**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 6 residents (Resident #42) reviewed for accidents. The facility failed to provide adequate supervision to prevent Resident #42 from eloping from the facility and being located in an empty lot with multiple fall and environment hazards approximately 550 feet behind facility and approximately 300 feet from highway on 10/13/24 at 1:30 am. The facility failed to keep Resident #42 in a safe environment to prevent an elopement on 10/13/24 at 1:30 am. The noncompliance was identified as PNC (past non-compliance). The IJ (immediate jeopardy) began on 10/13/24 and ended 10/14/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for serious injury, accidents, and death. Findings included: Record review of a facility face sheet dated 11/11/24 for Resident #42 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), dementia, and hyperlipidemia (high cholesterol). Record review of a comprehensive MDS assessment dated [DATE] for Resident #42 indicated that she had a BIMS score of 9, which indicated that she had moderately impaired cognition. She had hallucinations and delusions. Wandering behavior was not present during 7-day lookback period. She was independent with most all ADLs and was able to independently ambulate at least 150 feet. She was always continent to bowel and bladder. She had a wander/elopement alarm device. Record review of a comprehensive care plan initiated on 9/1/22 and most recently revised on 10/18/24 for Resident #42 indicated that she was a high risk for elopement related to progressing dementia and signs of sundowning with interventions that read: .check for placement of wanderguard Q shift . dated 4/15/24 and .Use audible monitoring system to alert staff of exit seeking behaviors as appropriate . dated 9/22/23. Care plan also indicated that she exhibited wandering/exit seeking and had an intervention that read: .Check for proper functioning of the audible alarm system every shift and PRN as ordered . dated 9/21/22. Interventions added after incident included: .Monitor resident for tailgating when visitors are in the building or on the unit . dated 10/13/24 and .Electronic monitoring as needed with family consent . dated 10/18/24. Record review of a physician's order summary report dated 11/11/24 for Resident #42 indicated that she had the following order dated 10/13/24: .Check function of wanderguard every shift for wandering .; and the following order dated 4/14/24: .Wanderguard - check placement every shift for safety . Record review of a facility form titled AHS - Elopement/Wandering Risk Assessment dated 8/16/24 for Resident #42 indicated that she was at risk for elopement or unsafe wandering. Record review of a facility form titled AHS - Elopement/Wandering Risk Assessment dated 10/13/24 for Resident #42 indicated that she was at risk for elopement or unsafe wandering. Record review of a facility incident report dated 10/13/24 for Resident #42 indicated that she eloped from the facility and was located outside the facility and redirected back to building without issues. Administrator, DON, physician, and responsible party all appropriately notified. Record review of a witness statement dated 10/13/24 and completed by RN H read .I heard alarm sounding on 100 hall - station 1. I went outside the door and looked at area around exit door area not seeing anyone I went back inside and checked resident [Resident #42] room to ensure that she was in there. She had just stated that she was going to bed per her norm. Not seeing resident in bed or [bathroom] in her room, I went back outside and looked around exit area and toward road. I then went to notify the other staff members. As I was walking down to unit 2 I approached [LVN F] and [CNA E] and informed them of [Resident #42] was not in her room and asked if they had seen her. The stated they had not. The other aides from unit 2 were also coming up the hall. I went outside the therapy room exit door and walked toward [facility name] to circle the back side of the building. The other staff members went outside the short hall door and [LVN F] remained in the building. When I rounded the side of the building where aides were searching, I heard [CNA G] ask if that was a person over there. I looked and saw her too. [CNA E] and myself [CNA E] ran toward her and were able to redirect resident back inside building without incident. Resident stated that she was looking at the stars. Resident showed no signs of distress or injury . Record review of a witness statement dated 10/13/24 and completed by LVN F read .I heard an alarm going off and discovered it was the exit door in short hallway next to DON office. Nurse proceeded to door and looked outside door and did not see any one. Sent [CNA M], Aide to inform [RN H]. As she walked down hall toward front, [RN H] was coming towards us. He asked if we had seen [Resident #42] because she was not in her room. [CNA G] and [CNA E] the at door with us. The 4 staff members then went outside building, going in different directions searching for resident. I stayed inside building monitoring doors and other facility residents. Shortly after, resident was found outside and safely returned . Record review of a witness statement dated 10/13/24 and completed by CNA G read .I heard alarm going off and it was the door by DON office in that short hall. [RN H] let us know that he could not find [Resident #42]. He said they had just seen her but she is not in her room and they can't find her. We went outside to look for her. [LVN F] the nurse stayed inside. We saw someone moving ahead of us and [RN H] and [CNA E] took off towards her. I went back in and went to unit one to monitor. [CNA M] monitored station 2 with [LVN F] until they got her and came back inside . Record review of a witness statement dated 10/13/24 and completed by CNA M read .I heard an alarm going off. I went down to the door that was alarming - the door on hall next to DON office. I was with [CNA G]. We did not see a resident near by the door or in hall. [LVN F] said go get [RN H] but I turned and he was walking toward me and asked us if we had seen [Resident #42]. We had not seen her so then we went outside and all walked toward the smoke shack. We looked in different directions for her. It was almost right away that we saw her walking toward the Texas Burger. [CNA E] and [RN H] ran after her. Me and [CNA G] went back in the building to check on the other residents . Record review of a witness statement dated 10/13/24 and completed by CNA E read .I was in the break room eating and heard alarm going off at smoking door exit. Went to door - no residents around and looked out window and didn't see anyone there. I went to look for [RN H] to tell him. Walking down 200 hall I seen the nurse from station 2 walking down hall. She said the door was alarming on the short hall by DON office. [RN H] come around from 100 hall asking if we seen [Resident #42]. He told us she wasn't in her room. I had just seen [Resident #42] because she was up front she turned back around to go towards her room. We all went toward the short hall door. Me, [CNA G], and [CNA M] immediately go outside to look for her. [RN H] went out the therapy exit door. [CNA M], [CNA G], and I looked in all different directions. Just as [CNA M] said is that a person over there [RN H] was coming back around the building and met us there and said yes it is so we take off. I run and [RN H] was running/speed walking and we caught up to her towards the [business name]. We came back to the facility and went back inside . During an interview and observation on 11/11/24 at 12:40 pm the DON said Resident #42 was found in an empty lot between facility and [business name]. The empty lot where Resident #42 was located was observed to be approximately 550 feet behind facility and approximately 300 feet from highway. Multiple hazards were observed in the empty lot such as fall/trip hazards, ant beds, holes, rusty pipes, broken glass, and uneven ground. During a telephone interview on 11/11/24 at 2:25 pm CNA G said that the door on unit 1 alarmed first. She said she immediately headed to respond to the alarm, and that is when she saw RN H coming down the hall and he told her that Resident #42 was not in her room. She said they then went outside the door on the short hall. She said she was standing next to the smoke shack when she was outside looking for her and saw Resident #42's figure moving in the distance. She said she was unsure how long Resident #42 was outside but thought that it was about 3 to 4 minutes from the first alarm going off until they found her. During an observation on 11/11/24 at 2:38 pm, the exit door on 100-hall that Resident #42 eloped from was set off with wanderguard by this surveyor. Nursing staff immediately responded to the alarm. The exit door on the short hall by the DON's office was also set off from the outside with the same wanderguard. The exit door to the smoking area was also set off with wanderguard from outside. Each door was observed to alarm separately. During an interview on 11/11/24 at 3:25 pm the Administrator said she felt like the resident took the shorter path around the back of the building instead of going completely around because it would have taken her longer. She said she felt like the staff did a good job of retrieving Resident #42 and bringing her back inside the facility. She said Resident #42 now has a sitter at night and staff check on her every 15 minutes throughout the day. During an observation and interview on 11/11/24 at 4:20 pm Resident #42 was observed at the nurse's station. She ambulated without difficulty and without assistive devices. She was unable to recall incident or appropriately answer questions. She had impaired cognition and verbalized that she worked at facility doing shorthand. Wanderguard was observed in place to right wrist. During a telephone interview on 11/12/24 at 9:28 pm LVN F said she stayed inside the facility with other residents while the rest of the staff went outside to look for Resident #42. She was able to verbalize training regarding elopements and appropriate actions to take in the event of an elopement. During a telephone interview on 11/12/24 at 9:35 pm CNA E said she had been at the nurse's station and Resident #42 had been walking around at the nurse's station and then Resident #42 turned and walked back towards her room. She said RN H was rounding, checking on the residents and was in a resident's room. She said she then walked to the break room to eat lunch. She said she heard the door alarm going out to the smoking area start going off while she was eating lunch, so she got up and went to check it. She said she looked around outside and did not see anyone. She said she was not sure if it was a malfunction or what it was, she had never dealt with an elopement before. She said that she put the code in to turn the alarm off and immediately went to look for RN H. She said she couldn't find him, so she headed to the unit 2 nurses' station and the alarm for the door on the short hall next to the DON office was going off and the nurse did not know the code. She said they then saw RN H coming up the hallway saying that Resident #42 was not in her room, and he could not find her. They immediately went outside to look for her while LVN F stayed inside the facility. She said RN H had already made a perimeter around the building and when he was coming back around from the side, CNA G said is that a person over there? and that was when they saw her walking towards [Texas Burger]. She said she started running towards Resident and RN H was right behind her walking really fast. She said they got up to her almost to [Texas Burger] in the empty lot. They were able to bring her back inside and RN H took over after that. She was able to appropriately answer questions related to elopement training. During an interview on 11/13/24 at 10:05 am the Maintenance man said that he used a wanderguard to set off each door weekly to ensure they functioned correctly. He said residents that eloped could be at risk for all kinds of injuries such as being hit by a car and killed. During an interview on 11/13/24 at 10:20 am the Administrator said if residents eloped, they could be harmed, a lot of things could happen, they could fall, or maybe get lost. She said Resident #42 now has a sitter at night and was more closely supervised during the day, that staff were documenting her location every 15 minutes. She said they have placed checking of the wanderguard on the MAR, checked all residents in facility for elopement risk, tightened up on the door codes to prevent resident's from using codes to exit. During an interview on 11/13/24 at 10:40 am the DON said if a resident eloped, they could be at risk for falls, getting in the road, being ran over, getting injured, hunger, thirst, and low blood sugar. She said she expects her staff to immediately respond to door alarms to help prevent elopements. During a telephone interview on 11/13/24 at 10:30 am RN H said he checked on residents every hour and a half or so, and that Resident #42 must have just slipped by him. He said she did wander the facility and wore a wanderguard. He said she could have been seriously injured or harmed or she could have run out into the street. He said he was in a resident's room when he initially heard the door alarm going off, he said staff should immediately respond to the alarms, but he was tied up with a resident and it took him a minute or so to respond. Record review of a facility policy titled Missing Resident Policy dated 10/24/22 and revised 8/15/23 read: .This facility ensures that resident who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk The facility took the following action to correct the non-compliance on 10/14/24: Record review of Elopement/Wandering Risk assessment history indicated all residents were reassessed for elopement risk by 10/13/24. The facility identified seven residents to be at risk and to require additional supervision. Record review of 15-minute check documentation forms dated 10/13/24 through 11/11/24 indicated that staff document Resident #42's location every 15 minutes throughout the day. Record review of invoices from [business name], a private sitting company indicate that facility paid for a private sitter for Resident #42 from the night of 10/14/24 through 11/11/24. Record review of facility form for elopement drill indicated that facility held elopement drills on 10/13/24 for day shift attended by 8 staff members; 10/13/24 for night shift attended by 5 staff members; 10/14/24 day shift attended by 10 staff members; and 10/14/24 night shift attended by 7 staff members. Record review of facility log sheets dated 10/13/24 through 10/19/24 indicated that documentation of daily door checks were done for front door, dining room door, 100-hall exit door, exit door by DON office, therapy exit door, 400-hall exit door and 500-hall exit door. Record review of Resident #42's physician orders indicated that a new order was put into place to check function of wanderguard every shift for wandering dated 10/13/24. During interviews on 11/12/24 between 1:10 pm and 1:40 pm LVN B, MA L, Medical Records, LVN K, CNA C, and CNA G were able to verbalize training regarding elopements and appropriate actions to take in the event of an elopement. The noncompliance was identified as PNC. The IJ began on 10/13/24 and ended 10/14/24. