**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the right of the residents to be free from abuse for 2 of 4 residents (Resident #2, Resident #3) reviewed for abuse. The facility failed to protect other residents from being kicked by Resident #1, when Resident #1 kicked Resident #3's feet when he walked by him on 1/12/25 at 5:20 am. The facility failed to recognize and put measures in place for Resident #1's increased behaviors from 01/09/2025 through 01/12/2025, which resulted in Resident #1 choking Resident #2. An Immediate Jeopardy (IJ) was identified on 02/27/2025 at 1:40 PM. The IJ template was provided to the facility on [DATE] at 1:06 p.m. While the IJ was removed on 02/28/2025, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet dated 02/27/2025 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE], with diagnoses including depression, hypercholesterolemia (high blood cholesterol that limits blood flow), hypertension (high blood pressure), delusional disorders (mental illness that causes people to have false beliefs), and dementia (degenerative brain disease - loss of memory, language). Record review of the comprehensive MDS dated [DATE] indicated Resident #1 had a BIMS score of 0 and was severely cognitively impaired. Resident #1's MDS indicated wandering behavior was exhibited, and physical and verbal behaviors towards others. Resident #1 was not assessed due to medical condition or safety concerns for eating, toileting, showering, dressing and personal hygiene, ambulation, or transfers. Record review of the consolidated physician orders dated 02/27/2025 indicated Resident #1 had an order for behavior monitoring for Diazepam,(medication used to treat anxiety, muscle spasms, and seizures) Seroquel (medication used to treat schizophrenia (disorder that affects a person's ability to think clearly), bipolar disorder (mood swings) and depression), Trazodone (medication used to treat depression) , and Wellbutrin (medication used to treat depression). Document number of times the resident has exhibited the above behavior during shift. Document the intervention and document the outcome with a start date of 09/25/2024. Record review of the care plan with a revision date of 01/15/2024 indicated Resident #1 had the potential to be physically aggressive related to dementia with the following interventions Administer medications as ordered after attempting non-medical approaches, analyze times of day, places, circumstances, triggers and what de-escalates behavior, anticipate needs such as food, water, toileting, if behavior is threat to self or others immediately call for assistance. If signs of agitation shown - intervene before it escalates: remain calm, stand out of reach, listen and respond with empathy, engage in conversation. If response is aggressive, team member to calmly walk away, ask others to leave, ensure everyone is safe, immediately report this to nurse. Record review of the facilities Incident and Accidents Report dated 10/01/2024 - 01/26/2025 indicated no reported incidents involving Resident #1 and Resident #3. Record review of a progress note dated 01/09/2025 at 2:07 PM by LVN A, indicated Resident #1 had behaviors with 2 other residents without physical contact. Record review of a progress noted dated 01/09/2025 at 08:38 PM by LVN B, indicated Resident #1 snatched a cover off another resident in the commons area of the secured unit. Resident #1 swung at staff when approached. Record review of progress noted dated 01/09/2025 at 08:40 PM by LVN B, indicated Resident #1 was going into other resident's rooms. Resident #1 raised his hand to the nurse and then walked out of the room. Record review of progress note dated 01/09/2025 at 09:09 PM by LVN B, indicated Resident #1 was bent down and kneeled on the floor then laid down on the floor. Resident #1 was given a pillow and covered with a blanket. Record review of progress note dated 01/09/2025 at 09:19 PM by LVN B, indicated Resident #1 was bent down and kneeled on the floor then laid down on the floor then got up and started pacing from door to door, shaking the doors. The ADON and the DON were notified of the behaviors. Record review of progress noted dated 01/12/2025 at 01:42 AM by LVN F, indicated Resident #1 was exit seeking, restless, and in and out of other resident's rooms. Resident #1 removed his pants in the commons area in the secured unit. Record review of progress note dated 01/12/2025 at 05:20 AM by LVN F, indicated Resident #1 (as he walked by) kicked Resident #3's feet while he was sitting in his wheelchair. Resident #1 was going in other resident rooms and pacing the secured unit. Record review of progress noted dated 01/12/2025 at 07:00 AM by LVN C, indicated Resident #1 was up and pacing. Resident #1 was grabbing other resident's wheelchairs and attempting to move them. Resident #1 was crawling in hallway. Resident #1 continued to disturb other residents. Record review of progress noted dated 01/12/2025 at 08:40 AM by LVN C, indicated Resident #1 was entering rooms, busting in doors, combative with staff, required assistance by two staff members to remove from room. Resident #1 continued to push and pulled on other resident's wheelchairs. Resident was unable to be redirected. The MA reported Resident #1 continued to refuse his medications with multiple approaches. Resident #1 shoved LVN C in the chest then knocked the medication cup from LVN C. LVN C notified the Administrator, the DON, and the ADON of unable to control/redirect Resident #1, and the escalating behaviors. LVN C then notified Resident #1's family. Record review of progress note dated 01/12/2025 at 08:50 AM by LVN C indicated CNA D summoned for nurse and reported Resident #1 had entered Resident #2's room and physically attacked Resident #2. CNA D reported she observed Resident #2 lying in her bed with Resident #1 leaned over Resident 2 with his hands wrapped around her neck attempting to choke Resident #2. CNA D stated she had to physically pry Resident #1's hands/fingers off Resident #2's neck and restrain him to the floor. When LVN C entered Resident #2's room, Resident #1 was restrained by CNA D. Immediate notification made for 911 services. The family was notified of escalating behaviors and transfer and agreed to the transfer. Record review of a face sheet dated 02/27/2025 indicated Resident #2 was a 75 -year-old female, admitted to the facility on [DATE], with diagnoses including neuralgia (pain associated with nerves), weakness, age related physical debility, dementia (degenerative brain disease - loss of memory, language), and anxiety (intense, excessive worry). Record review of the comprehensive MDS dated [DATE] indicated Resident #2 had a BIMS score of 3 and was severely cognitively impaired. Resident #2's MDS indicated she required set up assistance with eating, partial assistance with personal hygiene, and substantial assistance with toileting, dressing, and showering. Resident #2's MDS indicated she was independent with ambulation. Record review of the consolidated physician orders dated 02/27/2025 indicated Resident 2 had an order to monitor for pain every shift. During an interview with the DON on 2/27/2025 at 10:10 AM , a copy of the Resident's #2 care plan was requested and not received prior to exiting the facility. Record review of progress note dated 01/12/2025 at 08:50 AM by LVN A indicated CNA D summoned for nurse and reported Resident #1 had entered Resident #2's room and physically attacked Resident #2. CNA D reported she observed Resident #2 lying in her bed with Resident #1 leaned over Resident 2 with his hands wrapped around her neck attempting to choke Resident #2. CNA D stated she had to physically pry Resident #1's hands/fingers off Resident #2's neck and restrain him to the floor. When LVN C entered Resident #2's room, Resident #1 was restrained by CNA D. CNA E was summoned to Resident #2's room and escorted Resident #2 from the room. Resident #2 was taken to a chair in the commons area of the memory care unit. Resident #2 was upset and crying. Assessment completed with vital signs within normal limits, oxygen saturation at 97%, no redness or bruising noted, and no petechia observed to bilateral eyes. Police officer and EMT arrived at the facility. The EMT completed a full assessment of Resident #2 until Resident #2 stopped the EMT and stated' I am fine. Resident #2 assured the EMT she was safe and could return to her room. Resident #2's family member arrived at the facility and took Resident #2 via private care to the hospital emergency room for evaluation. The Administrator and the DON were made aware of reportable to state. Record review of hospital discharge paperwork dated 01/12/2025 indicated Resident #2 was discharged with unremarkable findings. Record review of a face sheet dated 02/27/2025 indicated Resident #3 was an [AGE] year-old male, admitted to the facility on [DATE], with diagnoses including hypoglycemia (low blood sugar), type 2 diabetes mellitus (chronic disease when the body does not make insulin properly) mixed hyperlipidemia (causes high levels of cholesterol in the blood), hypertension (high blood pressure), and Alzheimer's disease (a progressive disease that destroys memory and other mental functions). Record review of the discharge MDS dated [DATE] indicated Resident #3 had a BIMS score of 0 and was severely cognitively impaired. Resident #3's MDS indicated wandering behavior was exhibited, physical and verbal behaviors towards others. The MDS indicated Resident #3 required set up assistance for eating. The MDS indicated Resident #3 required partial/moderate assistance for oral and toileting hygiene, partial assistance for shower, dressing, personal hygiene, ambulation, and transfers. Record review of the consolidated physician orders dated 02/27/2025 indicated Resident #3 had an order for behavior monitoring for Seroquel (medication used to treat schizophrenia (disorder that affects a person's ability to think clearly) Document number of times resident has exhibited the above behavior during shift. Document the intervention and document the outcome with a start date of 01/06/2025. During an interview with the DON on 2/27/25 at 10:10 AM, a copy of the Resident #3's care plan was requested and not received prior to exiting the facility. Record Review of Resident #3's progress notes dated 01/12/2025 indicated no incidents or assessments completed. Attempted interview on 02/25/2025 at 11:32 AM with Resident #2, she was not interview able. During an interview on 02/26/2025 at 09:30 AM, LVN C stated she had worked at the facility for approximately 2 years. LVN C stated Resident #1 was an elopement risk from another facility and required the secured unit. LVN C stated on 01/12/25 at 08:50 AM she received a telephone call from CNA E, to come to the secured unit to Resident #2's room. LVN C stated upon arrival CNA D had restrained Resident #1 on the floor. CNA E had removed Resident #2 to the commons area of the secured unit. LVN C stated she notified 911 for assistance. LVN C stated upon arrival of the police and the EMT, Resident #1 was transferred out of the facility. LVN C stated she completed an assessment on Resident #2. LVN C stated Resident #2 was upset and crying but then stated she was fine and declined any further care. LVN C stated Resident #2's family arrived and transported her to the emergency room via a private car. LVN C stated Resident #1's behaviors had escalated from the start of her shift at 06:00 AM. LVN C stated Resident #1 disturbed other residents by pulling on wheelchairs, walked with a rapid pace, crawled on the floors. LVN C stated she had not notified the physician of the increase of behaviors. LVN C stated she had contacted Resident #1's family at 08:40 AM. LVN C stated she contacted the ADON and the DON regarding Resident #1's escalated behaviors at 08:40 AM. LVN C stated, I guessed the ADON and DON were working to have the resident transferred out. LVN C stated she was not sure who was making the transfer arrangements at that time. LVN C stated she had reached out to the ADON and the DON via text message and neither were in the facility at that time. LVN C stated she could not recall what exactly she had been told by the ADON and the DON other than redirect Resident #1, but she would have charted the instructions received if she had received any. LVN C stated everything was happening very quickly and she had not delegated any 1 to 1 intervention because the facility did not have the staff. LVN C stated Resident #1 should have been transferred out to a behavioral unit due to escalating behaviors. LVN C stated 1 to 1 intervention could have prevented the choking incident between Resident #1 and Resident #2 but there was not enough staff. LVN C stated Resident #1 was not adequately monitored during the escalated behaviors that resulted in Resident #2 being choked while she was asleep in her bed. During an interview on 02/26/2025 at 10:21 AM, CNA E said Resident #1 had escalated behaviors on 1/12/2025 and was more difficult to redirect and was disturbing the other residents. CNA E said she had reported to LVN C several behaviors since the start of her shift at 6:00 AM. CNA E said Resident #1 was sitting at the table with her and CNA D and appeared settled at that moment. CNA E said she left the secured unit to retrieve the breakfast trays while CNA D was providing care with another resident. Upon returning to the secured unit, she heard CNA D hollering to get help. CNA E said upon entering resident #2's room, CNA D was attempting to restrain Resident #1 from going at Resident #2. CNA E said she removed Resident #2 to the commons area at the front of the secured unit. CNA E said she alerted LVN C by the phone located in the commons area of the secured unit to come and assist CNA D. CNA E said they continued to keep Resident #1 from other residents until the EMT arrived to transport Resident #1. During an interview on 02/26/2025 at 01:15 PM, CNA D said during her shift on 1/12/2025. she noticed Resident #1 was not in the commons area or his room after she finished providing care to another resident. CNA D stated while she looked for Resident #1, she faintly heard Resident #2 call for help. CNA D said when she entered Resident #2's room, Resident #1 was leaning over Resident #2 with both hands around her neck. CNA D said she had to pry Resident #1's hands and fingers from Resident #1's neck. CNA D said she got him down in a sitting position on the floor and placed his hands behind his back as Resident #1 continued to try to go at Resident #2. CNA D stated CNA E arrived back on the secured unit, and she yelled for her. CNA E removed Resident #2 from the room and notified LVN C by the phone located in the commons area of the secured unit. CNA D stated she continued to restrain Resident #1 until the police arrived. LVN C entered the room and then contacted 911. CNA D said the EMTs, and police assisted to transport Resident #1 out of the building to the hospital. During an interview on 02/26/2025 at 03:41 PM, the social worker stated she had not worked on a transfer for Resident #1 until 01/15/2025 after Resident #1 had transferred from the facility. The social worker stated she could not recall any conversation or text messages regarding Resident #1 until after he had left from the facility. The social worker stated escalated behaviors were addressed by putting the care plan interventions in place. When those interventions failed, the facility would transfer the resident with escalating behaviors out of the facility to a behavior unit. The social worker defined escalated behaviors as a change from the resident's baseline behavior such as increased agitation, crawling on floors, no longer able to distract the resident. The social worker said these failures could resulted in harm to residents such as death. During an interview on 02/26/2025 at 07:11 PM, LVN F said Resident #1's behavior had changed. LVN F stated Resident #1 could usually be redirected. LVN F stated that she reported to the ADON and the DON on 01/11/2025 that Resident #1 was more difficult to redirect. LVN F stated she was instructed to continue to redirect the resident and give medications as ordered. LVN F stated Resident #1 took off his pants in the commons area which he had never done anything like that before. LVN F stated the CNA reported to her that Resident #1 kicked Resident #3. LVN F stated she failed to complete the incident report and report the incident to the ADON, the DON, or the Administrator. LVN F stated the incident should have been investigated due to being a resident-to-resident altercation. LVN F stated it was at change of shift and although she had reported the incident to the oncoming shift, an incident report should have been completed by her at the time the incident had occurred. LVN F stated the physician should have been notified as well as the families of the residents involved. LVN F stated reporting should be completed for investigation and to protect the residents from abuse. During an interview on 02/26/2025 at 07:59 PM, LVN G stated Resident #1 experienced escalated behaviors on 01/09/2025. LVN G reported to the ADON and the DON that Resident #1 was crawling around and laying on the floor with his eyes closed. LVN G stated she was instructed by the ADON to give a pillow and blanket and ensure Resident #1 was warm and leave on the floor to sleep. LVN G stated she did not contact the physician for a change of condition related to increased behaviors. LVN G stated Resident #1 was pacing more often and faster. Resident #1 was blocking the doors and shaking the door handles to the secured unit which made it difficult for staff to get through. LVN G recalled Resident #1 took a swing at one of the CNAs. Resident #1 was entering in another resident's rooms and the staff had to coax Resident #1 out and attempted to detour him from going into another resident's rooms. LVN G stated Resident #1 raised his hand at her when she attempted to redirect Resident #1 from another resident's rooms. LVN G stated the CNA reported Resident #1 had jerked covers off of another resident in the commons area of the secured unit. LVN G said when the previous interventions were not effective, she should have also contacted the physician for orders. LVN G said as the charge nurse she was responsible for reporting the change of condition. LVN G said the residents were in harms way such as the choking or death. During an interview on 02/27/2025 at 10:10 AM, the DON identified escalating behaviors as increased agitation, loudness/screaming, and showing signs of aggression. The DON stated Resident #1 was at his baseline and was not showing signs of escalating behaviors. The DON did not respond to the state surveyor when asked if the charted behaviors reported to her through 01/09/2025 - 01/12/2025 describe the definitions as she had identified above as escalated behaviors