewed staff's charting and the 24-hour report but it was not a regular occurrence for her. The DON said the plan to address Resident #2's behaviors now were that the Psych NP was going to adjust her medications after his evaluation. The DON said she knew to help clam Resident #2 down, she liked to go outside when she was agitated so that was an intervention staff could use. The DON said Resident #2's care plan did not address her behaviors because before this incident she was not aware of them. The DON said the ADON and the MDS Coordinator were responsible for updating a resident's care plan if they knew what to update it with. The DON said the purpose of the care plan was to know what interventions should be used to address the situation or behavior. The DON said if the care plan was not updated for a resident, then staff would not know how to manage the resident's behavior and things could escalate. The DON said what happened between Residents #1 and #2 was considered physical abuse. The DON said all residents should be free from abuse. The DON said all staff were responsible for ensuring all residents were free from abuse. The DON said if residents were not free from abuse, they were at risk of potential injury, death, and being harmed. The DON said all staff had been trained on the facility's policy regarding abuse, specifically going over who to report abuse to, the types of abuse, and the timeliness to report abuse. Interview on 08/27/25 at 3:15 PM with the Administrator revealed she was told by the DON that Resident #2 had put her hands around Resident #1's neck. The Administrator said she and the DON got to the facility to get the statements from the nurse and CNA about what happened. The Administrator said the CNA told her that she was nearby Resident #2 who walked towards Resident #1 and started grabbing her neck. The Administrator said the CNA had quickly removed Resident #2's hands from Resident #1 and then separated the residents. The Administrator said Resident #2 was placed on every 15-minute checks by the nurse after everything was settled. The Administrator said the DON started an abuse in-service with staff that went over who to report abuse to, the types of abuse, and how quickly staff were supposed to report abuse. The Administrator said she did not look to see if Resident #1 had any injuries from Resident #2 or not. The Administrator said the 6 AM to 2 PM nurse, LVN B, came to the morning clinical meetings and would explain that she got agitated with staff and she would be redirected and kept away from other residents. The Administrator said no other shift nurses reported to the clinical meetings, it was only the 6 AM to 2 PM shift nurses. The Administrator said other shift nurses reported things on the 24-hour report or would call the DON to let her know what was going on, such as if a resident began to have behaviors. The Administrator said she knew CNA's were told to redirect Resident #2 and get her involved in some type of activity, take her outside, or play some music. The Administrator said she heard that Resident #2 had pushed another resident a few days ago but that resident did not have any injuries from the situation. The Administrator said she had not been told that Resident #2 had been swinging at or trying to hit other residents. The Administrator said she could only intervene if she knew what was happening and since she did not know about Resident #2's behaviors, she could not put things in place. The Administrator said she expected staff to communicate with her when a resident showed signs of increased agitation and behaviors. The Administrator said if she knew about the extent of Resident #2's behaviors she could have taken other steps to ensure the residents' safety, such as transferring her to be evaluated. The Administrator said Resident #2's care plan was not updated either to reflect her behaviors because the management staff did not know about it. The Administrator said she was the abuse coordinator for the facility, and this situation was considered physical abuse. The Administrator said all residents had the right to be free from abuse and all staff were responsible for making sure they were. The Administrator said if residents were not free from abuse they would be harmed or have some type of trauma happen to them up to and including death. Phone interview on 08/28/25 at 9:32 AM with the Psych NP revealed Resident #2 was physically aggressive during moments of agitation and was difficult to redirect. The Psych NP said staff had been communicating with him about the increase in her behaviors and he had added orders for a PRN Ativan gel and Seroquel more recently. The Psych NP said he noticed during his meetings with her that she was uncooperative, non-compliant, and had disorganized speech and he was not sure what was causing all of these behaviors. The Psych NP said staff also explained to him how difficult Resident #2 was to manage and control, that she had taken off the tank to the toilet and the soap dispensers from the walls, she was wheeling another resident down the hall in her wheelchair in an aggressive manner, and now she had choked another resident. The Psych NP said Resident #2's behaviors were quite frequent and often from what he had witnessed and was told. The Psych NP said from what he was told and understood, staff were trying to minimize her behaviors the be