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents and supervision. 1. The facility failed to properly secure Resident #1 in the facility van on [DATE] and Resident #1 fell forward while in transport striking his head on the side of the van causing a laceration and emergency room care. An IJ (Immediate Jeopardy) was identified on [DATE] at 4:30 pm. The IJ template was provided to the facility on [DATE] at 5:05 pm. While the IJ was removed on [DATE] at 12:07 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective systems. This failure placed all residents that used the facility van at risk of injury and death. Findings: Record review of a facility face sheet dated [DATE] indicated Resident #1 was an [AGE] year-old male that admitted to the facility on [DATE] with diagnosis of myocardial infarction (heart attack). Record review of a significant change MDS assessment dated [DATE] indicated Resident #1 had a BIMS of 9 indicating moderately impaired cognition and had impairment to both upper and lower extremities, was an amputee and was dependent for all ADLs. Record review of a comprehensive care plan dated [DATE] indicated Resident #1 had an ADL Self Care Performance Deficit and was at risk for not having their needs met in a timely manner and had the potential for falls with new intervention dated [DATE] to ensure prosthesis was in place for added safety and stability. Record review of an incident report dated [DATE] at 8:20 am during transport with two facility staff Resident #1 was witnessed leaning forward and hitting the inside wall of the van. Staff jumped up to catch wheelchair and Resident #1 but Resident #1 bumped his head on the inside of the van resulting in a small gash on his forehead. Resident #1 was assessed, and emergency medical services were notified to send to the emergency room (ER) . The doctor and family were notified of the incident. During an interview on [DATE] at 10:15 am Resident #1's family member said Resident #1 had gone to see his heart doctor in another city by the facility van. She and another family member met the van at the doctor's appointment. She said after the appointment the aide and driver loaded Resident #1 in the van and she and the other family member left. She said shortly after, her phone rang, and the van driver told her there was an incident when she came down a steep hill and applied the brakes, Resident #1 fell from his chair forward and hit his head. She said she and the other family member arrived and 911 had been called. She said she was in such a panic she did not pay attention to his wheelchair and if there was a restraint or not. She said she does not know if the facility could have done anything else because she did not know if they failed to secure him or not. During an interview on [DATE] at 1:00 pm CNA A said she had worked at the facility since 1980 and currently was in medical records but was also an aide. She said she was the aide on transport the day Resident #1 fell in the van. She said the driver had loaded Resident #1 and secured him with the lap belt, but she could not recall there being a shoulder harness in the van. She said she did not routinely ride as the attendant but did that day. She said they left the doctor's office and headed home. She said the driver was going slowly down a hill and she saw out of the corner of her eye Resident #1 falling forward but she could not reach him. She said the driver stopped and they assisted Resident #1 to the floor while they called the nursing home and 911. She said the ambulance picked him up and took him to the ER to be evaluated. She said a shoulder harness would be safer for the residents and could prevent falls or injuries. During an interview on [DATE] at 1:26 pm the van driver said she had been employed since [DATE]. She said on hire she was trained by the previous driver and the maintenance director. She said she was trained on how to properly secure the wheelchair wheels and place the seatbelt across the resident's lap. She said the day of the incident with Resident #1, Resident #1 was in a high back wheelchair that reclined, and she had leaned him slightly backwards for his comfort, secured the wheels and placed the seatbelt across his lap. She said when she was going down a hill and applied the brakes, Resident #1 fell over the front right side of his wheelchair and struck the side of the van. She said CNA A was sitting in the seat in front of him and tried to reach him but could not. She said Resident #1 did not fall out of the wheelchair onto the floor, but she and CNA A had assisted him to the floor. She said they tried to reposition Resident #1 in his wheelchair but could not because of his size and felt it was safer to lower him to the floor. She said they called his family and 911. She said by not having a shoulder harness in the van residents could become injured during transport. During an observation and interview on [DATE] at 1:35 pm the facility van was parked behind the facility. The van driver demonstrated how she loaded and secured residents for transport. The wheelchair was loaded, and wheels locked and secured using 4 straps. She then applied a lap belt under the armrest and over the lap and secured. No shoulder harness was applied, and the van driver said there had not been a shoulder harness and she was not trained on needing to apply one. She said a shoulder harness should be in place to secure the resident and keep them from going forward and getting hurt. During an interview on [DATE] at 2:09 pm the maintenance director said he had worked at the facility for 1 ½ years and he did a weekly check on the facility van. He said the checks included checking the fluids, lights, wheelchair lift, straps to secure the wheelchair and the seat belts. He said the van only had a lap belt and there was not a shoulder harness in the van that was used. He said he was trained on the van on hire by the previous van driver and by just having common knowledge on vehicles. He said he and the previous van driver trained the current van driver and training included verbal and demonstration of properly securing and transporting residents. He said he and the previous van driver did a few transports with the current van driver to ensure she was ready before her first trip. He said there was no literature of manufacturer information for the seatbelts in the van. He said there was not a vehicle operating manual to follow that he has seen but would try to locate one online. He said the van was a 2008 Ford Econoline van and was purchased before his hire date. He said the van driver was not trained on applying a shoulder harness because there was not one to apply. He said by not having a shoulder harness it could result in injury of a resident during transport. During an interview on [DATE] at 2:40 pm the Administrator said she had been the administrator since 2022 and had participated in the training of the van driver when she was hired along with the previous van driver. She said the maintenance director retrained the van driver after the incident with Resident #1. She said securing the resident properly was part of the initial training. She said that she thought the lap and shoulder harness were in use and was not aware there was no shoulder harness being used. She said the maintenance director was responsible for checking the securement devices in the van weekly and as needed. She said the training was to check the lap belt or the shoulder harness and at least one device had to be in place. She said by not having a shoulder harness it could cause falls and injuries. She said there were no other staff that drove the van and if the current van driver was not available, she used a private transport service. She said she would take the van out of service until a shoulder harness could be installed. Record review of an orientation checklist for community Driver-Van-Bus dated [DATE] indicated the van driver had received proper training on hire for transporting residents including applying lap and shoulder belts. Record review of a facility policy titled Transportation Policy and Procedure for Facility Based Vehicle dated 03/13 indicated assure that the vehicle is in good repair and in full compliance with all recommended maintenance as per vehicle operating manual. The authorized driver must complete a competency-based training to include but not limited to b. application of seat belt . Record review of Code of Federal Regulations website https://www.ecfr.gov/current/title-49/subtitle-A/part-38/subpart-B/section-38.23 at Title 49 Subtitle A Part 38 Subpart B § 38.23 Mobility aid accessibility last amended [DATE] indicated, .(d) Securement devices (7) Seat belt and shoulder harness. For each wheelchair or mobility aid securement device provided, a passenger seat belt and shoulder harness, complying with all applicable provisions of part 571 of this title, shall also be provided for use by wheelchair or mobility aid users. Such seat belts and shoulder harnesses shall not be used in lieu of a device which secures the wheelchair or mobility aid itself. Record review of weekly center-based vehicle maintenance logs dated from [DATE] to present date indicated the seatbelts operable including all straps, for wheelchair tie down, shoulder strap and floor wheelchair tie down straps were ok. Unable to review vehicle operating manual due to no manual found at the facility. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 4:30 pm. The facility's Administrator was notified. The Administrator was provided the IJ template on [DATE] at 5:05 pm. The following Plan of Removal (POR) submitted by the facility was accepted on [DATE] at 9:20 am. Plan of Removal - F 689 Free of Accidents and Hazards/supervision/devices Tag Cited: F-689 Issue Cited: Free of Accidents/Hazards/Supervision Tag Cited: F-689 Issue Cited: Free of Accidents and Hazards Failure to ensure the facility van had proper securement devices (shoulder harness and lap belt) and resulted in a resident falling forward out of wheelchair striking his head. 1. Immediate Action Taken A. Resident # 1 expired in the facility on [DATE] . B. The facility's van immediately stopped all van transport on [DATE] at 4:30 pm C. The facility's van is scheduled for replacement / installation of shoulder harness this Thursday 8-22-2024. D. The Administrator or designee completed the following with the one facility designated van driver: o In-service education on the Transportation Policy which provides direction on duties and responsibilities of driver, van safety, and forms required was completed on 8-19-2024 at 7:00pm. Skills check off on driving of the van, how to operate the wheelchair lift and the wheelchair securement system, use of seat and shoulder harness, and how to transport more than 1 wheelchair was completed on [DATE] at 8:00am at neighboring facility with a similar van. Van driver performed return demonstration on noted skills. This process will be redone once our van has the shoulder harness installed. o In-service education provided to van driver by administrator/designee on weekly maintenance log which includes checking Operable seatbelt straps, wheelchair tie down, shoulder strap, floor W/C tie down straps that van driver will complete and provide to administrator/designee weekly. This was completed on [DATE] at 7:00 pm. o The Administrator reviewed with van driver, a new signed job description. This was completed on [DATE] at 7:00 pm. 2. Identification of Residents Affected or Likely to be Affected: A. No other residents identified, all scheduled van transports for the remainder of the week will be transported by an outside vendor and will continue if needed until repairs are made to the facility van. 3. Actions to Prevent Occurrence/Recurrence: A. As of [DATE], any staff member hired for van transports will be provided the following by the facility maintenance supervisor. o In-service education on the Transportation Policy which provides direction on duties of driver, driving of the van, how to operate the wheelchair lift and the wheelchair securement system, use of seat and shoulder harness, and how to transport more than 1 wheelchair prior to driving the van. o In-service education on weekly maintenance log which includes checking Operable seatbelt straps, W/C/ tie down, shoulder strap, floor W/C tie down straps that van driver will complete and provides to administrator/designee weekly o Completed a skills validation check list on van driver to acknowledge skills competence on how to operate the wheelchair lift and the wheelchair securement system, seatbelts including shoulder harness, and will complete a return demonstration. o Have van driver sign job description duties Immediate Jeopardy Removal Plan F-689 - (Free of Accidents and Hazards) B. The weekly maintenance log will be reviewed in the morning meeting by the Administrator or designee on [DATE] the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to Accidents/Hazards/Supervision and reviewed plan to sustain compliance. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: _____[DATE]____________ Plan of removal was monitored as follows: During an interview on [DATE] at 9:40 am the van driver was able to verbalize the proper technique for loading and securing a resident in a wheelchair, weekly completing the check of operable seatbelt straps, understanding of transportation policy, job description, and new skills checkoff with maintenance director using another facility van. The van driver verbalized the facility van was no longer in operation and all appointments had been rescheduled with a private transportation service. During an observation on [DATE] at 11:45 am the van driver was able to properly demonstrate using a different facility van how to place both the lap belt and shoulder harness to secure a resident during transport. During an interview on [DATE] at 12:00 pm the maintenance director said he went through the checklist with the van driver 3 times, then observed her secure a wheelchair in the van, and verbalized the inservice training to include the van was not to be used until it was repaired, weekly maintenance log and checkoff with each transport once transports resume and a lap and shoulder belt must be in place. Record review of inservice training titled Van safety ( review weekly maintenance log, checkoff form prior to transport, van to have lap belt and shoulder belt, and new training to occur after shoulder harness was installed) dated [DATE] indicated Administrator, Maintenance director and van driver signed and understood the information. Record review of a Transportation Policy dated [DATE] indicated the van driver signed on [DATE]. Record review of an Orientation checklist Community Driver-Van-Bus dated [DATE] indicated the van driver had received new skills validation by the maintenance director. Record review of a job description for the van driver indicated had been resigned on [DATE]. Record review of an email dated [DATE] indicated an appointment had been made with a wheelchair van company to evaluate and repair restraint system. Record review of facility form titled appointments for remainder of week indicated 3 residents had appointments and transportation had been arranged with a private transport company. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 12:07 pm.; however, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from physical abuse for one of four residents (Resident #1) reviewed for abuse. 1. The facility failed to prevent physical abuse for Resident #1 witnessed by HA to have been hit on the head by CNA A on 02/27/2024 at approximately 3:00 a.m. during incontinence care. The noncompliance was identified as PNC. The IJ began on 02/27/2024 and ended on 03/05/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for physical harm, psychosocial harm, unsafe environment, and further abuse. Findings included: Review of facility policy, titled Abuse/Neglect Policy & Procedure, with no date, revealed the following: PREVENTION AND REPORTING: 1. The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. 2. The facility has designed and implemented processes, which strives to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. 3. The facility has implemented the following processes in an effort to provide residents/patients and staff a safe and comfortable environment. 4. Administrator is the Abuse Coordinator. The Administrator considers the Director of Nursing a designee for reporting and investigation of alleged abuse. In their absence, Admin and DON can appoint appropriate supervisory personnel to initiate investigation. 5. The Administrator and Director of Nursing are responsible for investigation and reporting. They are also ultimately responsible for the following as they relate to abuse, neglect, and/or misappropriation of property standards and procedures: Ongoing monitoring Reporting Investigation Tracking and trending 6. Implementation and ongoing monitoring consist of the following: Screening Training Prevention Identification Protection Investigation Reporting DEFINITIONS: Abuse Willful infliction of injury Unreasonable confinement Intimidation with resulting physical harm or mental anguish Punishment with resulting physical harm or pain or mental health Deprivation by the individual, including a caretaker, of good or service that is necessary to attain or maintain physical, mental, and psychosocial well being . Physical Abuse Includes hitting, slapping, pinching, scratching, spitting, holding, roughly, etc. It also includes controlling behavior through corporal punishment . Training 1. Provide training for new employees through orientation and with ongoing training programs. Training will include, but not limited to: Definitions of abuse, neglect, mistreatment, and misappropriation of property. Identification of abuse . Utilization of appropriate interventions to deal with aggressive and/or catastrophic (detrimental) reactions of residents/patients. How to provide protection for residents/patients How to investigate and report incidents of abuse, neglect, mistreatment, and misappropriation of property. Prevention of abuse, neglect, mistreatment, and misappropriation of property including, but not limited to, recognizing signs of burnout, frustration and stress . Prevention Ensure that prevention techniques are implemented in the facility including, but not limited to, ongoing supervision of employees through visual observation of care delivery and recognition of signs of burnout, frustration, and stress. 1. Identify, correct, and intervene in situations where abuse, neglect, and/or mistreatment are more likely to occur. This includes, but is not limited to, identification/analysis of: Secluded areas of the facility Sufficient staffing on each shift to meet the needs of the residents/patients Assigned staff demonstrating knowledge of individual resident/patient needs Sufficient and appropriate supervisory staff to identify inappropriate behaviors Residents with needs and behaviors which might lead to conflict or neglect 2. Encourage residents/patients and families to report concerns, incident, and grievances without fear of retribution. Provide feedback regarding the concerns that have been expressed. 3. Instruct staff that they are required to report resident concerns, incidents, and grievances. Identification 1. Identify events, such as suspicious bruising of residents/ patients, occurrences, patterns, and trends that mat constitute abuse, neglect, and/or mistreatment and investigate . 3. instruct staff, resident/patient, family call my visitor, etc. to report immediately, without fear of reprisal, any knowledge or suspicion of suspected abuse, neglect, mistreatment, and/or misappropriation of property. Protection 1. provide for the immediate safety of the resident patient upon identification of suspected abuse, neglect, mistreatment, and/or this appropriation of property. Means of providing protection include, but are not limited to: Moving resident/patient to another room or unit Provide 1:1 monitoring as appropriate Immediate suspension of suspected employee(s) pending outcome of the investigation . 2. Initiate behavior crisis management interventions, as applicable . 2. Administrator and/or designee will initiate the Investigation. The investigation should be thorough with witness statements from staff, resident, family members who are interview-able and have information regarding the allegation . Employee Suspension from Duty 1. Any time an allegation is made involving abuse, neglect, or mistreatment of a resident/patient which names a specific employee, laws and regulations are specific about protecting all residents/patients from harm / potential harm farmer which means suspending the employee until the completion of the investigation. 2. The employee is not to remain on duty, and is not to be assigned to any other area of the facility. 3. The administrator, or in his/her absence the Director of Nursing, Assistant Director of Nursing, or Charge nurse, in that order, must relieve the employee of his/her duty without pay until the investigation is complete. If the allegation is substantiated, the employee will be terminated immediately. 4. if the result of the investigation is in favor of the employee or is inconclusive, the employee will be paid regular wages during the time he/she was relieved from duty. Reporting 1. Notify the Administrator, DON, or Shift Supervisor/Charge Nurse immediately if suspected abuse, neglect, mistreatment, or misappropriation of property occurs. 2. Notify the appropriate State agency(s) after identification of alleged incident. initiate process according to State-specific regulations. 3. Person(s) initially identifying potential abuse, neglect, mistreatment, and/or misappropriation of property are accountable to report to proper chain of command. 4. Notify the legal guardian, spouse, or responsible family members/ significant other of the alleged or suspected abuse, neglect, mistreatment, and/or misappropriation of property. 5. Notify the physician of allegation and investigation. 6. Initiate contact with local law enforcement, immediately, when warranted, as required by state law. 7. Report results of investigation to the proper authorities as required by State law. 8. Follow up with resident/patient results and outcome of investigation and ensure their feelings of safety and security. Review of facility policy, titled Reporting Abuse, Neglect, and Mistreatment, with no date, revealed the following: Alleged, suspected or observed abuse, neglect or mistreatment of a resident or patient or his/her belongings are thoroughly investigated by the Administrator and/or the Director of Nursing. Alleged, suspected or observed violations are reported immediately to the Administrator, Regional [NAME] President, Medical Director, VP Quality & Compliance, Ombudsman, State Health and Environmental Departments, and all other officials required by state law. In all cases, the Administrator or Director of Nursing will immediately notify the resident or patient's legal guardian, family member, responsible party or significant other of the alleged, suspected or observed abuse, neglect or mistreatment. If a direct caregiver is observed, suspected or alleged to have engaed in abuse, neglect or mistreatment of resident/patient belongings, the caregiver will be relieved of duty and placed under investigative suspension by the Administrator, Director of Nursing or Nursing Supervisor, until the investigation is completed . Review of a facesheet for Resident #1, dated 03/27/2024, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses including: altered mental status, chronic pain, speech disturbances, muscle weakness, contracture of muscle (multiple sites), and dysphagia (difficulty swallowing). Review of Resident #1's Quarterly MDS, dated [DATE], revealed he had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate impairment. Resident #1's behavior and functional status revealed he had no physical or verbal behavioral symptoms directed towards others exhibited, he had impairment to both sides of upper and lower extremities and required substantial/maximal assistance with toileting hygiene. Review of Resident #1's care plan, revised 03/05/2024, revealed he had interventions in place for history of aggression with staff and dementia with behaviors to include: stopping and returning if resident becomes agitated, approach resident in a calm manner, talk while providing care, when resident becomes agitated intervene before agitation escalates by guiding away from source of distress, engaging calmly in conversation, approach at a later time if response is aggressive, and encourage resident to express feelings appropriately. Review of incident statement, dated 02/28/2024, signed by Administrator, revealed the following: Informed by [CNA C] that another [HA] had informed her that she had witnessed abuse by another staff member [CNA A]. Called [HA] to confirm statement. [HA] stated she was in the resident's room [Resident #1], with [CNA A] during incontinent care the resident punched her [HA] in the stomach, and she stepped back away from him. Then [CNA A] rolled resident over to his back and hollered motherfucker, do not do that again while slapping him in the forehead several times. The resident then swung at [CNA A]. When asked why [HA] did not report to supervisor immediately, she stated because she was scared of [CNA A] and that she had a look when she turned to look at her and she was upset about everything. Did not tell anyone until the next day when she told the other CNA, who reported to me. Review of witness statement, dated 02/28/2024 at 3:00 p.m., signed by CNA C, revealed the following: On 2-27-24 at approx. 6:30 pm, staff member [HA] told me that on Monday night while doing incontinent care, [Resident #1] had punched her in the stomach. HA said she stepped back and [CNA A] rolled [Resident #1] over and slapped him in the face and grabbed his hand. She said this scared her and she didn't know what to do. I told her she needed to go and report this to DON or Admin. She said she felt that she could come to me and that she didn't want to get anyone in trouble. [HA] said she had called her family member to talk about the situation. Review of witness statement, dated 02/28/2028, signed by HA, revealed the following: [HA] interviewed about incident that occurred with (Resident #1). She stated that on Tuesday morn (morning) at 3am (3:00 a.m.) during incontinent rounds, she and co-worker [CNA A] went into [Resident #1's] room. When they first went in the room he drew is fist back. [HA] stated she tried to talk him down because usually this will work. They began performing care and rolled him over toward her (she was between the bed and the wall) but he started hitting her in the stomach. [CNA A] then rolled him back over and slapped him more than once on the forehead. [HA] stated [CNA A] said I'll beat the f--- out of you. You know you laying in the bed and can't move. They finished the care and put a brief on him and left the room. After this [HA] said she went outside because she was upset. She stated she thought about leaving but didn't, she came back inside to complete shift. She didn't go to charge nurse at that time. Stated she was afraid she would be in trouble as well. This was the last round of the evening so nothing else occurred with other residents and [CNA A]. [HA] stated she went back into [Resident #1's] room and gave him a hug. He was fine and didn't seem upset. Stated she knows she should have said something but that she had never seen anything like this and it just scared her. Tuesday 2-27-24 at 6:30pm [HA] told [CNA C] what had occurred with [Resident #1] that morning during her shift. Review of witness statement, dated 02/28/2024, signed by LVN D, revealed the following: DON interviewed [LVN D] regarding alleged abuse incident that occurred with Resident #1. [LVN D] stated aides did not tell her that [Resident #1] hit [HA] or anything else that occurred after that point. She stated they told her that [Resident #1] was being difficult during incontinent care. The time reported to her was between 3am (3:00 a.m.) and 4am (4:00 a.m.) so it would have been their last round with him that night. Review of Associate Disciplinary Memorandums, dated 02/28/2024, revealed CNA A, HA, and CNA C were suspended pending investigation. CNA C and HA were reinstated and received training on abuse. CNA C received formal written disciplinary action for failing to report abuse. Supervisors Comments revealed CNA C was aware of reporting guidelines, understands not to wait if she believed anything has occurred, and stated she told employee to report to DON or Admin. CNA A was discharged effective 03/05/2024 due to employee confirming allegation of incident that warrants termination. Review of witness statement, dated 02/29/2024, signed