of Resident #1. The DON said the behaviors exhibited by Resident #1 were typical behaviors of a resident with dementia. The DON said when the staff notified her of the incident with Resident #1 choking Resident #2, she told the staff (CNA E and LVN C) via text message that Resident #1 needed to be sent out because the facility did not provide 1 to 1 care. The DON stated the physician was notified as well as the families after the incident occurred. The DON said there was no way to know the choking incident was going to happen prior to the incident taking place. The DON said the incident with Resident #1 kicking Resident #3 could have been an accident while Resident #1 walked by Resident #3. The DON stated, we don't care what the residents do to the staff - residents hit staff all the time and it did not mean the behaviors were escalated. The DON said they educated the staff on better resident approaching strategies to prevent residents hitting staff. The DON later said when Resident #1 kicked Resident #3 feet, it was considered a resident-to-resident altercation and should have been reported as an incident and investigated to rule out abuse. During an interview on 02/27/2025 at 10:30 AM, the ADON stated Resident #1 exhibited behaviors of a dementia patient and she had not considered the behaviors to be escalated between the dates of 01/09/2025 - 01/12/2025. The ADON described an escalated behavior as something different from their typical baseline behavior and that varied between each individual resident. The ADON stated staff had reported Resident #1 jerking the blanket off another Resident but Resident #1 could have thought that was his blanket. The ADON stated she had told the staff to give Resident #1 the pillow and blanket and ensure resident was warm because he was sleeping and settled/safe on the floor. The ADON said it had not been reported except during the time of 01/09/2025 - 01/12/2025 of Resident #1 pulling/jerking covers from other residents or crawling/laying/sleeping in the floors. The ADON said it was not unusual for dementia residents to wander in and out of room rooms. The ADON stated that was why Resident #1 was in the secured unit due to wandering. The ADON said the incident when Resident #1 hit Resident #3 should have been reported as an incident and the physician, family, the abuse coordinator should have been notified for further investigation. The ADON said abuse allegations should be investigated to protect all residents from abuse. During an interview on 02/27/2025 at 10:50 AM, the Administrator stated behaviors were often unpredictable and predictable to a point. The Administrator said the facility and staff do their best to minimize behaviors and keep all residents safe. The Administrator said, it was not the best ideal to take eyes off of Resident #1 during the 10-minute time frame that the incident occurred within. The Administrator stated he expected staff to report incidents of suspected abuse including suspected resident to resident altercations so that the incident was then followed up on by him with a thorough investigation. The Administrator stated all staff were responsible for ensuring that no resident was subject to any type of abuse. The Administrator said the choking incident and failure of reporting incidents appropriately placed residents at a potential risk of abuse by physical or emotional trauma. The facility policy titled Abuse, Neglect Exploitation, & Misappropriation Policy dated 09/2024 indicated: .The resident has the right to be free of abuse, neglect, exploitation, and misappropriation of resident property and other reportable incidents that affect the Health and Safety of the resident .Physical Abuse includes slapping, biting .5. Abuse toward a resident can occur as: a. resident to resident abuse; . The Administrator was notified on 02/27/2025 at 01:04 PM that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 02/27/2025 at 1:06 PM. The facility's Plan of Removal was accepted on 02/27/2025 at 06:30 PM. and included: Tag F-600: Systemic Approach 1. Resident 1 was transferred to The Local Hospital's Emergency Department where he was admitted to the Behavioral Health hospital on 1/12/2025. As indicated on SRI #556297, the resident is not to return to the facility to eliminate the risk of behavior happening again. 2. The Medical Director was immediately notified by the Director of Nurses on 2/27/2025 at 2:11pm and the Chief Operating Officer at 1:07pm of the Immediate Jeopardy. 3. Administrator review of the following facility policy on 2.27.2025: a. Abuse, Neglect, Exploitation, & Misappropriation Policy b. Resident to Resident Altercations 4. An immediate in-service to be provided by Regional Nurse Consultant to Administrator, DON and staff at facility with the subject of Recognizing Escalating Behaviors and Effective Measures to Put in Place to Protect Residents on 2/27/2025 at 2:20pm. a. Main takeaways from training include: the use of interventions which include 1:1 monitoring, redirecting, social services department visits and using calming music. 5. An Immediate in-service of the facility's Abuse policy to be conducted for all staff. Employees not present at building will be called via phone and provided in-service information. Inservice of staff will be completed by 2/28/2025 by 5:00pm. Other staff will be in-serviced before their next shift. A questionnaire will be created from the abuse policy. Questionnaires will be provided at random to employees to ensure retention of policy. Employees answering wrongly on questionnaires will receive more training. Admin/DON/ADON are responsible for conducting the training. 6. An immediate QAPI meeting to be held by IDT on 2.27.2025 a. Review of incident b. Establish areas of improvement c. Create plan to monitor and manage areas of improvement 7. Safe Surveys were conducted at the time of the incident. Results from the survey can be found with supportive documents provided to State surveyor and in SRI folder administrator keeps on hand. Safe survey results indicated no other residents were in need of additional supervision. 8. Monitoring: a. Admin or DON will conduct weekly random questionnaires of the abuse policy for a period of 4 weeks to ensure staff retain knowledge from the Abuse Policy. 9. Root Cause Analysis was conducted on 2/27/2024 identifying issues related to incidents on 1/12/2025. It was established that employees need more education of the abuse policy and aware of effective ways to de-escalate resident behaviors. This education was immediately provided on 2/27/2025. 10. Quality Assurance a. An ad hoc Quality Assurance Meeting will be conducted with IDT, including medical director via phone call on 2/27/2025. b. The IJs for F689 and F600 were noted and steps for removal were discussed. c. Incidents have been reviewed with plans to improve. i. Improvement plans include Notifying physician immediately, placing interventions in place immediately such as 1:1 monitoring, redirecting, separating residents, and removing residents from environment. Deescalating behaviors and recognizing signs of escalating behaviors. d. Plan on Removal being conducted. e. The Medical Director made no relevant comments at the time of meeting. He agreed that discussions related to the incident during the meeting are thorough and will be effective. O2/28/2025, the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the immediate jeopardy by: Record Review of in-service dated 02/27/2025 provided by the Regional Nurse to the Administrator, the DON, and the ADON with the following topics: A. Abuse, Neglect, Exploitation, & Misappropriation Policy B. Resident to Resident Altercations Record Review of the in-service dated 02/27/2025 at 2:20 PM provided by the Regional Nurse Consult to the Administrator, the DON, and the staff at the facility with the subject topic of: Recognizing Escalating Behaviors and effective measure to put in place to protect the residents such as intervention of 1:1 monitoring, redirecting, social services departments visit, and using calming music. Record review of in-service dated 02/27/2025 of the facility's Abuse policy conducted for all staff. (Employees not present at the building will be called via phone and provided in-service information. In-service of staff will be completed by 2/28/2025 by 5:00pm. Other staff will be in-serviced before their next shift. ) Record review of a questionnaire created from the abuse policy with 25 employee/staff correctly completed on 02/28/2025. (Questionnaires will be provided at random to employees to ensure retention of policy. Employees answering wrongly on questionnaires will receive more training. Admin/DON/ADON were responsible for conducting the training) Record review of signed QAPI Committee Meeting completed on 2/27/2025 at 2:20 PM addressed the following: a. An ad hoc Quality Assurance Meeting will be conducted with IDT, including medical director via phone call on 2/27/2025. b. The IJs for F689 and F600 were noted and steps for removal were discussed. c. Incidents have been reviewed with plans to improve. i. Improvement plans include Notifying physician immediately, placing interventions in place immediately such as 1:1 monitoring, redirecting, separating residents, and removing residents from environment. Deescalating behaviors and recognizing signs of escalating behaviors. d. Plan on Removal being conducted. e. The Medical Director made no relevant comments at the time of meeting. He agreed that discussions related to the incident during the meeting are thorough and will be effective. Interviews of nursing staff on 2/28/2025 from 09:49 AM - 11:55 AM (6 AM - 6 PM Shift) DON, ADON, MDS Nurse, LVN C, CNA D, CNA E, CNA L, MA P, LVN Q, LVN W, LVN A, CNA AA, (6PM - 6AM) MA X, LVN Y, LVN Z, CNA BB, CNA CC, CNA DD, CNA EE, Administrator, Dietary Manager, Assistant Dietary Manager, Housekeeping Supervisor, Social Worker, Maintenance Supervisor, Director Business Development, Medical Records, Dietary Aide H, Housekeeper K, Housekeeper M, Housekeeper N, Director of Rehabilitation, PTA U, OT V, Activities Assistant. During these interviews staff were able to correctly identify types of abuse such as physical, sexual, verbal and resident to resident altercations; who to notify if abuse was suspected - such as the abuse coordinator, physician, families; proper documentation in resident charts, incident reports and care plans; recognizing escalated behaviors such as increased screaming and agitation and notifying the physician immediately of escalating behaviors; ways to de-escalate behaviors 1 to 1 monitoring, redirecting, separating residents, removing residents from the environment, calming music, and social services. On 02/28/2025 at 12:00 PM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facilities need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 2 of 3 residents (Resident #2 and Resident #3) reviewed for accidents and supervision. The facility failed to increase supervision and implement interventions when Resident #1 displayed increased behaviors beginning on 1/9/25 to prevent resident to resident altercations. The facility failed to ensure Resident #1 received adequate supervision to prevent escalating behaviors towards other residents. The facility failed to ensure Resident #1 received adequate supervision after displaying increased behaviors beginning on 1/9/25 which resulted in Resident #1 choking Resident #2. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 1:40 PM on 02/27/2025. While the IJ was removed on 02/28/2025, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of accidents, injury, or death. Findings included: Record review of a face sheet dated 02/27/2025 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE], with diagnoses including depression, hypercholesterolemia (high blood cholesterol that limits blood flow), hypertension (high blood pressure), delusional disorders (mental illness that causes people to have false beliefs), and dementia (degenerative brain disease - loss of memory, language). Record review of the comprehensive MDS dated [DATE] indicated Resident #1 had a BIMS score of 0 and was severely cognitively impaired. Resident #1's MDS indicated wandering behavior was exhibited, and physical and verbal behaviors towards others. Resident #1 was not assessed due to medical condition or safety concerns for eating, toileting, showering, dressing and personal hygiene, ambulation, or transfers. Record review of the consolidated physician orders dated 02/27/2025 indicated Resident #1 had an order for behavior monitoring for Diazepam,(medication used to treat anxiety, muscle spasms, and seizures) Seroquel (medication used to treat schizophrenia (disorder that affects a person's ability to think clearly), bipolar disorder (mood swings) and depression), Trazodone (medication used to treat depression) , and Wellbutrin (medication used to treat depression). Document number of times the resident has exhibited the above behavior during shift. Document the intervention and document the outcome with a start date of 09/25/2024. Record review of the care plan with a revision date of 01/15/2024 indicated Resident #1 had the potential to be physically aggressive related to dementia with the following interventions Administer medications as ordered after attempting non-medical approaches, analyze times of day, places, circumstances, triggers and what de-escalates behavior, anticipate needs such as food, water, toileting, if behavior is threat to self or others immediately call for assistance. If signs of agitation shown - intervene before it escalates: remain calm, stand out of reach, listen and respond with empathy, engage in conversation. If response is aggressive, team member to calmly walk away, ask others to leave, ensure everyone is safe, immediately report this to nurse. Record review of the facilities Incident and Accidents Report dated 10/01/2024 - 01/26/2025 indicated no reported incidents involving Resident #1 and Resident #3. Record review of a progress note dated 01/09/2025 at 2:07 PM by LVN A, indicated Resident #1 had behaviors with 2 other residents without physical contact. Record review of a progress noted dated 01/09/2025 at 08:38 PM by LVN B, indicated Resident #1 snatched a cover off another resident in the commons area of the secured unit. Resident #1 swung at staff when approached. Record review of progress noted dated 01/09/2025 at 08:40 PM by LVN B, indicated Resident #1 was going into other resident's rooms. Resident #1 raised his hand to the nurse and then walked out of the room. Record review of progress note dated 01/09/2025 at 09:09 PM by LVN B, indicated Resident #1 was bent down and kneeled on the floor then laid down on the floor. Resident #1 was given a pillow and covered with a blanket. Record review of progress note dated 01/09/2025 at 09:19 PM by LVN B, indicated Resident #1 was bent down and kneeled on the floor then laid down on the floor then got up and started pacing from door to door, shaking the doors. The ADON and the DON were notified of the behaviors. Record review of progress noted dated 01/12/2025 at 01:42 AM by LVN F, indicated Resident #1 was exit seeking, restless, and in and out of other resident's rooms. Resident #1 removed his pants in the commons area in the secured unit. Record review of progress note dated 01/12/2025 at 05:20 AM by LVN F, indicated Resident #1 (as he walked by) kicked Resident #3's feet while he was sitting in his wheelchair. Resident #1 was going in other resident rooms and pacing the secured unit. Record review of progress noted dated 01/12/2025 at 07:00 AM by LVN C, indicated Resident #1 was up and pacing. Resident #1 was grabbing other resident's wheelchairs and attempting to move them. Resident #1 was crawling in hallway. Resident #1 continued to disturb other residents. Record review of progress noted dated 01/12/2025 at 08:40 AM by LVN C, indicated Resident #1 was entering rooms, busting in doors, combative with staff, required assistance by two staff members to remove from room. Resident #1 continued to push and pulled on other resident's wheelchairs. Resident was unable to be redirected. The MA reported Resident #1 continued to refuse his medications with multiple approaches. Resident #1 shoved LVN C in the chest then knocked the medication cup from LVN C. LVN C notified the Administrator, the DON, and the ADON of unable to control/redirect Resident #1, and the escalating behaviors. LVN C then notified Resident #1's family. Record review of progress note dated 01/12/2025 at 08:50 AM by LVN C indicated CNA D summoned for nurse and reported Resident #1 had entered Resident #2's room and physically attacked Resident #2. CNA D reported she observed Resident #2 lying in her bed with Resident #1 leaned over Resident 2 with his hands wrapped around her neck attempting to choke Resident #2. CNA D stated she had to physically pry Resident #1's hands/fingers off Resident #2's neck and restrain him to the floor. When LVN C entered Resident #2's room, Resident #1 was restrained by CNA D. Immediate notification made for 911 services. The family was notified of escalating behaviors and transfer and agreed to the transfer. Record review of a face sheet dated 02/27/2025 indicated Resident #2 was a 75 -year-old female, admitted to the facility on [DATE], with diagnoses including neuralgia (pain associated with nerves), weakness, age related physical debility, dementia (degenerative brain disease - loss of memory, language), and anxiety (intense, excessive worry). Record review of the comprehensive MDS dated [DATE] indicated Resident #2 had a BIMS score of 3 and was severely cognitively impaired. Resident #2's MDS indicated she required set up assistance with eating, partial assistance with personal hygiene, and substantial assistance with toileting, dressing, and showering. Resident #2's MDS indicated she was independent with ambulation. Record review of the consolidated physician orders dated 02/27/2025 indicated Resident 2 had an order to monitor for pain every shift. During an interview with the DON on 2/27/2025 at 10:10 AM , a copy of the Resident's #2 care plan was requested and not received prior to exiting the facility. Record review of progress note dated 01/12/2025 at 08:50 AM by LVN A indicated CNA D summoned for nurse and reported Resident #1 had entered Resident #2's room and physically attacked Resident #2. CNA D reported she observed Resident #2 lying in her bed with Resident #1 leaned over Resident 2 with his hands wrapped around her neck attempting to choke Resident #2. CNA D stated she had to physically pry Resident #1's hands/fingers off Resident #2's neck and restrain him to the floor. When LVN C entered Resident #2's room, Resident #1 was restrained by CNA D. CNA E was summoned to Resident #2's room and escorted Resident #2 from the room. Resident #2 was taken to a chair in the commons area