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when CNA B transferred her roughly from bed to a geri-chair and then slapped her hand when she attempted to hold onto the bed on 08/31/24. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 08/31/24 and ended on 09/03/24. The facility had corrected the noncompliance before the investigation began. This failure placed residents at risk of abuse, trauma, and psychosocial harm. Findings included: Review of Resident #1's admission Record, dated 10/31/24, reflected the resident was a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #1's Quarterly MDS Assessment, dated 07/04/24, reflected there was not a BIMS score calculated. Further review reflected a Staff Assessment for Mental Status was completed which revealed Resident #1 had a memory problem resulting in inattention and an altered level of consciousness. For the section regarding Functional Abilities and Goals reflected Resident #1 required substantial/maximal assistance with rolling left and right, lying to sitting on side of bed, and chair/bed-to-chair transfer which meant that the helper did more than half of the effort. The same section reflected Resident #1 used a manual wheelchair. Review of Resident #1's Annual MDS Assessment, dated 10/04/24, reflected for her Functional Abilities section, Resident #1 was dependent with rolling left and right and chair/bed-to-chair transfer meaning the helper did all the effort or the assistance of 2 or more helpers was required to complete the activity. Resident #1 had active diagnoses of Non-Alzheimer's Dementia (a neurodegenerative disease that starts slowly and progressively worsens), Seizure Disorder or Epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), and Senile Degeneration of Brain (a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform everyday activities). Review of Resident #1's progress notes reflected the following: - On 09/03/24 at 5:27 AM the DON wrote: Notified by POA that patient was the recipient of physical aggression from staff. Noted that resident was handled roughly during transfer from bed to Geri-chair and subsequently was slapped on the hand when being moved in Geri chair. No injury noted to resident at time of notification. - On 09/03/24 at 2:33 PM the DON wrote: Patient needs stat x-ray of c-spine, back, left shoulder, arm, right wrist/forearm to rule out fracture. Patient is unable to sit upright for extended periods of time independently, is unable to use right arm. - On 09/04/24 at 6:13 AM RN A wrote: The X-ray in the previous shift was done during the shift, no evidence of fractures, results sent to Dr [Physician C], she denied pain at this time, no new complaint from her, will continue with the plan of care. - On 09/05/24 at 2:00 PM the DON wrote: Resident noted to be up in Geri chair. No adverse effects noted at this time related to occurrence that happened on 8/31/24. No skin issues noted/reported at this time. Resident remains at baseline. Review of Resident #1's care plan reflected the following: - Focus: Resident has an allegation of (Abuse), Date Initiated: 09/03/2024; Goal: Resident will not experience a negative outcome from alleged event through this review period; Interventions/Tasks: Any negative event will be reported to the abuse coordinator immediately. The facility will adhere to the abuse and neglect policies and protocols. - Focus: Resident requires a mechanical lift transfer(Hoyer) r/t (inability to bear weight) 2 person assist. Date Initiated: 09/03/2024; Goal: Resident will be provided a safe transfer utilizing a mechanical lift(Hoyer)throughout the review period.; Interventions/Tasks: 1. Resident has been identified as totally dependent for transfers. 2. Lifting equipment will be operated in accordance with instruction and training. 