by CNA A, revealed the following: [CNA A] interviewed in person by DON and Administrator on 2-29-24 at 10:15am. She was off on 2-28-24 when the investigation initiated and we were unable to reach her until late that evening. The meeting was set up for Thursday 2-29-24 to obtain statement and her version of events that occurred on 2-27-24 at 3am with [Resident #1]. STATEMENT: We went in to do incontinent care on [Resident #1]. He punched [HA] in the stomach. I tried to hold him down with his hands on his chest so he couldn't hit her anymore. When she was cleaning between his legs he tried to punch me. I told him: stop this, this is not how things go. We don't hit women, it does not work that way. [HA] said my doesn't even hit me. He continued to try to hit us. I did not hit him, it wouldn't do any good anyway. So I just held him down. I did not tell the nurse at that time, she wouldn't do anything anyway. I thought [HA] was going to tell her. No one should have to go into a room and wonder if they are going to get hit. It was self defense. Follow up: Admin asked about the curse words that were alleged. Asked her if she used the f-word. stated that she did not curse . maybe the worst she said was damn don't do this. Admin asked about the allegation that she slapped on the forehead several times and she said well yes she did do that just to get him to stop hitting. I asked her to demonstrate and she slapped her forehead several times with her fingers, palm down in front of nose. Admin asked about why she didn't just back away when he was combative as this could be one approach - she stated they just had to get the job done. Review of personnel record for CNA A revealed she was hired on 12/06/2018 and signed and dated policy for reporting abuse, responsibility for reporting abuse, and Senate [NAME] 9 employee acknowledgement that mistreatment or abuse will not be tolerated and will be subject to immediate discharge. Review of personnel record for HA revealed she was hired on 12/28/2023 and signed and dated policy for reporting abuse and responsibility for reporting abuse. Review of audit, titled Staff Awareness on What Constitutes Abuse, dated 01/25/2024, revealed CNA A and HA met criteria for knowing when and who to report allegations of abuse. Audit revealed met criteria for knowledge of reporting physical abuse immediately to the Administrator. Review of training records, dated 3/5/2024, completed by CNA A, revealed the following education was provided: Preventing, Recognizing, and Reporting Abuse, and Managing Anger completed on 08/13/2023 and Communication and People with Dementia completed on 02/05/2024. Review of training records, dated 3/1/2024, completed by CNA C, reveled the following education was provided: Communication and People with Dementia completed on 1/31/2024, Managing Anger on 08/09/2023, and Preventing, Recognizing, and Reporting Abuse on 03/03/2024. Review of Provider Investigation Report, dated 03/06/2024, revealed the following: .Description of the Allegation: Employee (HA) alleged that resident (Resident #1) had hit her in the stomach while they were performing incontinent care. (CNA A) had cursed at the resident telling him not to do that and slapped him on the forehead several times . Description of assessment . Resident had no physical injuries. His forehead had no discoloration or bruising noted. No redness or complaints of pain. Resident was interviewed as to the allegation and denied anything had occurred. His behavior was normal for his baseline. He has been doing his normal routine with no concerns from staff. DON checked daily for three days and assessed his mood and behaviors with no changes noted . Provider Response: . Upon receipt of allegations, employees involved were suspended immediately, including the individual making the allegation, pending outcome of investigation. Resident was assessed for injuries and evaluated for his feeling of safety, and any need for intervention as a result of the alleged incident. Resident had no physical injuries and denied the occurrence of the incident, stating he had no complaints about the staff. Residents responsible party, position and investment were notified. Police were called to report the allegation . Investigation Summary: . Resident #1 was the first with no injuries noted. He also denied that anything had occurred regarding an employee slapping him and cursing at him. His roommate, who was alert and oriented, was interviewed about if he witnessed or heard anything at the time this was alleged to occur, he stated that he didn't know of anything out of the ordinary but that (Resident #1) was all the time fighting the girls. Resident's roommate, (Resident #2), was asked about his feeling of safety and if anything had ever happened to him, as far as staff mistreating him, during his stay here and he stated no everything was fine. Responsible party of (Resident #1) was notified of allegation and to determine if he had shared anything related to allegation or any other time regarding his feeling of safety and well-being. She was not aware of anything abnormal or anything with him. Staff working the night of the alleged abuse were interviewed and were not aware of anything out of the ordinary occurring (with exception of the witness who reported the incident). (CNA A), alleged perpetrator, was interviewed. (CNA A) Stated that after (Resident #1) punched (HA) in this stomach, she (CNA A) had held him down so he could not hit her anymore. (CNA A) Stated that he had also tried to hit her. She denied cursing at him but said she told him this was unacceptable-that you cannot hit women. initially she denied slapping him but when asked by administrator if she had hit him on the forehead she stated she only did it to get him to stop hitting them. She demonstrated the same motion that was displayed by (HA) during her interview. Fingertips slapping forehead, palm down in front of face. Residents cared for by (CNA A) were interviewed to determine if they felt safe and if there were any other issues to report regarding staff treatment of residence. (Resident #1) continues to display no negative effects related to the incident. (CNA A) confirmed the allegation and was terminated from employment .Physician, family, police, and Ombudsman were notified of the incident. Investigation Findings: Confirmed. Provider Action Taken Post Investigation: Employee (CNA A) was terminated post investigation. (CNA C) and (HA) were suspended but reinstated after receiving additional training on abuse/neglect, reporting guidelines, and how to handle dementia and combative residence. Facility staff received in service training on abuse neglect, handling them into residence, and how they handle combative residents. Post test given and follow up on any staff lacking proper knowledge during testing related to abuse/neglect. training upon hire, at minimum annually and as needed. Review of Resident #1's progress notes by ADON, dated 02/29/2024, revealed Resident #1 head to toe skin assessment was performed with no skin alterations noted. Review of Provider Investigation Report, dated 3/6/2024, revealed monitoring statements signed by the Administrator for Resident #1, dated between 02/28/2024 and 03/01/2024 The monitoring statements signed by the Administrator revealed Resident #1 had exhibited no physical or psychosocial harm, had no indication of stress, no behaviors, he was socializing normally, and had no concerns. Review of statement, dated 03/06/2024, signed by Administrator, revealed Ombudsman spoke with Resident #1 that told her They fired her and slapped his head a few times when asked what happened and he denied that it hurt and had no further concerns. Review of inservices and employee roster provided by Administrator and DON, dated between 02/28/2024 and 03/01/2024 revealed all nursing staff received education on abuse and reporting. During an interview with the Administrator and DON on 03/26/2024 at 1:42 p.m., the Administrator said she was the abuse coordinator and was aware of a self-reported incident of abuse concerning Resident #1. The Administrator said the aide admitted that she did pat his head lightly to try to keep him from hitting her and they terminated her. She said the resident showed no signs of psychosocial or physical harm when the Administrator monitored him for three days following report of incident documented in her monitoring statements in provider investigation report. During an interview on 03/26/2024 at 3:05 p.m., the Ombudsman said Resident #1 was physically abused with two staff in the room and the Ombudsman had spoken with his RP and she was okay with how the facility was handling it. The Ombudsman said he has a speech impediment and was not aware of any skin changes or bruising. During an interview on 03/26/2024 at 3:26 p.m., PTA said he did not suspect abuse at this facility and had received training on abuse and handling dementia residents via in-services. PTA said if he suspected abuse he would report it to the ADM immediately. PTA said Resident #1 was doing good and has known him for 6 or 7 years and has had no change in condition. PTA said he can have behaviors but that he has known him for a long time but that they had a good relationship and he knew how to talk and approach him to maintain his trust. PTA said Resident #1 liked coming to therapy and doing his legs and had never had any concerns with staff being abusive or rough with him. During an interview and observation on 03/26/2024 at 4:20 p.m., Resident #1 said he was doing good and that everyone was nice to him at the facility. Resident #1 said he had no concerns. The Resident appeared well groomed, free from apparent injury, pleasant, and in no distress sitting up in wheelchair in his room watching television. During an interview on 03/27/2024 at 11:41 a.m., HA L said she did not suspect abuse, had been trained on abuse, reporting, and dementia residents via in-services, and had been employed at the facility for 2 years. HA L said it was important for resident's care plan to be followed to prevent harm and make sure all residents receive proper care. During an interview on 03/27/2024 at 11:56 a.m., CNA T said she had been employed at the facility for 5 years and did not suspect abuse. CNA T said she had received training on abuse, reporting, and caring for dementia residents. CNA T said if there is a resident that is showing signs or aggression she would try again later after the resident had calmed down and that if she ever witnessed any abuse she would report to the ADM or DON immediately. During an interview via phone on 03/27/2024 at 12:45 p.m., CNA C said The hospitality aide that worked at night came in and said I need to talk to you. She said I don't know what to do [CNA A] slapped the resident in the face twice. I said you should have reported it to the charge nurse. CNA C said HA told her she was scared, and afraid CNA A would retaliate on her if she reported the incident. CNA C said she knew should have reported it then, but she did not report it until the next day to her DON because she had told HA to report it. CNA C said Resident #1 had no injuries or behavior changes and the facility had provided training on abuse and when to report. CNA C said she would report to the DON or ADM any suspected abuse immediately and the abuse coordinator was the Administrator. CNA C felt the facility took care of that situation. CNA C said she had no previous concerns with the care provided by CNA A and believed it was an isolated incident. CNA C said it was important to report abuse immediately to ensure resident safety. During an interview on 03/27/2024 at 1:45 p.m., the Administrator said staff expectation was to report alleged abuse immediately. The Administrator said it was important to report immediately so that residents could be prevented from further harm and to allow the facility to respond to the situation. The Administrator said all staff received education on abuse and reporting. The Administrator said she has conducted a verbal audit check monthly to ensure staff knowledge on abuse, neglect, and reporting. The Administrator said she was the abuse coordinator and was responsible for training on abuse. During an interview via phone on 03/27/2024 at 2:11 p.m., HA said she had been at the facility for 5 months and works on the night shift. HA said she did witness the incident with Resident #1 and said she saw CNA A hit the resident on the face with her fingers on his forehead multiple times, roll him around and heard her tell the resident she could have someone come in to whoop his ass whenever she wanted to with him being in this bed. HA said after that happened CNA A left the room and HA stepped out of the room due to being upset and scared. HA said she returned to the room to finish his care and gave him a hug. HA said he had no injuries and never had any social isolation following the incident. HA said she has taken care of him since then and that he seems to be doing better with no combative behavior and appears happy. HA said the incident happened early in the morning between midnight and 4:00 a.m. HA said she did not know if CNA A worked the next day and that she does not remember working with her. HA said that she knew she should have reported the incident immediately to the abuse coordinator but that it was late and did not have her phone number. HA said she notified another CNA, CNA C, around 6:30 p.m. on 2/27/2024 and that CNA C notified the Administrator immediately. HA said that she had received training on abuse briefly in orientation and that she did receive training following the incident. HA said the abuse coordinator was the Administrator and that it was important for alleged abuse to be reported immediately to her to prevent abuse from occurring and further protect residents from harm. HA said she believed the incident was isolated and had no concerns with CNA A prior to this incident. HA said that CNA A was fired and that she felt the facility handled the situation appropriately. During an interview and record review on 03/27/2024 at 5:28 p.m., the Administrator said her expectations of staff was to report abuse immediately and that if she was notified of the abuse allegation promptly she would have responded the same way by suspending the perpetrator once notified, ensure residents were safe, and assess the resident/victim involved in the incident. The Administrator confirmed via timesheet the perpetrator continued to work the remainder of her shift following the abuse incident as well as the following shift the next day. The Administrator said the perpetrator was showing signs of different behavior and believe she had personal things going on at home that may have contributed to this isolated incident and that the employee had no concerns with her background check and had been working at the facility for 5 years. The Administrator and DON said they were responsible for training staff on abuse, reporting, and their expectations of staff when caring for aggressive residents included to approach in a calm manner, to stop what they are doing and come back later once the resident has calmed down. The Administrator said she had conducted an audit check of nursing staff to ensure knowledge of abuse, reporting, and handling residents with dementia and she would continue to conduct verbal audit checks monthly to verify knowledge of training. During an interview via phone on 03/28/2024 at 11:23 a.m., Detective K said there have been no warrants issued at this time for CNA A and that she had no criminal history or background indicating history of abusive behavior. Detective K said she was aware Resident #1's family was looking to

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to implement policies and procedures that prohibit and prevent abuse, neglect, and exploitation of resident to ensure residents were free from physical abuse for one of four residents (Resident #1) reviewed for abuse. 