of the memory care unit. Resident #2 was upset and crying. Assessment completed with vital signs within normal limits, oxygen saturation at 97%, no redness or bruising noted, and no petechia observed to bilateral eyes. Police officer and EMT arrived at the facility. The EMT completed a full assessment of Resident #2 until Resident #2 stopped the EMT and stated' I am fine. Resident #2 assured the EMT she was safe and could return to her room. Resident #2's family member arrived at the facility and took Resident #2 via private care to the hospital emergency room for evaluation. The Administrator and the DON were made aware of reportable to state. Record review of hospital discharge paperwork dated 01/12/2025 indicated Resident #2 was discharged with unremarkable findings. Record review of a face sheet dated 02/27/2025 indicated Resident #3 was an [AGE] year-old male, admitted to the facility on [DATE], with diagnoses including hypoglycemia (low blood sugar), type 2 diabetes mellitus (chronic disease when the body does not make insulin properly) mixed hyperlipidemia (causes high levels of cholesterol in the blood), hypertension (high blood pressure), and Alzheimer's disease (a progressive disease that destroys memory and other mental functions). Record review of the discharge MDS dated [DATE] indicated Resident #3 had a BIMS score of 0 and was severely cognitively impaired. Resident #3's MDS indicated wandering behavior was exhibited, physical and verbal behaviors towards others. The MDS indicated Resident #3 required set up assistance for eating. The MDS indicated Resident #3 required partial/moderate assistance for oral and toileting hygiene, partial assistance for shower, dressing, personal hygiene, ambulation, and transfers. Record review of the consolidated physician orders dated 02/27/2025 indicated Resident #3 had an order for behavior monitoring for Seroquel (medication used to treat schizophrenia (disorder that affects a person's ability to think clearly) . Document number of times resident has exhibited the above behavior during shift. Document the intervention and document the outcome with a start date of 01/06/2025. During an interview with the DON at 2/27/25 at 10:10 AM, a copy of the Resident #3's care plan was requested and not received prior to exiting the facility. Record Review of Resident #3's progress notes dated 01/12/2025 indicated no incidents or assessments completed. Attempted interview on 02/25/2025 at 11:32 AM with Resident #2, she was not interview able. During an interview on 02/26/2025 at 09:30 AM, LVN C stated she had worked at the facility for approximately 2 years. LVN C stated Resident #1 was an elopement risk from another facility and required the secured unit. LVN C stated on 01/12/25 at 08:50 AM she received a telephone call from CNA E, to come to the secured unit to Resident #2's room. LVN C stated upon arrival CNA D had restrained Resident #1 on the floor. CNA E had removed Resident #2 to the commons area of the secured unit. LVN C stated she notified 911 for assistance. LVN C stated upon arrival of the police and the EMT, Resident #1 was transferred out of the facility. LVN C stated she completed an assessment on Resident #2. LVN C stated Resident #2 was upset and crying but then stated she was fine and declined any further care. LVN C stated Resident #2's family arrived and transported her to the emergency room via a private car. LVN C stated Resident #1's behaviors had escalated from the start of her shift at 06:00 AM. LVN C stated Resident #1 disturbed other residents by pulling on wheelchairs, walked with a rapid paced crawled on the floors. LVN C stated she had not notified the physician of the increase of behaviors. LVN C stated she had contacted Resident #1's family at 08:40 AM. LVN C stated she contacted the ADON and the DON regarding Resident #1's escalated behaviors at 08:40 AM. LVN C stated, I guessed the ADON and the DON were working to have the resident transferred out. LVN C stated she was not sure who was making the transfer arrangements at that time. LVN C stated she had reached out to the ADON and the DON via text message and neither were in the facility at that time. LVN C stated she could not recall what exactly she had been told by the ADON and DON other than redirect Resident #1, but she would have charted the instructions received if she had received any. LVN C stated everything was happening very quickly and she had not delegated any 1 to 1 intervention because the facility did not have the staff. LVN C stated there was not enough staff to do 1 to 1 supervision with Resident #1. LVN C stated lack of staff for the 1 to 1 supervision of Resident #1 resulted in another resident being harmed. During an interview on 02/26/2025 at 10:21 AM, CNA E said Resident #1 had escalated behaviors on 1/12/2025 and was more difficult to redirect and was disturbing the other residents. CNA E said she had reported to LVN C several behaviors since the start of her shift at 6:00 AM. CNA E said Resident #1 was sitting at the table with her and CNA D and appeared settled at that moment. CNA E said she left the secured unit to retrieve the breakfast trays while CNA D was providing care with another resident. Upon returning to the secured unit, she heard CNA D hollering to get help. CNA E said upon entering resident #2's room, CNA D was attempting to restrain Resident #1 from going at Resident #2. CNA E said she removed Resident #2 to the commons area at the front of the secured unit. CNA E said she alerted LVN C by the phone located in the commons area of the secured unit to come and assist CNA D. CNA E said she should have stayed on the unit and prevented the incident, but she had left the unit to get the trays for the other residents because there was no other staff to do so at that time. CNE E said she had notified the charge nurse and she thought she had sent a text message to the DON and ADON about Resident #1 behaviors and was told to continue to monitor and distract Resident #1. CNA E said the lack of supervision during Resident #1's escalating behaviors resulted in Resident #2 being choked in her room. During an interview on 02/26/2025 at 01:15 PM, CNA D said during her shift on 1/12/2025. she noticed Resident #1 was not in the commons area or his room after she finished providing care to another resident. CNA D stated while she looked for Resident #1, she faintly heard Resident #2 call for help. CNA D said when she entered Resident #2's room, Resident #1 was leaning over Resident #2 with both hands around her neck. CNA D said she had to pry Resident #1's hands and fingers from Resident #1's neck. CNA D said she got him down in a sitting position on the floor and placed his hands behind his back as Resident #1 continued to try to go at Resident #2. CNA D stated CNA E arrived back on the secured unit, and she yelled for her. CNA E removed Resident #2 from the room and notified LVN C by the phone located in the commons area of the secured unit. CNA D stated she continued to restrain Resident #1 until the police arrived. LVN C entered the room and then contacted 911. CNA D said the EMTs, and police assisted to transport Resident #1 out of the building to the hospital. CNA D said Resident #1 should not have been left alone. CNA D said Resident #1 was out of control. CNA D said the charge nurse had been notified previously through out the morning. CNA D said lack of supervision resulted in Resident #2 being choked. During an interview on 02/26/2025 at 03:41 PM, the social worker stated she had not worked on a transfer for Resident #1 until 01/15/2025 after Resident #1 had transferred from the facility. The social worker stated she could not recall any conversation or text messages regarding resident #1 until after he had left from the facility. The social worker stated when the care plan interventions failed, Resident #1 should have been placed on 1 to 1 supervision for all resident safety including the safety of Resident #1 and transferred from the facility. The social worker stated the physician should have been notified by the clinical staff and new orders should have been received. During an interview on 02/26/2025 at 07:11 PM, LVN F said Resident #1's behavior had changed LVN F stated Resident #1 could usually be redirected. LVN F stated that she reported to the ADON andthe the DON on 01/11/2025 that Resident #1 was more difficult to redirect. LVN F stated she was instructed to continue to redirect the resident and give medications as ordered. LVN F stated Resident #1 took off his pants in the commons area which he had never done anything like that before. LVN F stated the CNA reported to her that Resident #1 kicked Resident #3. LVN F stated she failed to complete the incident report and report the incident to the ADON, the DON or the Administrator. LVN F stated the incident should have been investigated due to being a resident-to-resident altercation. LVN F stated it was at change of shift and although she had reported the incident to the oncoming shift, an incident report should have been completed by her at the time the incident had occurred. LVN F stated the physician should have been notified as well as the families of the residents involved. LVN F stated reporting should be completed for investigation and to protect the residents from abuse. During an interview on 02/26/2025 at 07:59 PM, LVN G stated Resident #1 experienced escalated behaviors on 01/09/2025. LVN G reported to the ADON and the DON that Resident #1 was crawling around and laying on the floor with his eyes closed. LVN G stated she was instructed by the ADON to give a pillow and blanket and ensure Resident #1 was warm and leave on the floor to sleep. LVN G stated she did not contact the physician for a change of condition related to increased behaviors. LVN G stated Resident #1 was pacing more often and faster. Resident #1 was blocking the doors and shaking the door handles to the secured unit which made it difficult for staff to get through. LVN G recalled Resident #1 took a swing at one of the CNAs. Resident #1 was entering in another resident's rooms and the staff had to coax Resident #1 out and attempted to detour him from going into another resident's rooms. LVN G stated Resident #1 raised his hand at her when she attempted to redirect Resident #1 from another resident's rooms. LVN G stated the CNA reported Resident #1 had jerked covers off of another resident in the commons area of the secured unit. LVN G stated she should have contacted the physician and received new orders regarding Resident #1's change in escalating behaviors to ensure the other residents were not placed in harm or danger of Resident #1. During an interview on 02/27/2025 at 10:10 AM, the DON identified escalating behaviors as increased agitation, loudness/screaming, and showing signs of aggression. The DON stated Resident #1 was at his baseline and was not showing signs of escalating behaviors. The DON did not respond to the state surveyor when asked if the charted behaviors reported to her through 01/09/2025 - 01/12/2025 describe the definitions as she had identified above as escalated behaviors of Resident #1. The DON said the behaviors exhibited by Resident #1 were typical behaviors of a resident with dementia. The DON said when the staff notified her of the incident with Resident #1 choking Resident #2, she told the staff (CNA E and LVN C) via text message that Resident #1 needed to be sent out because the facility did not provide 1 to 1 care. The DON stated the physician was notified as well as the families after the incident occurred. The DON said there was no way to know the choking incident was going to happen prior to the incident taking place. The DON said the incident with Resident #1 kicking Resident #3 could have been an accident while Resident #1 walked by Resident #3. The DON stated, we don't care what the residents do to the staff - residents hit staff all the time and it did not mean the behaviors were escalated. The DON said they educated the staff on better resident approaching strategies to prevent residents hitting staff. The DON later said when Resident #1 kicked Resident #3 feet, it was considered a resident-to-resident altercation and should have been reported as an incident and investigated to rule out abuse. The DON said there was no just no way to know that Resident #1 was going to harm another resident prior to the incident occurring. During an interview on 02/27/2025 at 10:30 AM, the ADON stated Resident #1 exhibited behaviors of a dementia patient and she had not considered the behaviors to be escalated between the dates of 01/09/2025 - 01/12/2025. The ADON described an escalated behavior as something different from their typical baseline behavior and that varied between each individual resident. The ADON stated staff had reported Resident #1 jerking the blanket off another Resident but Resident #1 could have thought that was his blanket. The ADON stated she had told the staff to give Resident #1 the pillow and blanket and ensure resident was warm because he was sleeping and settled/safe on the floor. The ADON said it had not been reported except during the time of 01/09/2025 - 01/12/2025 of Resident #1 pulling/jerking covers from other residents or crawling/laying/sleeping in the floors. The ADON said it was not unusual for dementia residents to wander in and out of room rooms. The ADON stated that was why Resident #1 was in the secured unit due to wandering. The ADON said the incident when Resident #1 hit Resident #3 should have been reported as an incident and the physician, family, the abuse coordinator should have been notified for further investigation. The ADON said abuse allegations should be investigated to protect all residents from abuse. The ADON said when escalated behavior begin, the charge nurse should notify the physician for new orders and interventions. If those intervention and new orders are not effective, the charge nurse should be communicated to the physician to transfer the resident out of the facility to protect other residents as well as the resident with the behavioral changes. During an interview on 02/27/2025 at 10:50 AM, the Administrator stated behaviors were often unpredictable and predictable to a point. The Administrator said the facility and staff do their best to minimize behaviors and keep all residents safe. The Administrator said, it was not the best ideal to take eyes off of Resident #1 during the 10-minute time frame that the incident occurred within. The Administrator stated he expected staff to report incidents of suspected abuse including suspected resident to resident altercations so that the incident was then followed up on by him with a thorough investigation. The Administrator stated all staff were responsible for ensuring that no resident was subject to any type of abuse. The Administrator said the choking incident and failure of reporting incidents appropriately placed residents at a potential risk of abuse by physical or emotional trauma. The Administrator said the clinical staff was responsible for reporting and notifying the physician for changes of condition such as escalating behaviors to protect all the residents from any type of potential harm. The facility policy titled Abuse, Neglect Exploitation, & Misappropriation Policy dated 09/2024 indicated: .The resident has the right to be free of abuse, neglect, exploitation and misappropriation of resident property and other reportable incidents that affect the Health and Safety of the resident .Physical Abuse includes slapping, biting .5. Abuse toward a resident can occur as: a. resident to resident abuse; . The Administrator was notified on 02/27/2025 at 01:04 PM that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 02/27/2025 at 1:06 PM. The facility's Plan of Removal was accepted on 02/27/2025 at 06:30 PM. and included: Tag F-689: Systemic Approach 1. Resident 1 was transferred to The Local Hospital's Emergency Department where he was admitted to the Behavioral Health hospital on 1/12/2025. As indicated on SRI #556297, the resident is not to return to the facility to eliminate the risk of behavior happening again. 2. The Medical Director was immediately notified by the Director of Nurses on 2/27/2025 at 2:11pm and the Chief Operating Officer at 1:07pm of the Immediate Jeopardy. 3. Administrator review of the following facility policy on 2.27.2025: a. Abuse, Neglect, Exploitation, & Misappropriation Policy b. Resident to Resident Altercations 4. An immediate in-service to be provided by Regional Nurse Consultant to Administrator, DON and staff at facility with the subject of Recognizing Escalating Behaviors and Effective Measures to Put in Place to Protect Residents on 2/27/2025 at 2:20pm. a. Main takeaways from training include: the use of interventions which include 1:1 monitoring, redirecting, social services department visits and using calming music. 5. An Immediate in-service of the facility's Abuse policy to be conducted for all staff. Employees not present at building will be called via phone and provided in-service information. Inservice of staff will be completed by 2/28/2025 by 5:00pm. Other staff will be in-serviced before their next shift. A questionnaire will be created from the abuse policy. Questionnaires will be provided at random to employees to ensure retention of policy. Employees answering wrongly on questionnaires will receive more training. Admin/DON/ADON are responsible for conducting the training. 6. An immediate QAPI meeting to be held by IDT on 2.27.2025 a. Review of incident b. Establish areas of improvement c. Create plan to monitor and manage areas of improvement 7. Safe Surveys were conducted at the time of the incident. Results from the survey can be found with supportive documents provided to State surveyor and in SRI folder administrator keeps on hand. Safe survey results indicated no other residents were in need of additional supervision. 8. Monitoring: a. Admin or DON will conduct weekly random questionnaires of the abuse policy for a period of 4 weeks to ensure staff retain knowledge from the Abuse Policy. 9. Root Cause Analysis was conducted on 2/27/2024 identifying issues related to incidents on 1/12/2025. It was established that employees need more education of the abuse policy and aware of effective ways to de-escalate resident behaviors. This education was immediately provided on 2/27/2025. 