5. Report change in conditions which may necessitate a re-evaluation of the resident and the lift. [sic] - Focus: [Resident #1] has a communication problem r/t Dementia, non-verbal .Interventions/Tasks: Ensure/provide a safe environment. Observation of the first video provided by Resident #1's POA on 10/30/24 at 8:22 AM revealed the following: The video was time stamped and dated for 08/31/24 at 6:58 AM; the video did not include any sound. The video began and Resident #1 was in bed. There was a geri-chair at the foot of the bed and CNA B began pushing the geri-chair to the side of the bed. CNA B locked the left side of the geri-chair from the back and then walked in front of the geri-chair and pulled it closer to the bed. CNA B turned to Resident #1 and pulled her legs over the side of the bed and used his left arm to raise her up. CNA B used his right hand to reposition Resident #1's knees. Resident #1 had her arms crossed on her chest and CNA B uncrossed the resident's arms to put his underneath hers to lift her up and transfer her to the geri-chair. The geri-chair began to move backwards and CNA B used his left arm to hold the geri-chair while he used his right arm to hold Resident #1 up. CNA B placed Resident #1 on her back on the geri-chair seat portion, grabbed her left leg to raise it with his right hand while his left hand went under her left arm to pull her up towards him and into the chair, but the chair began to again move backwards. CNA B put Resident #1 back in the bed and rolled her over onto the bed, pulled the geri-chair closer to the side of the bed and locked the right side of the geri-chair from the back. CNA B walked to the front of the geri-chair and to the side of Resident #1's bed where she was still lying there. CNA B turned Resident #1 over and put his right arm underneath her bent legs and used his left arm to hold her by her neck to transfer her to the geri-chair. CNA B put Resident #1 in the geri-chair perpendicular where her head and legs were on the armrests of the chair. The video ended. Observation of the second video provided by Resident #1's POA on 10/30/24 at 8:22 AM revealed the following: The video was time stamped and dated for 08/31/24 at 7:09 AM; the video did not include any sound. The video began and Resident #1 was in the geri-chair, her bed was made, and she had a blanket covering her. CNA B had a trash bag in his hand, and he grabbed something (unable to determine what it was) from Resident #1's recliner in the corner and walked behind the geri-chair and set the item down out of the camera's view. CNA B then started to pull Resident #1's geri-chair backwards with his right hand while he still had the trash bag in his left hand. Resident #1's arms and hands were underneath the blanket but could be seen on the armrests. While being wheeled backwards, Resident #1 grabs the edge of the bed when CNA B forcefully takes her arm and placed it on her lap. CNA B then smacked Resident #1's arm from on top of the blanket. Resident #1 moved her arm back to the armrest and was wheeled out of the room away from the camera's view. The video ended. Observation on 10/31/24 at 9:45 AM of Resident #1 revealed she was in a common area lying in a geri-chair. The resident was dressed and groomed. Resident #1 had her eyes closed, and she did not awaken or respond when spoken to. Resident #1 was wearing a long-sleeved shirt but did not appear to have any bruises, injuries, or pain. Observation on 10/31/24 at 12:30 PM of Resident #1 revealed she was in the dining room with her POA being assisted to eat lunch. Resident #1 was still in her geri-chair and was falling asleep during the meal. Resident #1 was not able to answer any questions or acknowledge the surveyor's presence due to her cognitive condition. Telephone interview on 10/28/24 at 12:13 PM with Resident #1's POA revealed she showed the Administrator, who was the Abuse Coordinator, a video of Resident #1 being abused by CNA B from 08/31/24. Resident #1's POA said she showed the Administrator the video on 09/03/24. Resident #1's POA said after seeing the video, the Administrator called the police and the facility terminated CNA B. Resident #1's POA said the facility took x-rays and followed up to check on Resident #1. Resident #1's POA said Resident #1 does not have the ability to show any emotion or pain and did not have any bruises or injuries from the situation. Telephone interview on on 10/31/24 at 12:48 PM with CNA B revealed he remembered caring for Resident #1, but that it was some time ago. CNA B said he was trying to transfer Resident #1 to her geri-chair one day when she was holding onto him. CNA B said he had to take Resident #1's hand off of him while still holding onto her during the transfer. CNA B said he had locked the chair but what happened during the transfer was that Resident #1 was very heavy and he could not hold her up for the transfer. CNA B said he did not use a gait belt to transfer Resident #1. CNA B said he did not slap Resident #1's hand or arm at any point and had transferred her appropriately. CNA B said he was terminated from the facility. Observation on 10/31/24 at 1:13 PM of revealed CNA F and RA Z