1. The facility failed to prevent physical abuse of Resident #1 who was hit on the head by CNA A on 02/27/2024. 2. The facility failed to ensure CNA A was not allowed to work after the allegation of abuse had been reported The noncompliance was identified as PNC. The IJ began on 02/27/2024 and ended on 03/05/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for physical harm, psychosocial harm, unsafe environment, and further abuse. Findings included: Review of facility policy, titled Abuse/Neglect Policy & Procedure, with no date, revealed the following: PREVENTION AND REPORTING: 1. The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. 2. The facility has designed and implemented processes, which strives to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. 3. The facility has implemented the following processes in an effort to provide residents/patients and staff a safe and comfortable environment. 4. Administrator is the Abuse Coordinator. The Administrator considers the Director of Nursing a designee for reporting and investigation of alleged abuse. In their absence, Admin and DON can appoint appropriate supervisory personnel to initiate investigation. 5. The Administrator and Director of Nursing are responsible for investigation and reporting. They are also ultimately responsible for the following as they relate to abuse, neglect, and/or misappropriation of property standards and procedures: Ongoing monitoring Reporting Investigation Tracking and trending 6. Implementation and ongoing monitoring consist of the following: Screening Training Prevention Identification Protection Investigation Reporting DEFINITIONS: Abuse Willful infliction of injury Unreasonable confinement Intimidation with resulting physical harm or mental anguish Punishment with resulting physical harm or pain or mental health Deprivation by the individual, including a caretaker, of good or service that is necessary to attain or maintain physical, mental, and psychosocial well being . Physical Abuse Includes hitting, slapping, pinching, scratching, spitting, holding, roughly, etc. It also includes controlling behavior through corporal punishment . Training 1. Provide training for new employees through orientation and with ongoing training programs. Training will include, but not limited to: Definitions of abuse, neglect, mistreatment, and misappropriation of property. Identification of abuse . Utilization of appropriate interventions to deal with aggressive and/or catastrophic (detrimental) reactions of residents/patients. How to provide protection for residents/patients How to investigate and report incidents of abuse, neglect, mistreatment, and misappropriation of property. Prevention of abuse, neglect, mistreatment, and misappropriation of property including, but not limited to, recognizing signs of burnout, frustration and stress . Prevention Ensure that prevention techniques are implemented in the facility including, but not limited to, ongoing supervision of employees through visual observation of care delivery and recognition of signs of burnout, frustration, and stress. 1. Identify, correct, and intervene in situations where abuse, neglect, and/or mistreatment are more likely to occur. This includes, but is not limited to, identification/analysis of: Secluded areas of the facility Sufficient staffing on each shift to meet the needs of the residents/patients Assigned staff demonstrating knowledge of individual resident/patient needs Sufficient and appropriate supervisory staff to identify inappropriate behaviors Residents with needs and behaviors which might lead to conflict or neglect 2. Encourage residents/patients and families to report concerns, incident, and grievances without fear of retribution. Provide feedback regarding the concerns that have been expressed. 3. Instruct staff that they are required to report resident concerns, incidents, and grievances. Identification 1. Identify events, such as suspicious bruising of residents/ patients, occurrences, patterns, and trends that mat constitute abuse, neglect, and/or mistreatment and investigate . 3. instruct staff, resident/patient, family call my visitor, etc. to report immediately, without fear of reprisal, any knowledge or suspicion of suspected abuse, neglect, mistreatment, and/or misappropriation of property. Protection 1. provide for the immediate safety of the resident patient upon identification of suspected abuse, neglect, mistreatment, and/or this appropriation of property. Means of providing protection include, but are not limited to: Moving resident/patient to another room or unit Provide 1:1 monitoring as appropriate Immediate suspension of suspected employee(s) pending outcome of the investigation . 2. Initiate behavior crisis management interventions, as applicable . 2. Administrator and/or designee will initiate the Investigation. The investigation should be thorough with witness statements from staff, resident, family members who are interview-able and have information regarding the allegation . Employee Suspension from Duty 1. Any time an allegation is made involving abuse, neglect, or mistreatment of a resident/patient which names a specific employee, laws and regulations are specific about protecting all residents/patients from harm / potential harm farmer which means suspending the employee until the completion of the investigation. 2. The employee is not to remain on duty, and is not to be assigned to any other area of the facility. 3. The administrator, or in his/her absence the Director of Nursing, Assistant Director of Nursing, or Charge nurse, in that order, must relieve the employee of his/her duty without pay until the investigation is complete. If the allegation is substantiated, the employee will be terminated immediately. 4. if the result of the investigation is in favor of the employee or is inconclusive, the employee will be paid regular wages during the time he/she was relieved from duty. Reporting 1. Notify the Administrator, DON, or Shift Supervisor/Charge Nurse immediately if suspected abuse, neglect, mistreatment, or misappropriation of property occurs. 2. Notify the appropriate State agency(s) after identification of alleged incident. initiate process according to State-specific regulations. 3. Person(s) initially identifying potential abuse, neglect, mistreatment, and/or misappropriation of property are accountable to report to proper chain of command. 4. Notify the legal guardian, spouse, or responsible family members/ significant other of the alleged or suspected abuse, neglect, mistreatment, and/or misappropriation of property. 5. Notify the physician of allegation and investigation. 6. Initiate contact with local law enforcement, immediately, when warranted, as required by state law. 7. Report results of investigation to the proper authorities as required by State law. 8. Follow up with resident/patient results and outcome of investigation and ensure their feelings of safety and security. Review of facility policy, titled Reporting Abuse, Neglect, and Mistreatment, with no date, revealed the following: Alleged, suspected or observed abuse, neglect or mistreatment of a resident or patient or his/her belongings are thoroughly investigated by the Administrator and/or the Director of Nursing. Alleged, suspected or observed violations are reported immediately to the Administrator, Regional [NAME] President, Medical Director, VP Quality & Compliance, Ombudsman, State Health and Environmental Departments, and all other officials required by state law. In all cases, the Administrator or Director of Nursing will immediately notify the resident or patient's legal guardian, family member, responsible party or significant other of the alleged, suspected or observed abuse, neglect or mistreatment. If a direct caregiver is observed, suspected or alleged to have engaed in abuse, neglect or mistreatment of resident/patient belongings, the caregiver will be relieved of duty and placed under investigative suspension by the Administrator, Director of Nursing or Nursing Supervisor, until the investigation is completed . Review of a facesheet for Resident #1, dated 03/27/2024, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses including: altered mental status, chronic pain, speech disturbances, muscle weakness, contracture of muscle (multiple sites), and dysphagia (difficulty swallowing). Review of Resident #1's Quarterly MDS, dated [DATE], revealed he had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate impairment. Resident #1's behavior and functional status revealed he had no physical or verbal behavioral symptoms directed towards others exhibited, he had impairment to both sides of upper and lower extremities and required substantial/maximal assistance with toileting hygiene. Review of Resident #1's care plan, revised 03/05/2024, revealed he had interventions in place for history of aggression with staff and dementia with behaviors to include: stopping and returning if resident becomes agitated, approach resident in a calm manner, talk while providing care, when resident becomes agitated intervene before agitation escalates by guiding away from source of distress, engaging calmly in conversation, approach at a later time if response is aggressive, and encourage resident to express feelings appropriately. Review of incident statement, dated 02/28/2024, signed by Administrator, revealed the following: Informed by [CNA C] that another [HA] had informed her that she had witnessed abuse by another staff member [CNA A]. Called [HA] to confirm statement. [HA] stated she was in the resident's room [Resident #1], with [CNA A] during incontinent care the resident punched her [HA] in the stomach, and she stepped back away from him. Then [CNA A] rolled resident over to his back and hollered motherfucker, do not do that again while slapping him in the forehead several times. The resident then swung at [CNA A]. When asked why [HA] did not report to supervisor immediately, she stated because she was scared of [CNA A] and that she had a look when she turned to look at her and she was upset about everything. Did not tell anyone until the next day when she told the other CNA, who reported to me. Review of witness statement, dated 02/28/2024 at 3:00 p.m., signed by CNA C, revealed the following: On 2-27-24 at approx. 6:30 pm, staff member [HA] told me that on Monday night while doing incontinent care, [Resident #1] had punched her in the stomach. HA said she stepped back and [CNA A] rolled [Resident #1] over and slapped him in the face and grabbed his hand. She said this scared her and she didn't know what to do. I told her she needed to go and report this to DON or Admin. She said she felt that she could come to me and that she didn't want to get anyone in trouble. [HA] said she had called her family member to talk about the situation. Review of witness statement, dated 02/28/2028, signed by HA, revealed the following: [HA] interviewed about incident that occurred with (Resident #1). She stated that on Tuesday morn (morning) at 3am (3:00 a.m.) during incontinent rounds, she and co-worker [CNA A] went into [Resident #1's] room. When they first went in the room he drew is fist back. [HA] stated she tried to talk him down because usually this will work. They began performing care and rolled him over toward her (she was between the bed and the wall) but he started hitting her in the stomach. [CNA A] then rolled him back over and slapped him more than once on the forehead. [HA] stated [CNA A] said I'll beat the f--- out of you. You know you laying in the bed and can't move. They finished the care and put a brief on him and left the room. After this [HA] said she went outside because she was upset. She stated she thought about leaving but didn't, she came back inside to complete shift. She didn't go to charge nurse at that time. Stated she was afraid she would be in trouble as well. This was the last round of the evening so nothing else occurred with other residents and [CNA A]. [HA] stated she went back into [Resident #1's] room and gave him a hug. He was fine and didn't seem upset. Stated she knows she should have said something but that she had never seen anything like this and it just scared her. Tuesday 2-27-24 at 6:30pm [HA] told [CNA C] what had occurred with [Resident #1] that morning during her shift. Review of witness statement, dated 02/28/2024, signed by LVN D, revealed the following: DON interviewed [LVN D] regarding alleged abuse incident that occurred with Resident #1. [LVN D] stated aides did not tell her that [Resident #1] hit [HA] or anything else that occurred after that point. She stated they told her that [Resident #1] was being difficult during incontinent care. The time reported to her was between 3am (3:00 a.m.) and 4am (4:00 a.m.) so it would have been their last round with him that night. Review of Associate Disciplinary Memorandums, dated 02/28/2024, revealed CNA A, HA, and CNA C were suspended pending investigation. CNA C and HA were reinstated and received training on abuse. CNA C received formal written disciplinary action for failing to report abuse. Supervisors Comments revealed CNA C was aware of reporting guidelines, understands not to wait if she believed anything has occurred, and stated she told employee to report to DON or Admin. CNA A was discharged effective 03/05/2024 due to employee confirming allegation of incident that warrants termination. Review of witness statement, dated 02/29/2024, signed by CNA A, revealed the following: [CNA A] interviewed in person by DON and Administrator on 2-29-24 at 10:15am. She was off