10. Quality Assurance a. An ad hoc Quality Assurance Meeting will be conducted with IDT, including medical director via phone call on 2/27/2025. b. The IJs for F689 and F600 were noted and steps for removal were discussed. c. Incidents have been reviewed with plans to improve. i. Improvement plans include Notifying physician immediately, placing interventions in place immediately such as 1:1 monitoring, redirecting, separating residents, and removing residents from environment. Deescalating behaviors and recognizing signs of escalating behaviors. d. Plan on Removal being conducted. e. The Medical Director made no relevant comments at the time of meeting. He agreed that discussions related to the incident during the meeting are thorough and will be effective. O2/28/2025, the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the immediate jeopard by: Record Review of in-service dated 02/27/2025 provided by the Regional Nurse to the Administrator, the DON and the ADON with the following topics: A. Abuse, Neglect, Exploitation, & Misappropriation Policy B. Resident to Resident Altercations Record Review of the in service dated 02/27/2025 at 2:20 PM provided by the Regional Nurse Consult to Administrator,the DON and the staff at the facility with the subject topic of: Recognizing Escalating Behaviors and effective measure to put in place to protect the residents such as intervention of 1:1 monitoring, redirecting, social services departments visit and using calming music. Record review of in-service dated 02/27/2025 of the facility's Abuse policy conducted for all staff. (Employees not present at the building will be called via phone and provided in-service information. Inservice of staff will be completed by 2/28/2025 by 5:00pm. Other staff will be in-serviced before their next shift. ) Record review of a questionnaire created from the abuse policy with 25 employee/staff correctly completed on 02/28/2025. (Questionnaires will be provided at random to employees to ensure retention of policy. Employees answering wrongly on questionnaires will receive more training. Admin/DON/ADON were responsible for conducting the training) Record review of signed QAPI Committee Meeting completed on 2/27/2025 at 2:20 PM addressed the following: a. An ad hoc Quality Assurance Meeting will be conducted with IDT, including medical director via phone call on 2/27/2025. b. The IJs for F689 and F600 were noted and steps for removal were discussed. c. Incidents have been reviewed with plans to improve. i. Improvement plans include Notifying physician immediately, placing interventions in place immediately such as 1:1 monitoring, redirecting, separating residents, and removing residents from environment. Deescalating behaviors and recognizing signs of escalating behaviors. d. Plan on Removal being conducted. e. The Medical Director made no relevant comments at the time of meeting. He agreed that discussions related to the incident during the meeting are thorough and will be effective'. Interviews of nursing staff: on 2/28/2025 from 09:49 AM - 11:55 AM for( 6 AM - 6 PM shift) - DON, ADON, MDS Nurse, LVN C, CNA D, CNA E, CNA L, MA P, LVN Q, LVN W, LVN A, CNA AA (6PM - 6AM shift) - MA X, LVN Y, LVN Z, CNA BB, CNA CC, CNA DD, CNA EE Administrator, Dietary Manager, Assistant Dietary Manager, Housekeeping Supervisor, Social Worker, Maintenance Supervisor, Director Business Development, Medical Records, Dietary Aide H, Housekeeper K, Housekeeper M, Housekeeper N, Director of Rehabilitation, PTA U, OT V, Activities Assistant During these interviews staff were able to correctly identify types of abuse such as physical, sexual, verbal [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse or neglect for 3 of 7 residents reviewed for abuse. (Resident #1, Resident #3, and Resident #4) The facility failed to ensure Resident #4 was not verbally abused mentally abused, and harassed for the remainder of the night on 5/28/23 by LVN D The facility failed to educate staff on the de-escalation of an agitated or aggressive resident. The facility failed to identify harassment and intimidation as abuse for Resident #1 and Resident #3 when they complained about the care CNA A was providing. The facility failed to identify abuse when Resident #3 said CNA A intentionally caused her pain. CNA A was allowed to continue to intimidate and harass Resident #1 by going into her room and the shower room when she was receiving a shower. An Immediate Jeopardy (IJ) situation was identified on 12/27/23 at 3:00 p.m. while the IJ was removed on 12/28/23 at 8:18 p.m., the facility remained out of compliance at a potential for actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of physical harm and or emotional abuse. Findings included: Record review of Resident #4's face sheet with no date indicated he was admitted to the facility on [DATE] and discharge 6/2/23. Resident #4 was a [AGE] year-old male with admitting diagnoses of need for assistance with personal care, history of falling, colostomy status, mood disturbance, anxiety, and lack of coordination. Record review of Resident #4's admission MDS dated [DATE] indicated the resident had moderate cognitive impairment. His functional status indicated he required extensive assist of one person with transfers, toilet use and dressing. The resident was unable to stand and stabilize himself. He did not walk. He was unable to move himself off the toilet, and he was not steady with transfers from surface to surface. Review of Resident #4's baseline care plan dated 5/28/23 indicated his cognition was alert and cognitively intact and required one person assist with bed mobility, transfers walking in toileting . The care plan indicated the resident had a club foot, a new colostomy, and an abdominal incision. He had a new colostomy with interventions to teach the resident proper changing techniques and monitor site of colostomy. Record review of a Provider Investigation Report dated 5/28/23 at 9:59 p.m., indicated on the morning of 5/28/23 around 1:30 a.m. to 3:30 a.m. Resident #4 alleged LVN D verbally abused him. The report contained a letter from the Administrator that stated he first heard of the incident on Sunday, 5/28/23 at 7:30 p.m. Resident #4 said LVN D verbally abused him. The LVN continued to agitate and provoke Resident #4 to the end of his shift at 6:00 a.m. He said they flagged LVN D (an agency nurse) to no longer work for the facility. The investigation indicated Resident #4 was interviewed on 5/30/23 and said LVN D came to his room to help change his colostomy bag and did not bring the appropriate tools. Resident #4 said he felt LVN D did not want to help him. Resident #4 said he told LVN D to get his A out of his room. The Resident said LVN D responded with, I will mop you with the floor. Resident #4 responded. I'll beat your A. Resident #4 said he did not feel safe with LVN D in the building as his nurse. When asked Resident #4 said he did not have a knife. He said he felt he needed to bluff LVN D to ensure his safety. The resident's room was searched and there was no knife found. Interview with LVN D indicated Resident #4 had asked him to help him change his colostomy, in his room and then came to the nurse's station to ask again. LVN D said he told Resident #4 he would assist him when he finished his rounds. LVN D said when he went to the room Resident #4 was rude and talked harshly to him. LVN D said Resident #4 told him, To get his A out of his room. He said the resident continued to give him attitude the rest to the night. The resident told one of the aides he had a knife. The LVN D denied he had harassed the resident. The report indicated a statement from one of the aides indicated LVN D did try and provoke Resident #4 during the night. Record review of a statement that accompanied the Provider Investigation Report for Resident # 4 indicated on 5/28/23 [They (CNA C and CNA E) heard LVN D arguing loudly with Resident # 4. Resident #4 was saying if you are going to hit me then hit me. We (CNA C and CNA E) walked down the hall and LVN D was coming out the room. LVN D said if he was not a professional, he would have whopped Resident #4's A. After that, every time LVN D walked by Resident #4 he would giggle at him and smacked the wall like he was trying to intimidate Resident #4. LVN D really upset Resident #4 to the point he did not feel safe and wanted to leave. LVN D did tell us he told the resident if he was not a professional, he would whip his A.] the statement was signed by CNA C. Record review of the Provider Report Post Action Investigation indicated [ LVN D should have never allowed the situation to get out of hand. He should have been more patient with Resident #4 and never made Resident #4 feel he needed to protect himself. Resident #4 should have shown LVN D more patience as he was seeing other residents during his rounds. Both individuals should have conducted themselves more professionally to ensure a healthy exchange of information and services to be achieved. I feel both men were at fault and this situation could have easily ben avoided. I am finding this inconclusive because both men conducted themselves inappropriately. Neither one were at risk of injury or injured. They obviously do not get along with each other. I do not agree how LVN D conducted himself at the facility and we have taken measures for him not to return to the facility as he is not employee. He is an agency employee and will not be allowed to work another shift at this facility.] The form was signed by the Administrator on 5/31/23. During an interview on 12/18/23 at 2:20 p.m. CNA C said she and CNA E were working in another resident room and came into the hallway and heard loud voices coming from Resident #4's room on morning of 5/28/23. She said the LVN D came out of the room and was hollering back, I would whip your A if you were not a resident. She said Resident # 4 was very upset and wanted to leave the facility. He tried to exit through several of the doors. She said she spent the night trying to keep him from leaving and watching LVN D try and aggravate the resident. She said every time LVN D would pass by the Resident #4. He would giggle and hit on the wall or the side rails as if he was hitting someone. She said the nurse's behavior was not professional at all, in fact he acted like a child. She said she did not remember if she called anyone to report the incident or not. She spent the night trying to keep the peace and trying to keep Resident#4 from leaving. She said at one point they were outside in the smoking area, and Resident#4 said he would throw himself on the ground, throw his wheelchair down the steps, crawl down the steps and get back in his wheelchair and leave. During an interview on 12/18/23 at 2:25 p.m., the Administrator said he did not remember who notified him about the incident that happened on 5/28/23. He said he was told it happened on that morning around 1:30 a.m. or 2:00 a.m. he said it was not reported to him until 5/28/23 at 7:30 p.m. and he called it into the state around 9:00 p.m. He said in the defense of the resident he was very independent. He said the resident told the nurse he had a knife because he tried to intimidate him when he walked by. The Administrator said the resident did not have a knife and he could not find one. He said the resident admitted he just felt he needed some type of protection from the LVN D. During an interview on 12/18/23 at 3:30 p.m., CNA E said when they rounded the corner on the night of 5/28/23, LVN D and Resident #4 were arguing. The nurse was LVN D was hollering at the Resident #4. We (CNA C and CNA E) tried to deescalate the situation. CNA E said Resident #4 tried to leave through two different doors. She said the nurses' behavior was not professional, he was hollering and talking smart. Resident #1 Record review of Resident #1's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were Alzheimer's, disease, anxiety disorder, and history of falling. Record review of Resident #1's quarterly MDS dated [DATE] indicated she had no cognitive impairment. The resident used mobility devices of a walker and a wheelchair. She required partial assistance with hygiene, and partial assistance with chair to bed transfer, and partial assist with toilet transfer. Record review of Resident #1's care. Plan indicated she had a problem of ADL function. She required two people assist with bathing, two people assist with toileting, and two people assist with bed mobility. Record review of a Complaint/Concern form dated 7/3/23 indicated Resident #1 was filing a complaint against CNA A. Resident #1 said CNA A was rough in the way that she handled her care, causing her pain and discomfort when she was turning her, placing her in the chair and any other physical contact. Resident #1 said CNA A spoke to her in a rude and hurtful manner. Resident #1 said she refused to put up with it any longer. CNA A said Resident # 1, was always complaining about something and making notes to tell on me. Resident #1 disagreed with that statement. Resident #1 said that she refused to be spoken to or treated to rudely any longer. The resident said she asked CNA A to stop on several occasions, but it continued. Resident #1 said it had become harassment. The resident did not want CNA A to be associated with her care any longer. Resident #3 Record review of a face sheet for Resident #3 with no date indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were stroke, removal of the right breast, acute kidney failure, stiffness in the right knee, need for assistance with personal care, abnormal posture Disorder of the bone upper arm, and muscle weakness. Record review of Resident #3's quarterly MDS dated [DATE] indicated she had no cognitive impairment. Her functional status was she used a wheelchair for mobility. She had impairment on her upper extremity shoulder, elbow, wrist, and hand, and she had impairment on her lower extremity hip knee, ankle, and foot. Record review of Resident #3's care plan dated 11/15/23 indicated a problem of limited range of motion to the right upper and lower extremities. Resident # 3 required assistance with active and passive range of motion in a splint applied to the right hand. Resident # 3 had problems of ADL function and required a lift for transfers. The resident required one or two people to aid turn and reposition in bed frequently to prevent skin breakdown. The resident required one person assist for dressing, and two people for a transfer by Hoyer lift. Record review of a Complaint/Concern Form dated 7/3/23 indicated Resident# 3 filed a complaint against CNA A. The Complaint indicated the aide was rough in the way she handled Resident #3's care, causing her pain and discomfort when she was turning Resident #3, placing her in the chair and other physical contact. Resident #3 said the way CNA A spoke to her was rude, hurtful, and she refused to put up with it any longer. The resident said CNA A told her that turning her hurt her because she was a big woman, and she was doing it by herself. Resident # 3 said she told CNA A she should ask for help. Resident # 3 said CNA A told her she stunk after Resident # 3 had breast surgery. The Resident # 3 said the CNA told her the smell coming from her breast stinking up the room. The form indicated CNA A said she and Resident #3 were friends and that was just the way they talked to each other. Resident #3 disagreed with that statement, and she said she did comment back to the aide but in self-defense. Resident #3 said they were not friends and she refused to be spoken to or treated rudely any longer. Resident # 3 said asked CNA A to stop on multiple occasions, but her attitude continued. Resident #3 said it had become harassment. The resident did not want CNA A to be associated with her care any longer. When talking to CNA A about the event, she said that she and the resident joked all the time, and she was unaware that it bothered the resident. CNA A stated, verbally that she would not joke like that again, and would have a more professional manner when interacting with residents. The investigation finding indicated, Resident # 3 said she did not have an issue with CNA A but was embarrassed by the event. The steps taken to correct the action was a counseling form on how to keep a professional manner. The steps taken to correct the issue was CNA A was removed from her care and could only provide care when assisting other staff. A counseling will be provided to CNA A on treating residents in a professional manner. Record review of a Counseling/Disciplinary note for CNA A dated 7/18/23 (15 days later) indicated the reason for the counseling was multiple complaints on CNA A for being verbally, aggressive, and short with Residents. The corrective actions were to speak with the aid about how to approach residents in a more professional manner and it was signed by the DON and CNA A on 7/19/23. There was no Inservice attached. Record review of a Complaint/Concern form dated 9/5/23 indicated Resident #1 reported that she continued to have problems with CNA A. She stated that on 8/30/23 CNA A continuously interrupted her shower to talk to the shower aid, making her uncomfortable. The resident stated CNA A's language was profane. Resident #1 said on the following day, 8/31/23 CNA A and another aide came into the room going through her roommates closet and cursing very loudly. Resident #1 said they were gossiping about other employees and used an extreme amount of profanity. Resident #1 said that she was very offended. Resident #1 said on the following morning she was sleeping when CNA A came into her room, and said loudly, Your breakfast is served. Wake up and eat it. Resident #1 said it was very rude, so she refused acknowledge her. Resident #1 said, I feel targeted . Resident #1 said she spoke to the nurse on the weekend about her concerns ( no statement from the nurse) Resident #1 said she felt CNA A used the excuse of taking care of her roommate, as an opportunity to antagonize an aggravate her . The allegation was investigated, and the IDT meeting was held. The findings were CNA A was guilty of the events, and will be given the option of quitting or resigning from her position. Signed by the Administrator Record review of a Counseling/Disciplinary note for CNA A dated 9/8/23 indicated CNA A was discharged and her last day at work was 9/8/23. The form indicated this would serve as termination. Corrective actions had already been taken and misconduct continued. The employee comments were, Do not understand what the reason. Signed by CNA A. During an interview on 12/14/23 at 11:00 a.m., the DON said she had determined Resident #1's allegations were true. She did not have statements from the shower aide, nurse, or CNA A. She said they had gotten multiple complaints regarding the aide and felt it was time to let her go. When asked about the statement on the grievance dated 9/5/23 that said CNA A was guilty of the allegations made by Resident #1. The DON said she did not remember how she verified the events that occurred were true regarding Resident #1's allegations. During an interview on 12/14/23 at 11:50 p.m., the DON and the Administrator said because of her previous behaviors with residents, CNA A was terminated, on 9/8/23. The DON said there was another resident on the same hall as Resident #1 who did not want CNA A in her room. That resident changed her details of the occurrence