transferred Resident #1 using a Hoyer lift from her geri-chair to her bed, and the transfer was completed safely and using proper technique. Interview on 10/31/24 at 2:37 PM with the ADON revealed he saw the video provided by Resident #1's POA which showed CNA B had transferred Resident #1 to the geri-chair. The ADON said the video then showed CNA B pulling the geri-chair backwards when Resident #1 grabbed the end of the bed and CNA B smacked her hand. The ADON said at the time of the video, Resident #1 was a one-person transfer using a gait belt and now was a hoyer lift transfer requiring at least two people. The ADON said CNA B was not appropriate in the type of care he provided Resident #1, and it was considered abuse which should never occur. The ADON said Resident #1 was assessed and she did not have any injuries or bruises from the incident. The ADON said safe surveys were completed for other residents to make sure they had not suffered any injuries either. The ADON said the facility decided to terminate CNA B immediately based on what they saw in the video. The ADON said the facility also began in-servicing staff immediately on abuse and neglect. The ADON said the facility also began checking on Resident #1 and ensuring staff were doing what they were supposed to regarding her care to monitor the situation. Interview on 10/31/24 at 2:53 PM with the Administrator revealed he got a call from Resident #1's POA, who said she had a video she wanted to show him on 09/03/24. The Administrator said he was concerned with what he saw on the videos. The Administrator said he saw CNA B trying to transfer Resident #1 by picking her up and putting her into the chair instead of using a gait belt to transfer her. The Administrator said the video showed CNA B trying to get Resident #1 to the chair without the amount of help that was needed to complete the transfer safely. The Administrator said the video also showed that when CNA B was pulling Resident #1 out of the room, she grabbed onto things to prevent herself from moving and he grabbed her hand off the bed and swatted at her wrist. The Administrator said after reviewing the videos he immediately reported the incident and terminated CNA B. The Administrator said the facility did extensive training on abuse with staff to try and prevent this incident from happening again. The Administrator said a head-to-toe assessment was also completed on Resident #1 which revealed no bruising or marks of any kind to her body. The Administrator said multiple x-rays were completed on Resident #1 as well which all came back negative for any injuries. The Administrator said safety rounds with other residents were also completed to see if anyone else in the building had been abused by CNA B, which none were. The Administrator said abuse of residents was not tolerated in the facility and would never be. The Administrator said the techniques of CNA B's transfer were so poor which ended up meaning he provided rough care and a rough transfer. The Administrator said all staff were responsible for ensuring all residents were free from any abuse. The Administrator said each resident had the right to be free from abuse in the facility. The Administrator said if residents were abused that could cause psychological or physical harm to them. The Administrator said CNA B was not following the facility's abuse policy based on what he saw in the videos. Record review of the facility's Provider Investigation Report, dated 09/10/24, reflected the following: - Investigation Summary: Administrator approached by [Resident #1's POA] regarding a video she recorded in resident room. On video it showed [CNA B] trying to transfer resident to geri-chair. It shows CNA struggling to get her into the chair, holding resident under her arms and then back to the bed in the same way. It then shows him trying to pick her up under her knees and behind her back to get her to chair, hitting her back on the arm rests, then pulling on her arms to pull her up. Upon leaving the room, the resident holds onto the bed. The CNA removes her hand from the bed, then swats at her hand. Provider completed provider response as outlined above. All xrays and head to toe assessments came back negative. All safe surveys came back with no other abuse present. Facility completed all in-service and competencies. CNA was terminated immediately, board notified, police called. - Investigation Findings: Confirmed Record review of undated safe surveys completed with residents revealed 33 residents were interviewed and no concerns were noted regarding care provided by CNA B. Record review of CNA B's personnel file included a disciplinary action form, dated 09/03/24, which reflected he was terminated due to an allegation of abuse that was founded on a video. Record