on 2-28-24 when the investigation initiated and we were unable to reach her until late that evening. The meeting was set up for Thursday 2-29-24 to obtain statement and her version of events that occurred on 2-27-24 at 3am with [Resident #1]. STATEMENT: We went in to do incontinent care on [Resident #1]. He punched [HA] in the stomach. I tried to hold him down with his hands on his chest so he couldn't hit her anymore. When she was cleaning between his legs he tried to punch me. I told him: stop this, this is not how things go. We don't hit women, it does not work that way. [HA] said my doesn't even hit me. He continued to try to hit us. I did not hit him, it wouldn't do any good anyway. So I just held him down. I did not tell the nurse at that time, she wouldn't do anything anyway. I thought [HA] was going to tell her. No one should have to go into a room and wonder if they are going to get hit. It was self defense. Follow up: Admin asked about the curse words that were alleged. Asked her if she used the f-word. stated that she did not curse . maybe the worst she said was damn don't do this. Admin asked about the allegation that she slapped on the forehead several times and she said well yes she did do that just to get him to stop hitting. I asked her to demonstrate and she slapped her forehead several times with her fingers, palm down in front of nose. Admin asked about why she didn't just back away when he was combative as this could be one approach - she stated they just had to get the job done. Review of personnel record for CNA A revealed she was hired on 12/06/2018 and signed and dated policy for reporting abuse, responsibility for reporting abuse, and Senate [NAME] 9 employee acknowledgement that mistreatment or abuse will not be tolerated and will be subject to immediate discharge. Review of personnel record for HA revealed she was hired on 12/28/2023 and signed and dated policy for reporting abuse and responsibility for reporting abuse. Review of audit, titled Staff Awareness on What Constitutes Abuse, dated 01/25/2024, revealed CNA A and HA met criteria for knowing when and who to report allegations of abuse. Audit revealed met criteria for knowledge of reporting physical abuse immediately to the Administrator. Review of training records, dated 3/5/2024, completed by CNA A, revealed the following education was provided: Preventing, Recognizing, and Reporting Abuse, and Managing Anger completed on 08/13/2023 and Communication and People with Dementia completed on 02/05/2024. Review of training records, dated 3/1/2024, completed by CNA C, reveled the following education was provided: Communication and People with Dementia completed on 1/31/2024, Managing Anger on 08/09/2023, and Preventing, Recognizing, and Reporting Abuse on 03/03/2024. Review of Provider Investigation Report, dated 03/06/2024, revealed the following: .Description of the Allegation: Employee (HA) alleged that resident (Resident #1) had hit her in the stomach while they were performing incontinent care. (CNA A) had cursed at the resident telling him not to do that and slapped him on the forehead several times . Description of assessment . Resident had no physical injuries. His forehead had no discoloration or bruising noted. No redness or complaints of pain. Resident was interviewed as to the allegation and denied anything had occurred. His behavior was normal for his baseline. He has been doing his normal routine with no concerns from staff. DON checked daily for three days and assessed his mood and behaviors with no changes noted . Provider Response: . Upon receipt of allegations, employees involved were suspended immediately, including the individual making the allegation, pending outcome of investigation. Resident was assessed for injuries and evaluated for his feeling of safety, and any need for intervention as a result of the alleged incident. Resident had no physical injuries and denied the occurrence of the incident, stating he had no complaints about the staff. Residents responsible party, position and investment were notified. Police were called to report the allegation . Investigation Summary: . Resident #1 was the first with no injuries noted. He also denied that anything had occurred regarding an employee slapping him and cursing at him. His roommate, who was alert and oriented, was interviewed about if he witnessed or heard anything at the time this was alleged to occur, he stated that he didn't know of anything out of the ordinary but that (Resident #1) was all the time fighting the girls. Resident's roommate, (Resident #2), was asked about his feeling of safety and if anything had ever happened to him, as far as staff mistreating him, during his stay here and he stated no everything was fine. Responsible party of (Resident #1) was notified of allegation and to determine if he had shared anything related to allegation or any other time regarding his feeling of safety and well-being. She was not aware of anything abnormal or anything with him. Staff working the night of the alleged abuse were interviewed and were not aware of anything out of the ordinary occurring (with exception of the witness who reported the incident). (CNA A), alleged perpetrator, was interviewed. (CNA A) Stated that after (Resident #1) punched (HA) in this stomach, she (CNA A) had held him down so he could not hit her anymore. (CNA A) Stated that he had also tried to hit her. She denied cursing at him but said she told him this was unacceptable-that you cannot hit women. initially she denied slapping him but when asked by administrator if she had hit him on the forehead she stated she only did it to get him to stop hitting them. She demonstrated the same motion that was displayed by (HA) during her interview. Fingertips slapping forehead, palm down in front of face. Residents cared for by (CNA A) were interviewed to determine if they felt safe and if there were any other issues to report regarding staff treatment of residence. (Resident #1) continues to display no negative effects related to the incident. (CNA A) confirmed the allegation and was terminated from employment .Physician, family, police, and Ombudsman were notified of the incident. Investigation Findings: Confirmed. Provider Action Taken Post Investigation: Employee (CNA A) was terminated post investigation. (CNA C) and (HA) were suspended but reinstated after receiving additional training on abuse/neglect, reporting guidelines, and how to handle dementia and combative residence. Facility staff received in service training on abuse neglect, handling them into residence, and how they handle combative residents. Post test given and follow up on any staff lacking proper knowledge during testing related to abuse/neglect. training upon hire, at minimum annually and as needed. Review of Resident #1's progress notes by ADON, dated 02/29/2024, revealed Resident #1 head to toe skin assessment was performed with no skin alterations noted. Review of Provider Investigation Report, dated 3/6/2024, revealed monitoring statements signed by the Administrator for Resident #1, dated between 02/28/2024 and 03/01/2024 The monitoring statements signed by the Administrator revealed Resident #1 had exhibited no physical or psychosocial harm, had no indication of stress, no behaviors, he was socializing normally, and had no concerns. Review of statement, dated 03/06/2024, signed by Administrator, revealed Ombudsman spoke with Resident #1 that told her They fired her and slapped his head a few times when asked what happened and he denied that it hurt and had no further concerns. Review of inservices and employee roster provided by Administrator and DON, dated between 02/28/2024 and 03/01/2024 revealed all nursing staff received education on abuse and reporting. During an interview with the Administrator and DON on 03/26/2024 at 1:42 p.m., the Administrator said she was the abuse coordinator and was aware of a self-reported incident of abuse concerning Resident #1. The Administrator said the aide admitted that she did pat his head lightly to try to keep him from hitting her and they terminated her. She said the resident showed no signs of psychosocial or physical harm when the Administrator monitored him for three days following report of incident documented in her monitoring statements in provider investigation report. During an interview on 03/26/2024 at 3:05 p.m., the Ombudsman said Resident #1 was physically abused with two staff in the room and the Ombudsman had spoken with his RP and she was okay with how the facility was handling it. The Ombudsman said he has a speech impediment and was not aware of any skin changes or bruising. During an interview on 03/26/2024 at 3:26 p.m., PTA said he did not suspect abuse at this facility and had received training on abuse and handling dementia residents via in-services. PTA said if he suspected abuse he would report it to the ADM immediately. PTA said Resident #1 was doing good and has known him for 6 or 7 years and has had no change in condition. PTA said he can have behaviors but that he has known him for a long time but that they had a good relationship and he knew how to talk and approach him to maintain his trust. PTA said Resident #1 liked coming to therapy and doing his legs and had never had any concerns with staff being abusive or rough with him. During an interview and observation on 03/26/2024 at 4:20 p.m., Resident #1 said he was doing good and that everyone was nice to him at the facility. Resident #1 said he had no concerns. The Resident appeared well groomed, free from apparent injury, pleasant, and in no distress sitting up in wheelchair in his room watching television. During an interview on 03/27/2024 at 11:41 a.m., HA L said she did not suspect abuse, had been trained on abuse, reporting, and dementia residents via in-services, and had been employed at the facility for 2 years. HA L said it was important for resident's care plan to be followed to prevent harm and make sure all residents receive proper care. During an interview on 03/27/2024 at 11:56 a.m., CNA T said she had been employed at the facility for 5 years and did not suspect abuse. CNA T said she had received training on abuse, reporting, and caring for dementia residents. CNA T said if there is a resident that is showing signs or aggression she would try again later after the resident had calmed down and that if she ever witnessed any abuse she would report to the ADM or DON immediately. During an interview via phone on 03/27/2024 at 12:45 p.m., CNA C said The hospitality aide that worked at night came in and said I need to talk to you. She said I don't know what to do [CNA A] slapped the resident in the face twice. I said you should have reported it to the charge nurse. CNA C said HA told her she was scared, and afraid CNA A would retaliate on her if she reported the incident. CNA C said she knew should have reported it then, but she did not report it until the next day to her DON because she had told HA to report it. CNA C said Resident #1 had no injuries or behavior changes and the facility had provided training on abuse and when to report. CNA C said she would report to the DON or ADM any suspected abuse immediately and the abuse coordinator was the Administrator. CNA C felt the facility took care of that situation. CNA C said she had no previous concerns with the care provided by CNA A and believed it was an isolated incident. CNA C said it was important to report abuse immediately to ensure resident safety. During an interview on 03/27/2024 at 1:45 p.m., the Administrator said staff expectation was to report alleged abuse immediately. The Administrator said it was important to report immediately so that residents could be prevented from further harm and to allow the facility to respond to the situation. The Administrator said all staff received education on abuse and reporting. The Administrator said she has conducted a verbal audit check monthly to ensure staff knowledge on abuse, neglect, and reporting. The Administrator said she was the abuse coordinator and was responsible for training on abuse. During an interview via phone on 03/27/2024 at 2:11 p.m., HA said she had been at the facility for 5 months and works on the night shift. HA said she did witness the incident with Resident #1 and said she saw CNA A hit the resident on the face with her fingers on his forehead multiple times, roll him around and heard her tell the resident she could have someone come in to whoop his ass whenever she wanted to with him being in this bed. HA said after that happened CNA A left the room and HA stepped out of the room due to being upset and scared. HA said she returned to the room to finish his care and gave him a hug. HA said he had no injuries and never had any social isolation following the incident. HA said she has taken care of him since then and that he seems to be doing better with no combative behavior and appears happy. HA said the incident happened early in the morning between midnight and 4:00 a.m. HA said she did not know if CNA A worked the next day and that she does not remember working with her. HA said that she knew she should have reported the incident immediately to the abuse coordinator but that it was late and did not have her phone number. HA said she notified another CNA, CNA C, around 6:30 p.m. on 2/27/2024 and that CNA C notified the Administrator immediately. HA said that she had received training on abuse briefly in orientation and that she did receive training following the incident. HA said the abuse coordinator was the Administrator and that it was important for alleged abuse to be reported immediately to her to prevent abuse from occurring and further protect residents from harm. HA said she believed the incident was isolated and had no concerns with CNA A prior to this incident. HA said that CNA A was fired and that she felt the facility handled the situation appropriately. During an interview and record review on 03/27/2024 at 5:28 p.m., the Administrator said her expectations of staff was to report abuse immediately and that if she was notified of the abuse allegation promptly she would have responded the same way by suspending the perpetrator once notified, ensure residents were safe, and assess the resident/victim involved in the incident. The Administrator confirmed via timesheet the perpetrator continued to work the remainder of her shift following the abuse incident as well as the following shift the next day. The Administrator said the perpetrator was showing signs of different behavior and believe she had personal things going on at home that may have contributed to this isolated incident and that the employee had no concerns with her background check and had been working at the facility for 5 years. The Administrator and DON said they were responsible for training staff on abuse, reporting, and their expectations of staff when caring for aggressive residents included to approach in a calm manner, to stop what they are doing and come back later once the resident has calmed down. The Administrator said she had conducted an audit check of nursing staff to ensure knowledge of abuse, reporting, and handling residents with dementia and she would continue to conduct verbal audit checks monthly to verify knowledge of training. During an interview via phone on 03/28/2024 at 11:23 a.m., Detective K said there have been no warrants issued at this time for CNA A and[TRUNC