several times so they could not validate her allegations. However, the resident said she did not like CNA A and did not want her back in her room. The DON and Administrator said Resident #1 and Resident #3's issues bordered on abuse but neither resident said they were abused. The Administrator and the DON said they did not know that CNA A continued to go into Resident #1's room. During an interview on 12/18/23 at 11:58 a.m., the Administrator said CNA A worked at a fast pace and the former DON loved her (the former DON left 6/30/23). He said he tried to work with CNA A. He felt her actions would get right up to the line of abuse and then she would pull back. The Administrator said he did not think CNA A was a nice person. The Administrator said one issue with CNA A was that she had a foul mouth. The Administrator said he had tried to encourage her not to use foul language around residents. He said CNA A did not have much respect for authority, and she did what she wanted to do. The Administrator said they had to let her go because warnings did not help, and she had gone past the point respecting the residents. During an interview on 12/18/23 at 12:50 p.m., Resident #3 said the things CNA A did to her could have been abuse. Resident # 3 stated it started out as joking, and she would never have called CNA A her friend. Resident # 3 said CNA A took the snide comments to a whole different level. Resident #3 said CNA A was rough when she provided care to her. Resident#3 said would tell CNA A she was rough and hurting her. She said CNA A knew she was hurting her and did not care. Resident# 3 said on one occasion when she complained to aide about her being rough, CNA A told her, Well you are not light. Resident # 3 asked her to get some help if she was too heavy and the aide refused. Resident #3 said she had a stroke on her right side, and it hurt when she was moved around roughly. Resident#3 said some of the things the aide said were hurtful and hurt her feelings. cane said when CNA A provided care to her, the aide knew she was rough, and hurt her but did not care. Resident#3 said complained after she could not take anymore. Resident #3 said CNA A was not allowed back in her room and did not speak to her in the hallway. During an interview on 12/18/23 at 12:55 p. m. Resident #2 said CNA A had been unkind to her on several occasions. When she finally told the staff, she felt threatened when the aide came in the room. She said she might have confused the events some, but the aide was mean, and she did not want her in her room. She said she heard they terminated her because she was mistreated another resident. During an interview on 12/18/23 at 2:10 p.m., Resident #1 said she remembered CNA A quite well. She had been rude and mean to her. She had requested she not be allowed in her room. She said on several occasions when she was in the shower room getting assistance with a shower. She said CNA A would come in and take a seat and try to intimidate her. She said CNA A would talk, and all kinds of filthy language would come out of her mouth. She asked her to leave the shower room on at least two occasions because she did not feel comfortable with her there. She said on several occasions she would come into her room and move her walker around in the room or come in to care for the roommate and use filthy language. She had complained back in September, and she was finally let go. Resident #1 said she felt the aide was trying to intimidate her because she had complained of her attitude and treatment towards her in the past. During an interview on 12/18/23 at 2:25 p.m., the Administrator he was not aware of any furniture being moved in Resident #1's room. He said there was a dresser she complained had been moved and he moved it back. It was only moved a few inches. He was not aware of any allegation that CNA A had been in Resident #1's room. He said he thought he had statements from staff regarding the issues with CNA A but could not find any. He said he did conduct in services after each episode of possible abuse. During an interview on 12/18/23 at 3:00 p.m., the DON said she did not remember Resident #1 saying anything about her things being moved around in her room. During a telephone interview on 12/18/23 at 3:38 p, CNA B (former shower aide) said CNA A did come in a few times when she was giving Resident #1 a shower. She said she had only come in to get a basin of warm water or something like that. She did not remember her cursing but she did remember Resident #1 asking CNA A to leave the shower room and she left. During an interview on 12/27/23 at 11:20 a.m. , the Administrator said they had a QA meeting scheduled for tomorrow, 12/28/23. He said they had not QA the event between Resident #4 and LVN D after reviewing his QA book. During an interview on 12/27/23 at 12:30 p.m. the Administrator said he said something about Abuse and Neglect during every in service. He did not have any additional content for the for the 6/9/23 after the incident with Resident #4. The administrator there was no in-service regarding Resident Behaviors or deescalating agitation or aggressive situations. During an interview on 12/27/23 at 1:55 p.m. Administrator said CNA A was guilty of using foul language in the shower room. He said CNA A admitted to using foul language in the shower room. The Administrator said CNA A never admitted to giving care to Resident #1 or doing anything with #1. He said CNA A was not allowed to give care to Resident #1. He said they had written on the grievance form she was guilty but not of all of the allegations made. He said they did not interview other staff or get statements about the incident, so they could not verify that Resident #1's allegations were true or not. They were aware CNA A continued to receive complaints about her behaviors and they could not allow her to continue to work for the facility. He said they had not taken statements from the aide or the aides that may have witnesses the behaviors. The Administrator said what was he supposed to do with the LVN D. He said if he sent the nurse home, they would have only had one nurse in the building that night. The Administrator said at that time if they called the former DON, she would not have answered the phone and she sure would not have come to the facility to fill for the LVN. He said he was between a rock and a hard place. If he sent the nurse home, he would not have had sufficient nursing coverage for the facility, what was he supposed to do? During an interview on 12/27/23 at 2:07 p.m., CNA A said Resident #1 asked her to leave the shower room a couple of times when she was getting a shower. CNA A said she had gone to the shower room to get hot water. CNA A said she may have said a curse word or two while in the shower, she was not sure. She said she may have delivered a breakfast tray to Resident #1 if she was passing trays and had one for her roommate. She said she was not told to not go in Resident #1's Room, she was told not to provide care to Resident #1. She said Resident #1 had a roommate and she provided care to her. CNA A said Resident #1 may have heard her cursing. CNA A said the Kiosk that they used to input resident care information was right outside of Resident #1's room and she often cursed while using it. CNA A said she was told not to go into Resident #3's room, and she had not been back in her room. She said Resident #3 was upset and it could have been something that she said. CNA said Resident #3 took what she said out of context. The aide said when she provided care to Resident #3 who was a two person assist, there was always at least one other person in the room with her. CNA A said she never provided care to Resident #3 without assistance. She said she told Resident #3 told her there was something wrong with her breast, it smelled. She said she even went to get the nurse ( can not remember who) to look at it. She said the nurse came in and told Resident #3 something was wrong or needed to take the bra off and it had a smell to it. CNA A said CNA O was the aide that was with her that day. CNA A said she may let a [NAME] word slip sometimes when she walked out of a room. She said the Administrator told her was not obligated to tell her why they terminated her. She said she had in services on abuse and knew what abuse was. CNA A said if cursing close to a resident was abuse, then Yes she did abuse residents. CNA A said she knew they wrote several things up on her about residents complaining. She said the Administrator told her that if he turned the write ups into the state his job would be on the line. CNA A said she had about 3 residents that complained about her on that hall and did not want her providing care to them but the facility never moved me from that hall. CNA A said when complaints started coming in the Administrator and DON brought her in to talk about the same things that happen back in July. She said she no longer worked at the facility and these things all happened a long time ago. CNA A wanted to know why the incidents with Resident #1 and Resident # 3 were being questioned about today. She said the Administrator told her they were not called into the State. During an interview on 12/27/23 at 2:12 p.m., Administrator said told CNA A on the incident in July if they continued to get complaints on her she would be terminated. The Administrator said CNA A had a very foul mouth he said he had heard her curing and had reprimanded her on several occasions to stop curing in the facility. He said Resident #1 was very dedicated to her religion and CNA A cursing would have been very offensive to Resident #1. He said CNA A knew that and that is probably why she cursed outside the resident's door or whenever Resident #1 could hear her. He said CNA B and CNA O were CNA A's friends and they would not say anything bad about CNA A. He said CNA O was terminated and she and CNA A work at the same place. The Administrator said when they worked at this facility they would team up and work with new aides, most of which would quit. He said it was not good for the business at all. During an interview on 12/27/23 at 2:31 p.m., the ADON said she had worked at the facility for 15 years. She said she took the position of ADON about June 2023. She said CNA A seemed to be very kind and caring to the residents in front of administrative staff. However, CNA A came across rough and plan speaking. The ADON said sometimes it appeared that CNA A was playing or joking. The ADON said CNA A told her Resident #3's breast smelled told to come down and because the breast smelled like death. She said Resident #3 did not want to get people in trouble and was kind of laughing at the time. The ADON said Resident #3's breast did smell and had dried blood and the nurses should have been washing a surgical wound. She said she knew they called CNA A in to talk to her after the two complaints were voiced by Resident #1 and Resident #3. She said she did not know where it went from there. The ADON said with the complaint on 9/5/23 they pulled CNA A in the office and told her had too many complaints on her and we needed to let her go. The ADON said she had heard CNA A curse on the hallway. The ADON said after reviewing the schedule and the time sheets. The only thing she could tell was the incidents with Residents #1 and #3 did not happen on 7/3/23. She said she did not work that day and neither did CNA A. she said she could not figure out when the incident happened, but it was before 7/3/23. Record review of the facilities, abuse and neglect protocol with no date indicated abuse is defined as the willful inflection of injury, unreasonable, confinement, intimidation, or punishment with resulting physical harm, pain of mental anguish. Abuse also included the derivation by an individual, included caregiver, goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The policy statement, a resident, have a right to be free from abuse, neglect. This includes but not limited to freedom from corporal, punishment, involuntary, seclusion, verbal, mental, physical abuse, the development, an implementation, and policy development, and implement policies and procedures in preventing abuse, neglect, or mistreatment of resident to identifying all possible incidence of abuse to protect resident during abuse investigations. Establish and implement a QAIP review and analysis abuse and implement changes to prevent future currencies of abuse . Each interview will be conducted separately in a private location. Witness reports will be obtained in writing either witness will write his or her statement, sign, and date. Or the investigator may obtain a statement read it back to the member and have him sign and date it. Reporting an alleged violation of abuse or neglect will be reported immediately, but not later than: Two hours if the alleged volition involves abuse or has resulted in serious bodily injury or 24 hours if the alleged violations involved abuse and had not resulted in serious bodily injury. This was determined to be an Immediate Jeopardy (IJ) on 12/27/23 at 3:00 p.m. The facility Administrator, and ADON were notified. The Administrator was provided with the IJ template on 12/27/23 at 3:00 p.m. Plan of Removal for [Tag F-600: The employee responsible for abuse to Resident 1 and 3 has been terminated on 9/8/2023. The shift key employee responsible for abuse on resident 4 has been red flagged and is no longer able to pick up shifts or return to this facility effective 5/28/2023. Administrator and DON followed up with residents after incidents to ensure no psychological impact was made. An immediate in-service has been started for all staff with the subject of De-escalating Resident Behaviors. Conduct a safe survey with all current interviewable residents. (See attachment 1 below). This will establish residents, individuals, or clients are no longer at a high risk of serious injury, harm, impairment, or death. o Surveys will be completed by 12:00pm 12/28/2023. o Surveys will be completed by the following department heads: Social Services BOM Dietary Supervisor MDS Coordinator Director of Rehabilitation ADON o Non-interviewable residents will have skin assessment completed once a week, for 3 months to be reviewed monthly in QA. Documented daily rounds to determine if non-interviewable residents are free from abuse to be completely 3 times a week for 3 months and reviewed in monthly QA. Create a new policy for Abuse which will include the following: o Definitions o Screening o Training o Prevention o Identification o Investigation o Protection o Reporting The new Policy was completed by Administrator. Policy[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure they implemented their abuse policy to ensure residents had the right to be free from abuse or neglect for 4 of 7 residents reviewed for abuse. (Resident #1, Resident #2, Resident #3, and Resident #4) The facility failed to follow their policy and ensure Resident #4 was not verbally abuse by LVN D and mental abused and harassed for the remainder of the night on 5/28/23. The facility failed to follow their policy and identify harassment, and intimidation for Resident #1, Resident #2, and Resident #3 when they reported CNA A had intentionally tried to intimidate them. The facility failed to follow their policy when Resident #3 said CNA A intentionally caused her pain. An Immediate Jeopardy (IJ) situation was identified on 12/27/23 at 3:00 p.m. while the IJ was removed on 12/28/23 at 8:18 p.m., the facility remained out of compliance at a potential for actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of physical harm and or emotional abuse. Findings included: Record review of Resident #4's face sheet with no date indicated he was admitted to the facility on [DATE] and discharge 6/2/23. Resident #4 was a [AGE] year-old male with admitting diagnoses of need for assistance with personal care, history of falling, colostomy status, mood disturbance, anxiety, and lack of coordination. Record review of Resident #4's admission MDS dated [DATE] indicated the resident had moderate cognitive impairment. His functional status indicated he required extensive assist of one person with transfers, toilet use and dressing. The resident was unable to stand and stabilize himself. He did not walk. He was unable to move himself off the toilet, and he was not steady with transfers from surface to surface. Review of Resident #4's baseline care plan dated 5/28/23 indicated his cognition was alert and cognitively intact and required one person assist with bed mobility, transfers walking in toileting . The care plan indicated the resident had a club foot, a new colostomy, and an abdominal incision. He had a new colostomy with interventions to teach the resident proper changing techniques and monitor site of colostomy. Record review of a Provider Investigation Report dated 5/28/23 at 9:59 p.m., indicated on the morning of 5/28/23 around 1:30 a.m. to 3:30 a.m. Resident #4 alleged LVN D verbally abused him. The report contained a letter from the Administrator that stated he first heard of the incident on Sunday, 5/28/23 at 7:30 p.m. Resident #4 said LVN D verbally abused him. The LVN continued to agitate and provoke Resident #4 to the end of his shift at 6:00 a.m. He said they flagged LVN D (an agency nurse) to no longer work for the facility. The investigation indicated Resident #4 was interviewed on 5/30/23 and said LVN D came to his room to help change his colostomy bag and did not bring the appropriate tools. Resident #4 said he felt LVN D did not want to help him. Resident #4 said he told LVN D to get his A out of his room. The Resident said LVN D responded with, I will mop you with the floor. Resident #4 responded. I'll beat your A. Resident #4 said he did not feel safe with LVN D in the building as his nurse. When asked Resident #4 said he did not have a knife. He said he felt he needed to bluff LVN D to ensure his safety. The resident's room was searched and there was no knife found. Interview with LVN D indicated Resident #4 had asked him to help him change his colostomy, in his room and then came to the nurse's station to ask again. LVN D said he told Resident #4 he would assist him when he finished his rounds. LVN D said when he went to the room Resident #4 was rude and talked harshly to him. LVN D said Resident #4 told him, To get his A out of his room. He said the resident continued to give him attitude the rest to the night. The resident told one of the aides he had a knife. The LVN D denied he had harassed the resident. The report indicated a statement from one of the aides indicated LVN D did try and provoke Resident #4 during the night. Record review of a statement that accompanied the Provider Investigation Report for Resident # 4 indicated on 5/28/23 [They (CNA C and CNA E) heard LVN D arguing loudly with Resident # 4. Resident #4 was saying if you are going to hit me