review of an in-service, dated 09/03/24, reflected staff had been trained regarding Customer Service and that all residents [were] to be treated with dignity and respect. Record review of an in-service, dated 09/03/24, reflected staff had been trained regarding Safe Handling and Transfers and that Hoyer lift requires 2 people, All transfers require use of gait belt, 2 person assist equals 2 person assist .if in doubt how to transfer ask for clarification .gait belts [sic]. Record review of an in-service, dated 09/03/24, reflected staff had been trained regarding Abuse and Neglect that covered the Abuse Coordinator, Time to Report, What to Report, and Abuse versus Neglect. Interview on 10/31/24 at 11:37 AM with CNA C revealed he knew the facility's abuse policy and that hitting a resident or providing rough care to a resident would be considered abuse. CNA C said he had been trained on how to properly transfer a resident. Interview on 10/31/24 at 1:32 PM with RN D revealed she knew the facility's abuse policy and that hitting a resident or providing rough care to a resident would be considered abuse. RN D said she had been trained on how to properly transfer a resident. Record review of the facility's Abuse, Neglect and Exploitation policy, dated 01/01/23, reflected: Definitions: 'Abuse' means the willful infliction of injury .with resulting physical harm, pain or mental anguish, which can include staff to resident abuse .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .'Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .'Physical Abuse' includes, but is not limited to hitting, slapping, punching, biting, and kicking .VI. Protection of Resident, The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. The Administrator was notified on 10/31/24 at 4:52 PM, that a past non-compliance IJ situation had been identified due to the above failures. It was determined this failure placed Resident #1 in an IJ situation on 08/31/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and supervision. CNA B failed to use a gait-belt to transfer Resident #1 from the bed to a geri-chair on 08/31/24 resulting in rough care during the transfer. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 08/31/24 and ended on 09/03/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for neglect, harm, pain, and injuries. Findings included: Record review of Resident #1's admission Record, dated 10/31/24, reflected the resident was a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's Quarterly MDS Assessment, dated 07/04/24, reflected there was not a BIMS score calculated. Further review reflected a Staff Assessment for Mental Status was completed which revealed Resident #1 had a memory problem resulting in inattention and an altered level of consciousness. For the section regarding Functional Abilities and Goals reflected Resident #1 required substantial/maximal assistance with rolling left and right, lying to sitting on side of bed, and chair/bed-to-chair transfer which meant that the helper did more than half of the effort. The same section reflected Resident #1 used a manual wheelchair. Record review of Resident #1's Annual MDS Assessment, dated 10/04/24, reflected for her Functional Abilities section, Resident #1 was dependent with rolling left and right and chair/bed-to-chair transfer meaning the helper did all the effort or the assistance of 2 or more helpers was required to complete the activity. Resident #1 had active diagnoses of Non-Alzheimer's Dementia (a neurodegenerative disease that starts slowly and progressively worsens), Seizure Disorder or Epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), and Senile Degeneration of Brain (a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform everyday activities). Record review of Resident #1's progress notes reflected the following: -On 09/03/24 at 05:27 (5:27 AM) the DON wrote: Notified by POA that patient was the recipient of physical aggression from staff. Noted that resident was handled roughly during transfer from bed to Geri-chair and subsequently was slapped on the hand when being moved in Geri chair. No injury noted to resident at time of notification. Record review of Resident #1's care plan reflected the following: -Focus: Resident has an allegation of (Abuse), Date Initiated: 09/03/2024; Goal: Resident will not experience a negative outcome from alleged event through this review period; Interventions/Tasks: Any negative event will be reported to the abuse coordinator immediately. The facility will adhere to the abuse and neglect policies and protocols. -Focus: Resident requires a mechanical lift transfer(Hoyer) r/t (inability to bear weight) 2 person assist. Date Initiated: 09/03/2024; Goal: Resident will be provided a safe transfer utilizing a mechanical lift(Hoyer)throughout the review period.; Interventions/Tasks: 1. Resident has been identified as totally dependent for transfers. 