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse or mistreatment were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to the administrator of the facility and to other officials (including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one of four residents (Resident #1) reviewed for abuse. 1. The facility failed to report physical abuse of Resident #1 to the Administrator immediately following HA witnessing CNA A hit Resident #1 on the head on 02/27/2024 at approximately 3:00 a.m. during incontinent care. 2. HA notified CNA C of a witnessed abuse incident on 02/27/2024 at 6:30 p.m. and CNA C did not report the allegation of abuse to the administrator/abuse prohibition coordinator until 02/28/2024 at approximately 3:00 p.m. The noncompliance was identified as PNC. The IJ began on 02/27/2024 and ended on 03/05/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for physical harm, psychosocial harm, unsafe environment, and further abuse. Findings included: Review of facility policy, titled Abuse/Neglect Policy & Procedure, with no date, revealed the following: PREVENTION AND REPORTING: 1. The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. 2. The facility has designed and implemented processes, which strives to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. 3. The facility has implemented the following processes in an effort to provide residents/patients and staff a safe and comfortable environment. 4. Administrator is the Abuse Coordinator. The Administrator considers the Director of Nursing a designee for reporting and investigation of alleged abuse. In their absence, Admin and DON can appoint appropriate supervisory personnel to initiate investigation. 5. The Administrator and Director of Nursing are responsible for investigation and reporting. They are also ultimately responsible for the following as they relate to abuse, neglect, and/or misappropriation of property standards and procedures: Ongoing monitoring Reporting Investigation Tracking and trending 6. Implementation and ongoing monitoring consist of the following: Screening Training Prevention Identification Protection Investigation Reporting DEFINITIONS: Abuse Willful infliction of injury Unreasonable confinement Intimidation with resulting physical harm or mental anguish Punishment with resulting physical harm or pain or mental health Deprivation by the individual, including a caretaker, of good or service that is necessary to attain or maintain physical, mental, and psychosocial well being . Physical Abuse Includes hitting, slapping, pinching, scratching, spitting, holding, roughly, etc. It also includes controlling behavior through corporal punishment . Training 1. Provide training for new employees through orientation and with ongoing training programs. Training will include, but not limited to: Definitions of abuse, neglect, mistreatment, and misappropriation of property. Identification of abuse . Utilization of appropriate interventions to deal with aggressive and/or catastrophic (detrimental) reactions of residents/patients. How to provide protection for residents/patients How to investigate and report incidents of abuse, neglect, mistreatment, and misappropriation of property. Prevention of abuse, neglect, mistreatment, and misappropriation of property including, but not limited to, recognizing signs of burnout, frustration and stress . Prevention Ensure that prevention techniques are implemented in the facility including, but not limited to, ongoing supervision of employees through visual observation of care delivery and recognition of signs of burnout, frustration, and stress. 1. Identify, correct, and intervene in situations where abuse, neglect, and/or mistreatment are more likely to occur. This includes, but is not limited to, identification/analysis of: Secluded areas of the facility Sufficient staffing on each shift to meet the needs of the residents/patients Assigned staff demonstrating knowledge of individual resident/patient needs Sufficient and appropriate supervisory staff to identify inappropriate behaviors Residents with needs and behaviors which might lead to conflict or neglect 2. Encourage residents/patients and families to report concerns, incident, and grievances without fear of retribution. Provide feedback regarding the concerns that have been expressed. 3. Instruct staff that they are required to report resident concerns, incidents, and grievances. Identification 1. Identify events, such as suspicious bruising of residents/ patients, occurrences, patterns, and trends that mat constitute abuse, neglect, and/or mistreatment and investigate . 3. instruct staff, resident/patient, family call my visitor, etc. to report immediately, without fear of reprisal, any knowledge or suspicion of suspected abuse, neglect, mistreatment, and/or misappropriation of property. Protection 1. provide for the immediate safety of the resident patient upon identification of suspected abuse, neglect, mistreatment, and/or this appropriation of property. Means of providing protection include, but are not limited to: Moving resident/patient to another room or unit Provide 1:1 monitoring as appropriate Immediate suspension of suspected employee(s) pending outcome of the investigation . 2. Initiate behavior crisis management interventions, as applicable . 2. Administrator and/or designee will initiate the Investigation. The investigation should be thorough with witness statements from staff, resident, family members who are interview-able and have information regarding the allegation . Employee Suspension from Duty 1. Any time an allegation is made involving abuse, neglect, or mistreatment of a resident/patient which names a specific employee, laws and regulations are specific about protecting all residents/patients from harm / potential harm farmer which means suspending the employee until the completion of the investigation. 2. The employee is not to remain on duty, and is not to be assigned to any other area of the facility. 3. The administrator, or in his/her absence the Director of Nursing, Assistant Director of Nursing, or Charge nurse, in that order, must relieve the employee of his/her duty without pay until the investigation is complete. If the allegation is substantiated, the employee will be terminated immediately. 4. if the result of the investigation is in favor of the employee or is inconclusive, the employee will be paid regular wages during the time he/she was relieved from duty. Reporting 1. Notify the Administrator, DON, or Shift Supervisor/Charge Nurse immediately if suspected abuse, neglect, mistreatment, or misappropriation of property occurs. 2. Notify the appropriate State agency(s) after identification of alleged incident. initiate process according to State-specific regulations. 3. Person(s) initially identifying potential abuse, neglect, mistreatment, and/or misappropriation of property are accountable to report to proper chain of command. 4. Notify the legal guardian, spouse, or responsible family members/ significant other of the alleged or suspected abuse, neglect, mistreatment, and/or misappropriation of property. 5. Notify the physician of allegation and investigation. 6. Initiate contact with local law enforcement, immediately, when warranted, as required by state law. 7. Report results of investigation to the proper authorities as required by State law. 8. Follow up with resident/patient results and outcome of investigation and ensure their feelings of safety and security. Review of facility policy, titled Reporting Abuse, Neglect, and Mistreatment, with no date, revealed the following: Alleged, suspected or observed abuse, neglect or mistreatment of a resident or patient or his/her belongings are thoroughly investigated by the Administrator and/or the Director of Nursing. Alleged, suspected or observed violations are reported immediately to the Administrator, Regional [NAME] President, Medical Director, VP Quality & Compliance, Ombudsman, State Health and Environmental Departments, and all other officials required by state law. In all cases, the Administrator or Director of Nursing will immediately notify the resident or patient's legal guardian, family member, responsible party or significant other of the alleged, suspected or observed abuse, neglect or mistreatment. If a direct caregiver is observed, suspected or alleged to have engaed in abuse, neglect or mistreatment of resident/patient belongings, the caregiver will be relieved of duty and placed under investigative suspension by the Administrator, Director of Nursing or Nursing Supervisor, until the investigation is completed . Review of a facesheet for Resident #1, dated 03/27/2024, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses including: altered mental status, chronic pain, speech disturbances, muscle weakness, contracture of muscle (multiple sites), and dysphagia (difficulty swallowing). Review of Resident #1's Quarterly MDS, dated [DATE], revealed he had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate impairment. Resident #1's behavior and functional status revealed he had no physical or verbal behavioral symptoms directed towards others exhibited, he had impairment to both sides of upper and lower extremities and required substantial/maximal assistance with toileting hygiene. Review of Resident #1's care plan, revised 03/05/2024, revealed he had interventions in place for history of aggression with staff and dementia with behaviors to include: stopping and returning if resident becomes agitated, approach resident in a calm manner, talk while providing care, when resident becomes agitated intervene before agitation escalates by guiding away from source of distress, engaging calmly in conversation, approach at a later time if response is aggressive, and encourage resident to express feelings appropriately. Review of incident statement, dated 02/28/2024, signed by Administrator, revealed the following: Informed by [CNA C] that another [HA] had informed her that she had witnessed abuse by another staff member [CNA A]. Called [HA] to confirm statement. [HA] stated she was in the resident's room [Resident #1], with [CNA A] during incontinent care the resident punched her [HA] in the stomach, and she stepped back away from him. Then [CNA A] rolled resident over to his back and hollered motherfucker, do not do that again while slapping him in the forehead several times. The resident then swung at [CNA A]. When asked why [HA] did not report to supervisor immediately, she stated because she was scared of [CNA A] and that she had a look when she turned to look at her and she was upset about everything. Did not tell anyone until the next day when she told the other CNA, who reported to me. Review of witness statement, dated 02/28/2024 at 3:00 p.m., signed by CNA C, revealed the following: On 2-27-24 at approx. 6:30 pm, staff member [HA] told me that on Monday night while doing incontinent care, [Resident #1] had punched her in the stomach. HA said she stepped back and [CNA A] rolled [Resident #1] over and slapped him in the face and grabbed his hand. She said this scared her and she didn't know what to do. I told her she needed to go and report this to DON or Admin. She said she felt that she could come to me and that she didn't want to get anyone in trouble. [HA] said she had called her family member to talk about the situation. Review of witness statement, dated 02/28/2028, signed by HA, revealed the following: [HA] interviewed about incident that occurred with (Resident #1). She stated that on Tuesday morn (morning) at 3am (3:00 a.m.) during incontinent rounds, she and co-worker [CNA A] went into [Resident #1's] room. When they first went in the room he drew is fist back. [HA] stated she tried to talk him down because usually this will work. They began performing care and rolled him over toward her (she was between the bed and the wall) but he started hitting her in the stomach. [CNA A] then rolled him back over and slapped him more than once on the forehead. [HA] stated [CNA A] said I'll beat the f--- out of you. You know you laying in the bed and can't move. They finished the care and put a brief on him and left the room. After this [HA] said she went outside because she was upset. She stated she thought about leaving but didn't, she came back inside to complete shift. She didn't go to charge nurse at that time. Stated she was afraid she would be in trouble as well. This was the last round of the evening so nothing else occurred with other residents and [CNA A]. [HA] stated she went back into [Resident #1's] room and gave him a hug. He was fine and didn't seem upset. Stated she knows she should have said something but that she had never seen anything like this and it just scared her. Tuesday 2-27-24 at 6:30pm [HA] told [CNA C] what had occurred with [Resident #1] that morning during her shift. Review of witness statement, dated 02/28/2024, signed by LVN D, revealed the following: DON interviewed [LVN D] regarding alleged abuse incident that occurred with Resident #1. [LVN D] stated aides did not tell her that [Resident #1] hit [HA] or anything else that occurred after that point. She stated they told her that [Resident #1] was being difficult during incontinent care. The time reported to her was between 3am (3:00 a.m.) and 4am (4:00 a.m.) so it would have been their last round with him that night. Review of Associate Disciplinary Memorandums, dated 02/28/2024, revealed CNA A, HA, and CNA C were suspended pending investigation. CNA C and HA were reinstated and received training on abuse. CNA C received formal written disciplinary action for failing to report abuse. Supervisors Comments revealed CNA C was aware of reporting guidelines, understands not to wait if she believed anything has occurred, and stated she told employee to report to DON or Admin. CNA A was discharged effective 03/05/2024 due to employee confirming allegation of incident that warrants termination. Review of witness statement, dated 02/29/2024, signed by CNA A, revealed the following: [CNA A] interviewed in person by DON and Administrator on 2-29-24 at 10:15am. She was off on 2-28-24 when