then hit me. We (CNA C and CNA E) walked down the hall and LVN D was coming out the room. LVN D said if he was not a professional, he would have whopped Resident #4's A. After that, every time LVN D walked by Resident #4 he would giggle at him and smacked the wall like he was trying to intimidate Resident #4. LVN D really upset Resident #4 to the point he did not feel safe and wanted to leave. LVN D did tell us he told the resident if he was not a professional, he would whip his A.] the statement was signed by CNA C. Record review of the Provider Report Post Action Investigation indicated [ LVN D should have never allowed the situation to get out of hand. He should have been more patient with Resident #4 and never made Resident #4 feel he needed to protect himself. Resident #4 should have shown LVN D more patience as he was seeing other residents during his rounds. Both individuals should have conducted themselves more professionally to ensure a healthy exchange of information and services to be achieved. I feel both men were at fault and this situation could have easily ben avoided. I am finding this inconclusive because both men conducted themselves inappropriately. Neither one were at risk of injury or injured. They obviously do not get along with each other. I do not agree how LVN D conducted himself at the facility and we have taken measures for him not to return to the facility as he is not employee. He is an agency employee and will not be allowed to work another shift at this facility.] The form was signed by the Administrator on 5/31/23. During an interview on 12/18/23 at 2:20 p.m. CNA C said she and CNA E were working in another resident room and came into the hallway and heard loud voices coming from Resident #4's room on morning of 5/28/23. She said the LVN D came out of the room and was hollering back, I would whip your A if you were not a resident. She said Resident # 4 was very upset and wanted to leave the facility. He tried to exit through several of the doors. She said she spent the night trying to keep him from leaving and watching LVN D try and aggravate the resident. She said every time LVN D would pass by the Resident #4. He would giggle and hit on the wall or the side rails as if he was hitting someone. She said the nurse's behavior was not professional at all, in fact he acted like a child. She said she did not remember if she called anyone to report the incident or not. She spent the night trying to keep the peace and trying to keep Resident#4 from leaving. She said at one point they were outside in the smoking area, and Resident#4 said he would throw himself on the ground, throw his wheelchair down the steps, crawl down the steps and get back in his wheelchair and leave. During an interview on 12/18/23 at 2:25 p.m., the Administrator said he did not remember who notified him about the incident that happened on 5/28/23. He said he was told it happened on that morning around 1:30 a.m. or 2:00 a.m. he said it was not reported to him until 5/28/23 at 7:30 p.m. and he called it into the state around 9:00 p.m. He said in the defense of the resident he was very independent. He said the resident told the nurse he had a knife because he tried to intimidate him when he walked by. The Administrator said the resident did not have a knife and he could not find one. He said the resident admitted he just felt he needed some type of protection from the LVN D. During an interview on 12/18/23 at 3:30 p.m., CNA E said when they rounded the corner on the night of 5/28/23, LVN D and Resident #4 were arguing. The nurse was LVN D was hollering at the Resident #4. We (CNA C and CNA E) tried to deescalate the situation. CNA E said Resident #4 tried to leave through two different doors. She said the nurses' behavior was not professional, he was hollering and talking smart. Resident #1 Record review of Resident #1's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were Alzheimer's, disease, anxiety disorder, and history of falling. Record review of Resident #1's quarterly MDS dated [DATE] indicated she had no cognitive impairment. The resident used mobility devices of a walker and a wheelchair. She required partial assistance with hygiene, and partial assistance with chair to bed transfer, and partial assist with toilet transfer. Record review of Resident #1's care. Plan indicated she had a problem of ADL function. She required two people assist with bathing, two people assist with toileting, and two people assist with bed mobility. Record review of a Complaint/Concern form dated 7/3/23 indicated Resident #1 was filing a complaint against CNA A. Resident #1 said CNA A was rough in the way that she handled her care, causing her pain and discomfort when she was turning her, placing her in the chair and any other physical contact. Resident #1 said CNA A spoke to her in a rude and hurtful manner. Resident #1 said she refused to put up with it any longer. CNA A said Resident # 1, was always complaining about something and making notes to tell on me. Resident #1 disagreed with that statement. Resident #1 said that she refused to be spoken to or treated to rudely any longer. The resident said she asked CNA A to stop on several occasions, but it continued. Resident #1 said it had become harassment. The resident did not want CNA A to be associated with her care any longer. Resident #3 Record review of a face sheet for Resident #3 with no date indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were stroke, removal of the right breast, acute kidney failure, stiffness in the right knee, need for assistance with personal care, abnormal posture Disorder of the bone upper arm, and muscle weakness. Record review of Resident #3's quarterly MDS dated [DATE] indicated she had no cognitive impairment. Her functional status was she used a wheelchair for mobility. She had impairment on her upper extremity shoulder, elbow, wrist, and hand, and she had impairment on her lower extremity hip knee, ankle, and foot. Record review of Resident #3's care plan dated 11/15/23 indicated a problem of limited range of motion to the right upper and lower extremities. Resident # 3 required assistance with active and passive range of motion in a splint applied to the right hand. Resident # 3 had problems of ADL function and required a lift for transfers. The resident required one or two people to aid turn and reposition in bed frequently to prevent skin breakdown. The resident required one person assist for dressing, and two people for a transfer by Hoyer lift. Record review of a Complaint/Concern Form dated 7/3/23 indicated Resident# 3 filed a complaint against CNA A. The Complaint indicated the aide was rough in the way she handled Resident #3's care, causing her pain and discomfort when she was turning Resident #3, placing her in the chair and other physical contact. Resident #3 said the way CNA A spoke to her was rude, hurtful, and she refused to put up with it any longer. The resident said CNA A told her that turning her hurt her because she was a big woman, and she was doing it by herself. Resident # 3 said she told CNA A she should ask for help. Resident # 3 said CNA A told her she stunk after Resident # 3 had breast surgery. The Resident # 3 said the CNA told her the smell coming from her breast stinking up the room. The form indicated CNA A said she and Resident #3 were friends and that was just the way they talked to each other. Resident #3 disagreed with that statement, and she said she did comment back to the aide but in self-defense. Resident #3 said they were not friends and she refused to be spoken to or treated rudely any longer. Resident # 3 said asked CNA A to stop on multiple occasions, but her attitude continued. Resident #3 said it had become harassment. The resident did not want CNA A to be associated with her care any longer. When talking to CNA A about the event, she said that she and the resident joked all the time, and she was unaware that it bothered the resident. CNA A stated, verbally that she would not joke like that again, and would have a more professional manner when interacting with residents. The investigation finding indicated, Resident # 3 said she did not have an issue with CNA A but was embarrassed by the event. The steps taken to correct the action was a counseling form on how to keep a professional manner. The steps taken to correct the issue was CNA A was removed from her care and could only provide care when assisting other staff. A counseling will be provided to CNA A on treating residents in a professional manner. Record review of a Counseling/Disciplinary note for CNA A dated 7/18/23 (15 days later) indicated the reason for the counseling was multiple complaints on CNA A for being verbally, aggressive, and short with Residents. The corrective actions were to speak with the aid about how to approach residents in a more professional manner and it was signed by the DON and CNA A on 7/19/23. There was no Inservice attached. Record review of a Complaint/Concern form dated 9/5/23 indicated Resident #1 reported that she continued to have problems with CNA A. She stated that on 8/30/23 CNA A continuously interrupted her shower to talk to the shower aid, making her uncomfortable. The resident stated CNA A's language was profane. Resident #1 said on the following day, 8/31/23 CNA A and another aide came into the room going through her roommates closet and cursing very loudly. Resident #1 said they were gossiping about other employees and used an extreme amount of profanity. Resident #1 said that she was very offended. Resident #1 said on the following morning she was sleeping when CNA A came into her room, and said loudly, Your breakfast is served. Wake up and eat it. Resident #1 said it was very rude, so she refused acknowledge her. Resident #1 said, I feel targeted . Resident #1 said she spoke to the nurse on the weekend about her concerns ( no statement from the nurse) Resident #1 said she felt CNA A used the excuse of taking care of her roommate, as an opportunity to antagonize an aggravate her . The allegation was investigated, and the IDT meeting was held. The findings were CNA A was guilty of the events, and will be given the option of quitting or resigning from her position. Signed by the Administrator Record review of a Counseling/Disciplinary note for CNA A dated 9/8/23 indicated CNA A was discharged and her last day at work was 9/8/23. The form indicated this would serve as termination. Corrective actions had already been taken and misconduct continued. The employee comments were, Do not understand what the reason. Signed by CNA A. During an interview on 12/14/23 at 11:00 a.m., the DON said she had determined Resident #1's allegations were true. She did not have statements from the shower aide, nurse, or CNA A. She said they had gotten multiple complaints regarding the aide and felt it was time to let her go. When asked about the statement on the grievance dated 9/5/23 that said CNA A was guilty of the allegations made by Resident #1. The DON said she did not remember how she verified the events that occurred were true regarding Resident #1's allegations. During an interview on 12/14/23 at 11:50 p.m., the DON and the Administrator said because of her previous behaviors with residents, CNA A was terminated, on 9/8/23. The DON said there was another resident on the same hall as Resident #1 who did not want CNA A in her room. That resident changed her details of the occurrence several times so they could not validate her allegations. However, the resident said she did not like CNA A and did not want her back in her room. The DON and Administrator said Resident #1 and Resident #3's issues bordered on abuse but neither resident said they were abused. The Administrator and the DON said they did not know that CNA A continued to go into Resident #1's room. During an interview on 12/18/23 at 11:58 a.m., the Administrator said CNA A worked at a fast pace and the former DON loved her (the former DON left 6/30/23). He said he tried to work with CNA A. He felt her actions would get right up to the line of abuse and then she would pull back. The Administrator said he did not think CNA A was a nice person. The Administrator said one issue with CNA A was that she had a foul mouth. The Administrator said he had tried to encourage her not to use foul language around residents. He said CNA A did not have much respect for authority, and she did what she wanted to do. The Administrator said they had to let her go because warnings did not help, and she had gone past the point respecting the residents. During an interview on 12/18/23 at 12:50 p.m., Resident #3 said the things CNA A did to her could have been abuse. Resident # 3 stated it started out as joking, and she would never have called CNA A her friend. Resident # 3 said CNA A took the snide comments to a whole different level. Resident #3 said CNA A was rough when she provided care to her. Resident#3 said would tell CNA A she was rough and hurting her. She said CNA A knew she was hurting her and did not care. Resident# 3 said on one occasion when she complained to aide about her being rough, CNA A told her, Well you are not light. Resident # 3 asked her to get some help if she was too heavy and the aide refused. Resident #3 said she had a stroke on her right side, and it hurt when she was moved around roughly. Resident#3 said some of the things the aide said were hurtful and hurt her feelings. cane said when CNA A provided care to her, the aide knew she was rough, and hurt her but did not care. Resident#3 said complained after she could not take anymore. Resident #3 said CNA A was not allowed back in her room and did not speak to her in the hallway. During an interview on 12/18/23 at 12:55 p. m. Resident #2 said CNA A had been unkind to her on several occasions. When she finally told the staff, she felt threatened when the aide came in the room. She said she might have confused the events some, but the aide was mean, and she did not want her in her room. She said she heard they terminated her because she was mistreated another resident. During an interview on 12/18/23 at 2:10 p.m., Resident #1 said she remembered CNA A quite well. She had been rude and mean to her. She had requested she not be allowed in her room. She said on several occasions when she was in the shower room getting assistance with a shower. She said CNA A would come in and take a seat and try to intimidate her. She said CNA A would talk, and all kinds of filthy language would come out of her mouth. She asked her to leave the shower room on at least two occasions because she did not feel comfortable with her there. She said on several occasions she would come into her room and move her walker around in the room or come in to care for the roommate and use filthy language. She had complained back in September, and she was finally let go. Resident #1 said she felt the aide was trying to intimidate her because she had complained of her attitude and treatment towards her in the past. During an interview on 12/18/23 at 2:25 p.m., the Administrator he was not aware of any furniture being moved in Resident #1's room. He said there was a dresser she complained had been moved and he moved it back. It was only moved a few inches. He was not aware of any allegation that CNA A had been in Resident #1's room. He said he thought he had statements from staff regarding the issues with CNA A but could not find any. He said he did conduct in services after each episode of possible abuse. During an interview on 12/18/23 at 3:00 p.m., the DON said she did not remember Resident #1 saying anything about her things being moved around in her room. During a telephone interview on 12/18/23 at 3:38 p, CNA B (former shower aide) said CNA A did come in a few times when she was giving Resident #1 a shower. She said she had only come in to get a basin of warm water or something like that. She did not remember her cursing but she did remember Resident #1 asking CNA A to leave the shower room and she left. During an interview on 12/27/23 at 11:20 a.m. , the Administrator said they had a QA meeting scheduled for tomorrow, 12/28/23. He said they had not QA the event between Resident #4 and LVN D after reviewing his QA book. During an interview on 12/27/23 at 12:30 p.m. the Administrator said he said something about Abuse and Neglect during every in service. He did not have any additional content for the for the 6/9/23 after the incident with Resident #4. The administrator there was no in-service regarding Resident Behaviors or deescalating agitation or aggressive situations. During an interview on 12/27/23 at 1:55 p.m. Administrator said CNA A was guilty of using foul language in the shower room. He said CNA A admitted to using foul language in the shower room. The Administrator said CNA A never admitted to giving care to Resident #1 or doing anything with #1. He said CNA A was not allowed to give care to Resident #1. He said they had written on the grievance form she was guilty but not of all of the allegations made. He said they did not interview other staff or get statements about the incident, so they could not verify that Resident #1's allegations were true or not. They were aware CNA A continued to receive complaints about her behaviors and they could not allow her to continue to work for the facility. He said they had not taken statements from the aide or the aides that may have witnesses the behaviors. The Administrator said what was he supposed to do with the LVN D. He said if he sent the nurse home, they would have only had one nurse in the building that night. The Administrator said at that time if they called the former DON, she would not have answered the phone and she sure would not have come to the facility to fill for the LVN. He said he was between a rock and a hard place. If he sent the nurse home, he would not have had sufficient nursing coverage for the facility, what was he supposed to do? During an interview on 12/27/23 at 2:07 p.m., CNA A said Resident #1 asked her to leave the shower room a couple of times when she was getting a shower. CNA A said she had gone to the shower room to get hot water. CNA A said she may have said a curse word or two while in the shower, she was not sure. She said she may have delivered a breakfast tray to Resident #1 if she was passing trays and had one for her roommate. She said she was not told to not go in Resident #1's Room, she was told not to provide care to Resident #1. She said Resident #1 had a roommate and she provided care to her. CNA A said Resident #1 may have heard her cursing. CNA A said the Kiosk that they used to input resident care information was right outside of Resident #1's room and she often cursed while using it. CNA A said she was told not to go into Resident #3's room, and she had not been back in her room. She said Resident #3 was upset and it could have been something that she said. CNA said Resident #3 took what she said out of context. The aide said when she provided care to Resident #3 who was a two person assist, there was always at least one other person in the room with her. CNA A said she never provided care to Resident #3 without assistance. She said she told Resident #3 told her there was something wrong with her breast, it smelled. She said she even went to get the nurse ( can not remember who) to look at it. She said the nurse came in and told Resident #3 something was wrong or needed to take the bra off and it had a smell to it. CNA A said CNA O was the aide that was with her that day. CNA A said she may let a [NAME] word slip sometimes when she walked out of a room. She said the Administrator told her was not obligated to tell her why they terminated her. She said she had in services on abuse and knew what abuse was. CNA A said if cursing close to a resident was abuse, then Yes she did abuse residents. CNA A said she knew they wrote several things up on her about residents complaining. She said the Administrator told her that if he turned the write ups into the state his job would be on the line. CNA A said she had about 3 residents that complained about her on that hall and did not want her providing care to them but the facility never moved me from that hall. CNA A said when complaints started coming in the Administrator and DON brought her in to talk about the same things that happen back in July. She said she no longer worked at the facility and these things all happened a long time ago. CNA A wanted to know why the incidents with Resident #1 and Resident # 3 were being questioned about today. She said the Administrator told her they were not called into the State. During an interview on 12/27/23 at 2:12 p.m., Administrator said told CNA A on the incident in July if they continued to get complaints on her she would be terminated. The Administrator said CNA A had a very foul mouth he said he had heard her curing and had reprimanded her on several occasions to stop curing in the facility. He said Resident #1 was very dedicated to her religion and CNA A cursing would have been very offensive to Resident #1. He said CNA A knew that and that is probably why she cursed outside the resident's door or whenever Resident #1 could hear her. He said CNA B and CNA O were CNA A's friends and they would not say anything bad about CNA A. He said CNA O was terminated and she and CNA A work at the same place. The Administrator said when they worked at this facility they would team up and work with new aides, most of which would quit. He said it was not good for the business at all. During an interview on 12/27/23 at 2:31 p.m., the ADON said she had worked at the facility for 15 years. She said she took the position of ADON about June 2023. She said CNA A seemed to be very kind and caring to the residents in front of administrative staff. However, CNA A came across rough and plan speaking. The ADON said sometimes it appeared that CNA A was playing or joking. The ADON said CNA A told her Resident #3's breast smelled told to come down and because the breast smelled like death. She said Resident #3 did not want to get people in trouble and was kind of laughing at the time. The ADON said Resident #3's breast did smell and had dried blood and the nurses should have been washing a surgical wound. She said she knew they called CNA A in to talk to her after the two complaints were voiced by Resident #1 and Resident #3. She said she did not know where it went from there. The ADON said with the complaint on 9/5/23 they pulled CNA A in the office and told her had too many complaints on her and we needed to let her go. The ADON said she had heard CNA A curse on the hallway. The ADON said after reviewing the schedule and the time sheets. The only thing she could tell was the incidents with Residents #1 and #3 did not happen on 7/3/23. She said she did not work that day and neither did CNA A. she said she could not figure out when the incident happened, but it was before 7/3/23. Record review of the facilities, abuse and neglect protocol with no date indicated abuse is defined as the willful inflection of injury, unreasonable, confinement, intimidation, or punishment with resulting physical harm, pain of mental anguish. Abuse also included the derivation by an individual, included caregiver, goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The policy statement, a resident, have a right to be free from abuse, neglect. This includes but not limited to freedom from corporal, punishment, involuntary, seclusion, verbal, mental, physical abuse, the development, an implementation, and policy development, and implement policies and procedures in preventing abuse, neglect, or mistreatment of resident to identifying all possible incidence of abuse to protect resident during abuse investigations. Establish and implement a QAIP review and analysis abuse and implement changes to prevent future currencies of abuse . Each interview will be conducted separately in a private location. Witness reports will be obtained in writing either witness will write his or her statement, sign, and date. Or the investigator may obtain a statement read it back to the member and have him sign and date it. Reporting an alleged violation of abuse or neglect will be reported immediately, but not later than: Two hours if the alleged volition involves abuse or has resulted in serious bodily injury or 24 hours if the alleged violations involved abuse and had not resulted in serious bodily injury. This was determined to be an Immediate Jeopardy (IJ) on 12/27/23 at 3:00 p.m. The facility Administrator, and ADON were notified. The Administrator was provided with the IJ template on 12/27/23 at 3:00 p.m. The Plan of Removal for: [Tag F-607: The employee responsible for abuse to Resident 1 and 3 has been terminated on 9/8/2023. The shift key employee responsible for abuse on resident 4 has been red flagged and is no longer able to pick up shifts or return to this facility effective 5/28/2023. Administrator and DON followed up with residents after incidents to ensure no psychological impact was made. An immediate in-service has been started for all staff with the subject of De-escalating Resident Behaviors. Conduct a safe survey with all current interviewable residents. (See attachment 1 below). This will establish residents, individuals, or clients are no longer at a high risk of serious injury, harm, impairment, or death. o Surveys will be completed by 12:00pm 12/28/2023. o Surveys will be completed by the following department heads: Social Services BOM Dietary Supervisor MDS Coordinator Director of Rehabilitation LVN, ADON If concerns arise from safe survey, statements will be taken from residents. If an allegation of abuse is noted, statements will be taken from all possible sources. In-service has already been provided targeting the importance of reporting as soon as possible and NOT allowing the abuse to continue. An in-service will be provided on behavior training for staff on how to deescalate resident behaviors. This in-service will be completed by DON/Admin by the end of 12/29/2023. An in-service will be provided for treating residents with dignity and respect. To be completed by DON/Admin by the end of 12/29/2023. Create a new policy for Abuse which will include the following: o Definitions o Screening o Training o Prevention o [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to have evidence violations were thoroughly investigated to prevent further abuse for 4 of 7 residents reviewed for abuse. (Resident #1, Resident #2, Resident #3, and Resident #4) The facility failed to ensure a thorough investigation when Resident #4 was not verbally abuse by LVN D and mental abused and harassed for the remainder of the night on 5/28/23. The facility failed to ensure a thorough investigation was conducted when residents complained of harassment, and intimidation for Resident #1, and Resident #3 when they reported CNA A had intentionally tried to intimidate them. The facility failed to complete a thorough investigation on abuse when Resident #3 said CNA A intentionally caused her pain. An Immediate Jeopardy (IJ) situation was identified on 12/27/23 at 3:00 p.m. while the IJ was removed on 12/28/23 at 8:18 p.m., the facility remained out of compliance at a potential for actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of physical harm and or emotional abuse. Findings included: Record review of Resident #4's face sheet with no date indicated he was admitted to the facility on [DATE] and discharge 6/2/23. Resident #4 was a [AGE] year-old male with admitting diagnoses of need for assistance with personal care, history of falling, colostomy status, mood disturbance, anxiety, and lack of coordination. Record review of Resident #4's admission MDS dated [DATE] indicated the resident had moderate cognitive impairment. His functional status indicated he required extensive assist of one person with transfers, toilet use and dressing. The resident was unable to stand and stabilize himself. He did not walk. He was unable to move himself off the toilet, and he was not steady with transfers from surface to surface. Review of Resident #4's baseline care plan dated 5/28/23 indicated his cognition was alert and cognitively intact and required one person assist with bed mobility, transfers walking in toileting . The care plan indicated the resident had a club foot, a new colostomy, and an abdominal incision. He had a new colostomy with interventions to teach the resident proper changing techniques and monitor site of colostomy. Record review of a Provider Investigation Report dated 5/28/23 at 9:59 p.m., indicated on the morning of 5/28/23 around 1:30 a.m. to 3:30 a.m. Resident #4 alleged LVN D verbally abused him. The report contained a letter from the Administrator that stated he first heard of the incident on Sunday, 5/28/23 at 7:30 p.m. Resident #4 said LVN D verbally abused him. The LVN continued to agitate and provoke Resident #4 to the end of his shift at 6:00 a.m. He said they flagged LVN D (an agency nurse) to no longer work for the facility. The investigation indicated Resident #4 was interviewed on 5/30/23 and said LVN D came to his room to help change his colostomy bag and did not bring the appropriate tools. Resident #4 said he felt LVN D did not want to help him. Resident #4 said he told LVN D to get his A out of his room. The Resident said LVN D responded with, I will mop you with the floor. Resident #4 responded. I'll beat your A. Resident #4 said he did not feel safe with LVN D in the building as his nurse. When asked Resident #4 said he did not have a knife. He said he felt he needed to bluff LVN D to ensure his safety. The resident's room was searched and there was no knife found. Interview with LVN D indicated Resident #4 had asked him to help him change his colostomy, in his room and then came to the nurse's station to ask again. LVN D said he told Resident #4 he would assist him when he finished his rounds. LVN D said when he went to the room Resident #4 was rude and talked harshly to him. LVN D said Resident #4 told him, To get his A out of his room. He said the resident continued to give him attitude the rest to the night. The resident told one of the aides he had a knife. The LVN D denied he had harassed the resident. The report indicated a statement from one of the aides indicated LVN D did try and provoke Resident #4 during the night. Record review of a statement that accompanied the Provider Investigation Report for Resident # 4 indicated on 5/28/23 [They (CNA C and CNA E) heard LVN D arguing loudly with Resident # 4. Resident #4 was saying if you are going to hit me then hit me. We (CNA C and CNA E) walked down the hall and LVN D was coming out the room. LVN D said if he was not a professional, he would have whopped Resident #4's A. After that, every time LVN D walked by Resident #4 he would giggle at him and smacked the wall like he was trying to intimidate Resident #4. LVN D really upset Resident #4 to the point he did not feel safe and wanted to leave. LVN D did tell us he told the resident if he was not a professional, he would whip his A.] the statement was signed by CNA C. Record review of the Provider Report Post Action Investigation indicated [ LVN D should have never allowed the situation to get out of hand. He should have been more patient with Resident #4 and never made Resident #4 feel he needed to protect himself. Resident #4 should have shown LVN D more patience as he was seeing other residents during his rounds. Both individuals should have conducted themselves more professionally to ensure a healthy exchange of information and services to be achieved. I feel both men were at fault and this situation could have easily ben avoided. I am finding this inconclusive because both men conducted themselves inappropriately. Neither one were at risk of injury or injured. They obviously do not get along with each other. I do not agree how LVN D conducted himself at the facility and we have taken measures for him not to return to the facility as he is not employee. He is an agency employee and will not be allowed to work another shift at this facility.] The form was signed by the Administrator on 5/31/23. During an interview on 12/18/23 at 2:20 p.m. CNA C said she and CNA E were working in another resident room and came into the hallway and heard loud voices coming from Resident #4's room on morning of 5/28/23. She said the LVN D came out of the room and was hollering back, I would whip your A if you were not a resident. She said Resident # 4 was very upset and wanted to leave the facility. He tried to exit through several of the doors. She said she spent the night trying to keep him from leaving and watching LVN D try and aggravate the resident. She said every time LVN D would pass by the Resident #4. He would giggle and hit on the wall or the side rails as if he was hitting someone. She said the nurse's behavior was not professional at all, in fact he acted like a child. She said she did not remember if she called anyone to report the incident or not. She spent the night trying to keep the peace and trying to keep Resident#4 from leaving. She said at one point they were outside in the smoking area, and Resident#4 said he would throw himself on the ground, throw his wheelchair down the steps, crawl down the steps and get back in his wheelchair and leave. During an interview on 12/18/23 at 2:25 p.m., the Administrator said he did not remember who notified him about the incident that happened on 5/28/23. He said he was told it happened on that morning around 1:30 a.m. or 2:00 a.m. he said it was not reported to him until 5/28/23 at 7:30 p.m. and he called it into the state around 9:00 p.m. He said in the defense of the resident he was very independent. He said the resident told the nurse he had a knife because he tried to intimidate him when he walked by. The Administrator said the resident did not have a knife and he could not find one. He said the resident admitted he just felt he needed some type of protection from the LVN D. During an interview on 12/18/23 at 3:30 p.m., CNA E said when they rounded the corner on the night of 5/28/23, LVN D and Resident #4 were arguing. The nurse was LVN D was hollering at the Resident #4. We (CNA C and CNA E) tried to deescalate the situation. CNA E said Resident #4 tried to leave through two different doors. She said the nurses' behavior was not professional, he was hollering and talking smart. Resident #1 Record review of Resident #1's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were Alzheimer's, disease, anxiety disorder, and history of falling. Record review of Resident #1's quarterly MDS dated [DATE] indicated she had no cognitive impairment. The resident used mobility devices of a walker and a wheelchair. She required partial assistance with hygiene, and partial assistance with chair to bed transfer, and partial assist with toilet transfer. Record review of Resident #1's care. Plan indicated she had a problem of ADL function. She required two people assist with bathing, two people assist with toileting, and two people assist with bed mobility. Record review of a Complaint/Concern form dated 7/3/23 indicated Resident #1 was filing a complaint against CNA A. Resident #1 said CNA A was rough in the way that she handled her care, causing her pain and discomfort when she was turning her, placing her in the chair and any other physical contact. Resident #1 said CNA A spoke to her in a rude and hurtful manner. Resident #1 said she refused to put up with it any longer. CNA A said Resident # 1, was always complaining about something and making notes to tell on me. Resident #1 disagreed with that statement. Resident #1 said that she refused to be spoken to or treated to rudely any longer. The resident said she asked CNA A to stop on several occasions, but it continued. Resident #1 said it had become harassment. The resident did not want CNA A to be associated with her care any longer. Resident #3 Record review of a face sheet for Resident #3 with no date indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were stroke, removal of the right breast, acute kidney failure, stiffness in the right knee, need for assistance with personal care, abnormal posture Disorder of the bone upper arm, and muscle weakness. Record review of Resident #3's quarterly MDS dated [DATE] indicated she had no cognitive impairment. Her functional status was she used a wheelchair for mobility. She had impairment on her upper extremity shoulder, elbow, wrist, and hand, and she had impairment on her lower extremity hip knee, ankle, and foot. Record review of Resident #3's care plan dated 11/15/23 indicated a problem of limited range of motion to the right upper and lower extremities. Resident # 3 required assistance with active and passive range of motion in a splint applied to the right hand. Resident # 3 had problems of ADL function and required a lift for transfers. The resident required one or two people to aid turn and reposition in bed frequently to prevent skin breakdown. The resident required one person assist for dressing, and two people for a transfer by Hoyer lift. Record review of a Complaint/Concern Form dated 7/3/23 indicated Resident# 3 filed a complaint against CNA A. The Complaint indicated the aide was rough in the way she handled Resident #3's care, causing her pain and discomfort when she was turning Resident #3, placing her in the chair and other physical contact. Resident #3 said the way CNA A spoke to her was rude, hurtful, and she refused to put up with it any longer. The resident said CNA A told her that turning her hurt her because she was a big woman, and she was doing it by herself. Resident # 3 said she told CNA A she should ask for help. Resident # 3 said CNA A told her she stunk after Resident # 3 had breast surgery. The Resident # 3 said