2. Lifting equipment will be operated in accordance with instruction and training. 5. Report change in conditions which may necessitate a re-evaluation of the resident and the lift. [sic] -Focus: [Resident #1] has a communication problem r/t Dementia, non-verbal .Interventions/Tasks: Ensure/provide a safe environment. Telephone interview on 10/28/24 at 12:13 PM with Resident #1's POA revealed she showed the Administrator, who was the Abuse Coordinator, a video of Resident #1 being abused by CNA B from 08/31/24. Resident #1's POA said after seeing the video, the Administrator called the police and the facility terminated CNA B. Resident #1's POA said the facility took x-rays and followed up to check on Resident #1. Resident #1's POA said Resident #1 does not have the ability to show any emotion or pain and did not have any bruises or injuries from the situation. Observation of the first video provided by Resident #1's POA on 10/30/24 at 8:22 AM revealed the following: The video was time stamped and dated for 08/31/24 at 6:58 AM; the video did not include any sound. The video began and Resident #1 was in bed. There was a geri-chair at the foot of the bed and CNA B began pushing the geri-chair to the side of the bed. CNA B locked the left side of the geri-chair from the back and then walked in front of the geri-chair and pulled it closer to the bed. CNA B turned to Resident #1 and pulled her legs over the side of the bed and used his left arm to raise her up. CNA B used his right hand to reposition Resident #1's knees. Resident #1 had her arms crossed on her chest and CNA B uncrossed the resident's arms to put his underneath hers to lift her up and transfer her to the geri-chair. The geri-chair began to move backwards and CNA B used his left arm to hold the geri-chair while he used his right arm to hold Resident #1 up. CNA B placed Resident #1 on her back on the geri-chair seat portion, grabbed her left leg to raise it with his right hand while his left hand went under her left arm to pull her up towards him and into the chair but the chair began to again move backwards. CNA B put Resident #1 back in the bed and rolled her over onto the bed, pulled the geri-chair closer to the side of the bed and locked the right side of the geri-chair from the back. CNA B walked to the front of the geri-chair and to the side of Resident #1's bed where she was still lying there. CNA B turned Resident #1 over and put his right arm underneath her bent legs and used his left arm to hold her by her neck to transfer her to the geri-chair. CNA B put Resident #1 in the geri-chair perpendicular where her head and legs were on the armrests of the chair. The video ended. Observation on 10/31/24 at 9:45 AM of Resident #1 revealed she was in a common area lying in a geri-chair; she appeared dressed and groomed. Resident #1 had her eyes closed and she did not wake while being talked to by the surveyor. Resident #1 was wearing a long-sleeved shirt but did not appear to have any bruises, injuries, or pain. Observation on 10/31/24 at 12:30 PM of Resident #1 revealed she was in the dining room with her POA being assisted to eat lunch. Resident #1 was still in her geri-chair and was falling asleep during the meal. Resident #1 was not able to answer any questions or acknowledge the surveyor's presence due to her cognitive condition. Telephone interview on 10/31/24 at 12:48 PM with CNA B revealed he remembered caring for Resident #1, but that it was some time ago. CNA B said he was trying to transfer Resident #1 to her geri-chair one day when she was holding onto him. CNA B said he had to take Resident #1's hand off of him while still holding onto her during the transfer. CNA B said he had locked the chair but what happened during the transfer was that Resident #1 was very heavy and he could not hold her up for the transfer. CNA B said he did not use a gait belt to transfer Resident #1. CNA B said he was terminated from the facility. Observation on 10/31/24 at 1:13 PM revealed CNA F and RA Z transferring Resident #1 by Hoyer lift from her geri-chair to her bed, and the transfer was completed was completed safely and using proper technique. Interview on 10/31/24 at 2:37 PM with the ADON revealed he saw the video provided by Resident #1's POA which showed CNA B had transferred Resident #1 to the geri-chair. The ADON said at the time of the video, Resident #1 was a one person transfer using a gait belt and now was a hoyer lift transfer requiring at least two people. The ADON said CNA B was not appropriate in the type of care he provided Resident #1, and it was considered abuse which should never occur. The ADON said Resident #1 was assessed and she did not