the investigation initiated and we were unable to reach her until late that evening. The meeting was set up for Thursday 2-29-24 to obtain statement and her version of events that occurred on 2-27-24 at 3am with [Resident #1]. STATEMENT: We went in to do incontinent care on [Resident #1]. He punched [HA] in the stomach. I tried to hold him down with his hands on his chest so he couldn't hit her anymore. When she was cleaning between his legs he tried to punch me. I told him: stop this, this is not how things go. We don't hit women, it does not work that way. [HA] said my doesn't even hit me. He continued to try to hit us. I did not hit him, it wouldn't do any good anyway. So I just held him down. I did not tell the nurse at that time, she wouldn't do anything anyway. I thought [HA] was going to tell her. No one should have to go into a room and wonder if they are going to get hit. It was self defense. Follow up: Admin asked about the curse words that were alleged. Asked her if she used the f-word. stated that she did not curse . maybe the worst she said was damn don't do this. Admin asked about the allegation that she slapped on the forehead several times and she said well yes she did do that just to get him to stop hitting. I asked her to demonstrate and she slapped her forehead several times with her fingers, palm down in front of nose. Admin asked about why she didn't just back away when he was combative as this could be one approach - she stated they just had to get the job done. Review of personnel record for CNA A revealed she was hired on 12/06/2018 and signed and dated policy for reporting abuse, responsibility for reporting abuse, and Senate [NAME] 9 employee acknowledgement that mistreatment or abuse will not be tolerated and will be subject to immediate discharge. Review of personnel record for HA revealed she was hired on 12/28/2023 and signed and dated policy for reporting abuse and responsibility for reporting abuse. Review of audit, titled Staff Awareness on What Constitutes Abuse, dated 01/25/2024, revealed CNA A and HA met criteria for knowing when and who to report allegations of abuse. Audit revealed met criteria for knowledge of reporting physical abuse immediately to the Administrator. Review of training records, dated 3/5/2024, completed by CNA A, revealed the following education was provided: Preventing, Recognizing, and Reporting Abuse, and Managing Anger completed on 08/13/2023 and Communication and People with Dementia completed on 02/05/2024. Review of training records, dated 3/1/2024, completed by CNA C, reveled the following education was provided: Communication and People with Dementia completed on 1/31/2024, Managing Anger on 08/09/2023, and Preventing, Recognizing, and Reporting Abuse on 03/03/2024. Review of Provider Investigation Report, dated 03/06/2024, revealed the following: .Description of the Allegation: Employee (HA) alleged that resident (Resident #1) had hit her in the stomach while they were performing incontinent care. (CNA A) had cursed at the resident telling him not to do that and slapped him on the forehead several times . Description of assessment . Resident had no physical injuries. His forehead had no discoloration or bruising noted. No redness or complaints of pain. Resident was interviewed as to the allegation and denied anything had occurred. His behavior was normal for his baseline. He has been doing his normal routine with no concerns from staff. DON checked daily for three days and assessed his mood and behaviors with no changes noted . Provider Response: . Upon receipt of allegations, employees involved were suspended immediately, including the individual making the allegation, pending outcome of investigation. Resident was assessed for injuries and evaluated for his feeling of safety, and any need for intervention as a result of the alleged incident. Resident had no physical injuries and denied the occurrence of the incident, stating he had no complaints about the staff. Residents responsible party, position and investment were notified. Police were called to report the allegation . Investigation Summary: . Resident #1 was the first with no injuries noted. He also denied that anything had occurred regarding an employee slapping him and cursing at him. His roommate, who was alert and oriented, was interviewed about if he witnessed or heard anything at the time this was alleged to occur, he stated that he didn't know of anything out of the ordinary but that (Resident #1) was all the time fighting the girls. Resident's roommate, (Resident #2), was asked about his feeling of safety and if anything had ever happened to him, as far as staff mistreating him, during his stay here and he stated no everything was fine. Responsible party of (Resident #1) was notified of allegation and to determine if he had shared anything related to allegation or any other time regarding his feeling of safety and well-being. She was not aware of anything abnormal or anything with him. Staff working the night of the alleged abuse were interviewed and were not aware of anything out of the ordinary occurring (with exception of the witness who reported the incident). (CNA A), alleged perpetrator, was interviewed. (CNA A) Stated that after (Resident #1) punched (HA) in this stomach, she (CNA A) had held him down so he could not hit her anymore. (CNA A) Stated that he had also tried to hit her. She denied cursing at him but said she told him this was unacceptable-that you cannot hit women. initially she denied slapping him but when asked by administrator if she had hit him on the forehead she stated she only did it to get him to stop hitting them. She demonstrated the same motion that was displayed by (HA) during her interview. Fingertips slapping forehead, palm down in front of face. Residents cared for by (CNA A) were interviewed to determine if they felt safe and if there were any other issues to report regarding staff treatment of residence. (Resident #1) continues to display no negative effects related to the incident. (CNA A) confirmed the allegation and was terminated from employment .Physician, family, police, and Ombudsman were notified of the incident. Investigation Findings: Confirmed. Provider Action Taken Post Investigation: Employee (CNA A) was terminated post investigation. (CNA C) and (HA) were suspended but reinstated after receiving additional training on abuse/neglect, reporting guidelines, and how to handle dementia and combative residence. Facility staff received in service training on abuse neglect, handling them into residence, and how they handle combative residents. Post test given and follow up on any staff lacking proper knowledge during testing related to abuse/neglect. training upon hire, at minimum annually and as needed. Review of Resident #1's progress notes by ADON, dated 02/29/2024, revealed Resident #1 head to toe skin assessment was performed with no skin alterations noted. Review of Provider Investigation Report, dated 3/6/2024, revealed monitoring statements signed by the Administrator for Resident #1, dated between 02/28/2024 and 03/01/2024 The monitoring statements signed by the Administrator revealed Resident #1 had exhibited no physical or psychosocial harm, had no indication of stress, no behaviors, he was socializing normally, and had no concerns. Review of statement, dated 03/06/2024, signed by Administrator, revealed Ombudsman spoke with Resident #1 that told her They fired her and slapped his head a few times when asked what happened and he denied that it hurt and had no further concerns. Review of inservices and employee roster provided by Administrator and DON, dated between 02/28/2024 and 03/01/2024 revealed all nursing staff received education on abuse and reporting. During an interview with the Administrator and DON on 03/26/2024 at 1:42 p.m., the Administrator said she was the abuse coordinator and was aware of a self-reported incident of abuse concerning Resident #1. The Administrator said the aide admitted that she did pat his head lightly to try to keep him from hitting her and they terminated her. She said the resident showed no signs of psychosocial or physical harm when the Administrator monitored him for three days following report of incident documented in her monitoring statements in provider investigation report. During an interview on 03/26/2024 at 3:05 p.m., the Ombudsman said Resident #1 was physically abused with two staff in the room and the Ombudsman had spoken with his RP and she was okay with how the facility was handling it. The Ombudsman said he has a speech impediment and was not aware of any skin changes or bruising. During an interview on 03/26/2024 at 3:26 p.m., PTA said he did not suspect abuse at this facility and had received training on abuse and handling dementia residents via in-services. PTA said if he suspected abuse he would report it to the ADM immediately. PTA said Resident #1 was doing good and has known him for 6 or 7 years and has had no change in condition. PTA said he can have behaviors but that he has known him for a long time but that they had a good relationship and he knew how to talk and approach him to maintain his trust. PTA said Resident #1 liked coming to therapy and doing his legs and had never had any concerns with staff being abusive or rough with him. During an interview and observation on 03/26/2024 at 4:20 p.m., Resident #1 said he was doing good and that everyone was nice to him at the facility. Resident #1 said he had no concerns. The Resident appeared well groomed, free from apparent injury, pleasant, and in no distress sitting up in wheelchair in his room watching television. During an interview on 03/27/2024 at 11:41 a.m., HA L said she did not suspect abuse, had been trained on abuse, reporting, and dementia residents via in-services, and had been employed at the facility for 2 years. HA L said it was important for resident's care plan to be followed to prevent harm and make sure all residents receive proper care. During an interview on 03/27/2024 at 11:56 a.m., CNA T said she had been employed at the facility for 5 years and did not suspect abuse. CNA T said she had received training on abuse, reporting, and caring for dementia residents. CNA T said if there is a resident that is showing signs or aggression she would try again later after the resident had calmed down and that if she ever witnessed any abuse she would report to the ADM or DON immediately. During an interview via phone on 03/27/2024 at 12:45 p.m., CNA C said The hospitality aide that worked at night came in and said I need to talk to you. She said I don't know what to do [CNA A] slapped the resident in the face twice. I said you should have reported it to the charge nurse. CNA C said HA told her she was scared, and afraid CNA A would retaliate on her if she reported the incident. CNA C said she knew should have reported it then, but she did not report it until the next day to her DON because she had told HA to report it. CNA C said Resident #1 had no injuries or behavior changes and the facility had provided training on abuse and when to report. CNA C said she would report to the DON or ADM any suspected abuse immediately and the abuse coordinator was the Administrator. CNA C felt the facility took care of that situation. CNA C said she had no previous concerns with the care provided by CNA A and believed it was an isolated incident. CNA C said it was important to report abuse immediately to ensure resident safety. During an interview on 03/27/2024 at 1:45 p.m., the Administrator said staff expectation was to report alleged abuse immediately. The Administrator said it was important to report immediately so that residents could be prevented from further harm and to allow the facility to respond to the situation. The Administrator said all staff received education on abuse and reporting. The Administrator said she has conducted a verbal audit check monthly to ensure staff knowledge on abuse, neglect, and reporting. The Administrator said she was the abuse coordinator and was responsible for training on abuse. During an interview via phone on 03/27/2024 at 2:11 p.m., HA said she had been at the facility for 5 months and works on the night shift. HA said she did witness the incident with Resident #1 and said she saw CNA A hit the resident on the face with her fingers on his forehead multiple times, roll him around and heard her tell the resident she could have someone come in to whoop his ass whenever she wanted to with him being in this bed. HA said after that happened CNA A left the room and HA stepped out of the room due to being upset and scared. HA said she returned to the room to finish his care and gave him a hug. HA said he had no injuries and never had any social isolation following the incident. HA said she has taken care of him since then and that he seems to be doing better with no combative behavior and appears happy. HA said the incident happened early in the morning between midnight and 4:00 a.m. HA said she did not know if CNA A worked the next day and that she does not remember working with her. HA said that she knew she should have reported the incident immediately to the abuse coordinator but that it was late and did not have her phone number. HA said she notified another CNA, CNA C, around 6:30 p.m. on 2/27/2024 and that CNA C notified the Administrator immediately. HA said that she had received training on abuse briefly in orientation and that she did receive training following the incident. HA said the abuse coordinator was the Administrator and that it was important for alleged abuse to be reported immediately to her to prevent abuse from occurring and further protect residents from harm. HA said she believed the incident was isolated and had no concerns with CNA A prior to this incident. HA said that CNA A was fired and that she felt the facility handled the situation appropriately. During an interview and record review on 03/27/2024 at 5:28 p.m., the Administrator said her expectations of staff was to report abuse immediately and that if she was notified of the abuse allegation promptly she would have responded the same way by suspending the perpetrator once notified, ensure residents were safe, and assess the resident/victim involved in the incident. The Administrator confirmed via timesheet the perpetrator continued to work the remainder of her shift following the abuse incident as well as the following shift the next day. The Administrator said the perpetrator was showing signs of different behavior and believe she had personal things going on at home that may have contributed to this isolated incident and that the employee had no concerns with her background check and had been working at the facility for 5 years. The Administrator and DON said they were r[