the CNA told her the smell coming from her breast stinking up the room. The form indicated CNA A said she and Resident #3 were friends and that was just the way they talked to each other. Resident #3 disagreed with that statement, and she said she did comment back to the aide but in self-defense. Resident #3 said they were not friends and she refused to be spoken to or treated rudely any longer. Resident # 3 said asked CNA A to stop on multiple occasions, but her attitude continued. Resident #3 said it had become harassment. The resident did not want CNA A to be associated with her care any longer. When talking to CNA A about the event, she said that she and the resident joked all the time, and she was unaware that it bothered the resident. CNA A stated, verbally that she would not joke like that again, and would have a more professional manner when interacting with residents. The investigation finding indicated, Resident # 3 said she did not have an issue with CNA A but was embarrassed by the event. The steps taken to correct the action was a counseling form on how to keep a professional manner. The steps taken to correct the issue was CNA A was removed from her care and could only provide care when assisting other staff. A counseling will be provided to CNA A on treating residents in a professional manner. Record review of a Counseling/Disciplinary note for CNA A dated 7/18/23 (15 days later) indicated the reason for the counseling was multiple complaints on CNA A for being verbally, aggressive, and short with Residents. The corrective actions were to speak with the aid about how to approach residents in a more professional manner and it was signed by the DON and CNA A on 7/19/23. There was no Inservice attached. Record review of a Complaint/Concern form dated 9/5/23 indicated Resident #1 reported that she continued to have problems with CNA A. She stated that on 8/30/23 CNA A continuously interrupted her shower to talk to the shower aid, making her uncomfortable. The resident stated CNA A's language was profane. Resident #1 said on the following day, 8/31/23 CNA A and another aide came into the room going through her roommates closet and cursing very loudly. Resident #1 said they were gossiping about other employees and used an extreme amount of profanity. Resident #1 said that she was very offended. Resident #1 said on the following morning she was sleeping when CNA A came into her room, and said loudly, Your breakfast is served. Wake up and eat it. Resident #1 said it was very rude, so she refused acknowledge her. Resident #1 said, I feel targeted . Resident #1 said she spoke to the nurse on the weekend about her concerns ( no statement from the nurse) Resident #1 said she felt CNA A used the excuse of taking care of her roommate, as an opportunity to antagonize an aggravate her . The allegation was investigated, and the IDT meeting was held. The findings were CNA A was guilty of the events, and will be given the option of quitting or resigning from her position. Signed by the Administrator Record review of a Counseling/Disciplinary note for CNA A dated 9/8/23 indicated CNA A was discharged and her last day at work was 9/8/23. The form indicated this would serve as termination. Corrective actions had already been taken and misconduct continued. The employee comments were, Do not understand what the reason. Signed by CNA A. During an interview on 12/14/23 at 11:00 a.m., the DON said she had determined Resident #1's allegations were true. She did not have statements from the shower aide, nurse, or CNA A. She said they had gotten multiple complaints regarding the aide and felt it was time to let her go. When asked about the statement on the grievance dated 9/5/23 that said CNA A was guilty of the allegations made by Resident #1. The DON said she did not remember how she verified the events that occurred were true regarding Resident #1's allegations. During an interview on 12/14/23 at 11:50 p.m., the DON and the Administrator said because of her previous behaviors with residents, CNA A was terminated, on 9/8/23. The DON said there was another resident on the same hall as Resident #1 who did not want CNA A in her room. That resident changed her details of the occurrence several times so they could not validate her allegations. However, the resident said she did not like CNA A and did not want her back in her room. The DON and Administrator said Resident #1 and Resident #3's issues bordered on abuse but neither resident said they were abused. The Administrator and the DON said they did not know that CNA A continued to go into Resident #1's room. During an interview on 12/18/23 at 11:58 a.m., the Administrator said CNA A worked at a fast pace and the former DON loved her (the former DON left 6/30/23). He said he tried to work with CNA A. He felt her actions would get right up to the line of abuse and then she would pull back. The Administrator said he did not think CNA A was a nice person. The Administrator said one issue with CNA A was that she had a foul mouth. The Administrator said he had tried to encourage her not to use foul language around residents. He said CNA A did not have much respect for authority, and she did what she wanted to do. The Administrator said they had to let her go because warnings did not help, and she had gone past the point respecting the residents. During an interview on 12/18/23 at 12:50 p.m., Resident #3 said the things CNA A did to her could have been abuse. Resident # 3 stated it started out as joking, and she would never have called CNA A her friend. Resident # 3 said CNA A took the snide comments to a whole different level. Resident #3 said CNA A was rough when she provided care to her. Resident#3 said would tell CNA A she was rough and hurting her. She said CNA A knew she was hurting her and did not care. Resident# 3 said on one occasion when she complained to aide about her being rough, CNA A told her, Well you are not light. Resident # 3 asked her to get some help if she was too heavy and the aide refused. Resident #3 said she had a stroke on her right side, and it hurt when she was moved around roughly. Resident#3 said some of the things the aide said were hurtful and hurt her feelings. cane said when CNA A provided care to her, the aide knew she was rough, and hurt her but did not care. Resident#3 said complained after she could not take anymore. Resident #3 said CNA A was not allowed back in her room and did not speak to her in the hallway. During an interview on 12/18/23 at 12:55 p. m. Resident #2 said CNA A had been unkind to her on several occasions. When she finally told the staff, she felt threatened when the aide came in the room. She said she might have confused the events some, but the aide was mean, and she did not want her in her room. She said she heard they terminated her because she was mistreated another resident. During an interview on 12/18/23 at 2:10 p.m., Resident #1 said she remembered CNA A quite well. She had been rude and mean to her. She had requested she not be allowed in her room. She said on several occasions when she was in the shower room getting assistance with a shower. She said CNA A would come in and take a seat and try to intimidate her. She said CNA A would talk, and all kinds of filthy language would come out of her mouth. She asked her to leave the shower room on at least two occasions because she did not feel comfortable with her there. She said on several occasions she would come into her room and move her walker around in the room or come in to care for the roommate and use filthy language. She had complained back in September, and she was finally let go. Resident #1 said she felt the aide was trying to intimidate her because she had complained of her attitude and treatment towards her in the past. During an interview on 12/18/23 at 2:25 p.m., the Administrator he was not aware of any furniture being moved in Resident #1's room. He said there was a dresser she complained had been moved and he moved it back. It was only moved a few inches. He was not aware of any allegation that CNA A had been in Resident #1's room. He said he thought he had statements from staff regarding the issues with CNA A but could not find any. He said he did conduct in services after each episode of possible abuse. During an interview on 12/18/23 at 3:00 p.m., the DON said she did not remember Resident #1 saying anything about her things being moved around in her room. During a telephone interview on 12/18/23 at 3:38 p, CNA B (former shower aide) said CNA A did come in a few times when she was giving Resident #1 a shower. She said she had only come in to get a basin of warm water or something like that. She did not remember her cursing but she did remember Resident #1 asking CNA A to leave the shower room and she left. During an interview on 12/27/23 at 11:20 a.m. , the Administrator said they had a QA meeting scheduled for tomorrow, 12/28/23. He said they had not QA the event between Resident #4 and LVN D after reviewing his QA book. During an interview on 12/27/23 at 12:30 p.m. the Administrator said he said something about Abuse and Neglect during every in service. He did not have any additional content for the for the 6/9/23 after the incident with Resident #4. The administrator there was no in-service regarding Resident Behaviors or deescalating agitation or aggressive situations. During an interview on 12/27/23 at 1:55 p.m. Administrator said CNA A was guilty of using foul language in the shower room. He said CNA A admitted to using foul language in the shower room. The Administrator said CNA A never admitted to giving care to Resident #1 or doing anything with #1. He said CNA A was not allowed to give care to Resident #1. He said they had written on the grievance form she was guilty but not of all of the allegations made. He said they did not interview other staff or get statements about the incident, so they could not verify that Resident #1's allegations were true or not. They were aware CNA A continued to receive complaints about her behaviors and they could not allow her to continue to work for the facility. He said they had not taken statements from the aide or the aides that may have witnesses the behaviors. The Administrator said what was he supposed to do with the LVN D. He said if he sent the nurse home, they would have only had one nurse in the building that night. The Administrator said at that time if they called the former DON, she would not have answered the phone and she sure would not have come to the facility to fill for the LVN. He said he was between a rock and a hard place. If he sent the nurse home, he would not have had sufficient nursing coverage for the facility, what was he supposed to do? During an interview on 12/27/23 at 2:07 p.m., CNA A said Resident #1 asked her to leave the shower room a couple of times when she was getting a shower. CNA A said she had gone to the shower room to get hot water. CNA A said she may have said a curse word or two while in the shower, she was not sure. She said she may have delivered a breakfast tray to Resident #1 if she was passing trays and had one for her roommate. She said she was not told to not go in Resident #1's Room, she was told not to provide care to Resident #1. She said Resident #1 had a roommate and she provided care to her. CNA A said Resident #1 may have heard her cursing. CNA A said the Kiosk that they used to input resident care information was right outside of Resident #1's room and she often cursed while using it. CNA A said she was told not to go into Resident #3's room, and she had not been back in her room. She said Resident #3 was upset and it could have been something that she said. CNA said Resident #3 took what she said out of context. The aide said when she provided care to Resident #3 who was a two person assist, there was always at least one other person in the room with her. CNA A said she never provided care to Resident #3 without assistance. She said she told Resident #3 told her there was something wrong with her breast, it smelled. She said she even went to get the nurse ( can not remember who) to look at it. She said the nurse came in and told Resident #3 something was wrong or needed to take the bra off and it had a smell to it. CNA A said CNA O was the aide that was with her that day. CNA A said she may let a [NAME] word slip sometimes when she walked out of a room. She said the Administrator told her was not obligated to tell her why they terminated her. She said she had in services on abuse and knew what abuse was. CNA A said if cursing close to a resident was abuse, then Yes she did abuse residents. CNA A said she knew they wrote several things up on her about residents complaining. She said the Administrator told her that if he turned the write ups into the state his job would be on the line. CNA A said she had about 3 residents that complained about her on that hall and did not want her providing care to them but the facility never moved me from that hall. CNA A said when complaints started coming in the Administrator and DON brought her in to talk about the same things that happen back in July. She said she no longer worked at the facility and these things all happened a long time ago. CNA A wanted to know why the incidents with Resident #1 and Resident # 3 were being questioned about today. She said the Administrator told her they were not called into the State. During an interview on 12/27/23 at 2:12 p.m., Administrator said told CNA A on the incident in July if they continued to get complaints on her she would be terminated. The Administrator said CNA A had a very foul mouth he said he had heard her curing and had reprimanded her on several occasions to stop curing in the facility. He said Resident #1 was very dedicated to her religion and CNA A cursing would have been very offensive to Resident #1. He said CNA A knew that and that is probably why she cursed outside the resident's door or whenever Resident #1 could hear her. He said CNA B and CNA O were CNA A's friends and they would not say anything bad about CNA A. He said CNA O was terminated and she and CNA A work at the same place. The Administrator said when they worked at this facility they would team up and work with new aides, most of which would quit. He said it was not good for the business at all. During an interview on 12/27/23 at 2:31 p.m., the ADON said she had worked at the facility for 15 years. She said she took the position of ADON about June 2023. She said CNA A seemed to be very kind and caring to the residents in front of administrative staff. However, CNA A came across rough and plan speaking. The ADON said sometimes it appeared that CNA A was playing or joking. The ADON said CNA A told her Resident #3's breast smelled told to come down and because the breast smelled like death. She said Resident #3 did not want to get people in trouble and was kind of laughing at the time. The ADON said Resident #3's breast did smell and had dried blood and the nurses should have been washing a surgical wound. She said she knew they called CNA A in to talk to her after the two complaints were voiced by Resident #1 and Resident #3. She said she did not know where it went from there. The ADON said with the complaint on 9/5/23 they pulled CNA A in the office and told her had too many complaints on her and we needed to let her go. The ADON said she had heard CNA A curse on the hallway. The ADON said after reviewing the schedule and the time sheets. The only thing she could tell was the incidents with Residents #1 and #3 did not happen on 7/3/23. She said she did not work that day and neither did CNA A. she said she could not figure out when the incident happened, but it was before 7/3/23. Record review of the facilities, abuse and neglect protocol with no date indicated abuse is defined as the willful inflection of injury, unreasonable, confinement, intimidation, or punishment with resulting physical harm, pain of mental anguish. Abuse also included the derivation by an individual, included caregiver, goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The policy statement, a resident, have a right to be free from abuse, neglect. This includes but not limited to freedom from corporal, punishment, involuntary, seclusion, verbal, mental, physical abuse, the development, an implementation, and policy development, and implement policies and procedures in preventing abuse, neglect, or mistreatment of resident to identifying all possible incidence of abuse to protect resident during abuse investigations. Establish and implement a QAIP review and analysis abuse and implement changes to prevent future currencies of abuse . Each interview will be conducted separately in a private location. Witness reports will be obtained in writing either witness will write his or her statement, sign, and date. Or the investigator may obtain a statement read it back to the member and have him sign and date it. Reporting an alleged violation of abuse or neglect will be reported immediately, but not later than: Two hours if the alleged volition involves abuse or has resulted in serious bodily injury or 24 hours if the alleged violations involved abuse and had not resulted in serious bodily injury. This was determined to be an Immediate Jeopardy (IJ) on 12/27/23 at 3:00 p.m. The facility Administrator, and ADON were notified. The Administrator was provided with the IJ template on 12/27/23 at 3:00 p.m. The Plan of Removal for: [Tag F-610: The employee responsible for abuse to Resident 1 and 3 has been terminated on 9/8/2023. The shift key employee responsible for abuse on resident 4 has been red flagged and is no longer able to pick up shifts or return to this facility effective 5/28/2023. Administrator and DON followed up with residents after incidents to ensure no psychological impact was made. An immediate in-service has been started for all staff with the subject of De-escalating Resident Behaviors. Conduct a safe survey with all current interviewable residents. (See attachment 1 below). This will establish residents, individuals, or clients are no longer at a high risk of serious injury, harm, impairment, or death. o Surveys will be completed by 12:00pm 12/28/2023. o Surveys will be completed by the following department heads: Social Services BOM Dietary Supervisor MDS Coordinator Director of Rehabilitation ADON o Non-interviewable residents will have skin assessment completed once a week, for 3 months to be reviewed monthly in QA. Documented daily rounds to determine if non-interviewable residents are free from abuse to be completely 3 times a week for 3 months and reviewed in monthly QA. Create a new policy for Abuse which will include the following: o Definitions o Screening o Training o Prevention o Identification o Investigation o Protection o Reporting The new Policy was completed by Administrator. Policy was completed 12/28/2023 at 10:00am N[TRUNCATED]