have any injuries or bruises from the incident. The ADON said safe surveys were completed for other residents to make sure they had not suffered any injuries either. The ADON said the facility decided to terminate CNA B immediately based on what they saw in the video. The ADON said the facility also began in-servicing staff immediately on abuse and neglect. The ADON said the facility also began checking on Resident #1 and ensuring staff were doing what they were supposed to regarding her care to monitor the situation. Interview on 10/31/24 at 2:53 PM with the Administrator revealed he got a call from Resident #1's POA who said she had a video she wanted to show him. The Administrator said he was concerned with what he saw on the videos. The Administrator said he saw CNA B trying to transfer Resident #1 by picking her up and putting her into the chair instead of using a gait belt to transfer her. The Administrator said the video showed CNA B trying to get Resident #1 to the chair without the amount of help that was needed to complete the transfer safely. The Administrator said after reviewing the videos he immediately reported the incident and terminated CNA B. The Administrator said a head-to-toe assessment was also completed on Resident #1 which revealed no bruising or marks of any kind to her body. The Administrator said multiple x-rays were completed on Resident #1 as well which all came back negative for any injuries. The Administrator said the techniques of CNA B's transfer were so poor which ended up meaning he provided rough care and a rough transfer. Follow-up interview on 10/31/24 at 4:52 PM with the Administrator revealed staff should seek help if they could not complete a transfer safely. The Administrator said the purpose of a safe transfer was to prevent injury or any negative outcome to the resident. The Administrator said staff were in-serviced regarding safe transfers and all staff were responsible for providing safe transfers to residents. Record review of the facility's Provider Investigation Report, dated 09/10/24, reflected the following: - Investigation Summary: Administrator approached by [Resident #1's POA] regarding a video she recorded in resident room. On video it showed [CNA B] trying to transfer resident to geri-chair. It shows CNA struggling to get her into the chair, holding resident under her arms and then back to the bed in the same way. It then shows him trying to pick her up under her knees and behind her back to get her to chair, hitting her back on the arm rests, then pulling on her arms to pull her up. Upon leaving the room, the resident holds onto the bed. The CNA removes her hand from the bed, then swats at her hand. Provider completed provider response as outlined above. All xrays and head to toe assessments came back negative. All safe surveys came back with no other abuse present. Facility completed all in-service and competencies. CNA was terminated immediately, board notified, police called. - Investigation Findings: Confirmed Record review of undated safe surveys completed with residents revealed 33 residents were interviewed and no concerns were noted. Record review of CNA B's personnel file included a disciplinary action form, dated 09/03/24, which reflected he was terminated due to an allegation of abuse that was founded on a video. Record review of an in-service, dated 09/03/24, reflected staff had been trained regarding Customer Service and that all residents [were] to be treated with dignity and respect. Record review of an in-service, dated 09/03/24, reflected staff had been trained regarding Safe Handling and Transfers and that Hoyer lift requires 2 people, All transfers require use of gait belt, 2 person assist equals 2 person assist .if in doubt how to transfer ask for clarification .gait belts [sic]. Interview on 10/31/24 at 11:37 AM with CNA C revealed he had been trained on how to properly transfer a resident. Interview on 10/31/24 at 1:15 PM with CNA F revealed she had been trained on how properly transfer a resident. CNA F said Resident #1 was now transferred using a hoyer lift whereas she was previously transferred using a gait belt. Interview on 10/31/24 at 1:32 PM with RN D revealed she had been trained on how to properly transfer a resident. RN D said Resident #1 was now transferred using a hoyer lift whereas she was previously transferred using a gait belt. Record review of the facility's Safe Resident Handling/Transfers policy, dated 09/03/24, reflected: Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them .13. Staff members are expected to maintain compliance with safe handling/transfer practices. The Administrator was notified on 11/13/24 that a past non-compliance IJ situation had been identified following administrative review due to the above failure.