**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 1 (Residents #7) of 6 residents reviewed for resident abuse. The facility failed to ensure Resident #7 was free from physical abuse from LVN B during an incident on 01/04/2025 that subsequently required surgery on 01/09/2025. A Past Non Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator on 02/19/2025 at 11:37 AM. The noncompliance began on 01/04/2025 and ended on 01/06/2025. The facility corrected the noncompliance before the investigation began. These failures placed residents at risk for serious injuries, abuse, and serious harm. Findings Included: Review of Resident #7's Face Sheet, dated 02/18/2025 at 1:30 PM, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included schizophrenia, generalized anxiety disorder, osteoporosis, opioid dependence, and anorexia. Review of Resident #7's Quarterly MDS dated [DATE] revealed she was cognitively intact with a BIMS score of 15. She received both scheduled and PRN pain medication. She was prescribed antipsychotics for her mental health. Review of Resident #7's Care Plan, revised 01/22/2025, revealed she had . falls . resulted in ulnar styloid avulsion fracture (bony projection of the wrist) . right wrist fracture . fracture of the olecranon (part of the elbow) . and interventions included to anticipate resident needs, encourage resident to leave splints in place on wrists for proper healing, monitor pain level, educate/encourage resident to wear appropriate footwear, educate/encourage resident to ask for assistance when needed, pharmacy consult to evaluate medications, ensure personal belongings were with resident's reach, enhanced monitoring for pain, bruising, and change in mental status, ensure environment was safe, and therapy evaluation and treatment per orders. Review of Resident #7's Radiology Results Report on 01/06/2025 at 12:41 PM revealed acute fracture of the right elbow and right wrist. Review of Resident #7's Clinical Record from her orthopedic surgery on 01/09/2025, dated 01/10/2025 at 10:00 am revealed Resident #7 presented for outpatient surgery for ORIF left and right wrist and ORIF right elbow . Patient sustained injuries with a previous fall . In interview with Resident #7 on 02/18/2025 at 11:25 AM, she stated that last month, LVN B threw her across the room and slammed her down to the ground. She stated LVN B caused injury to both of her arms and wrists. Resident #7 stated she had to have surgery because of her injuries. She declined further interview at this time and could not provide further detail. In an attempt for a follow up interview with Resident #7 on 02/19/2025 at 12:22 PM, she declined interview at this time. Interview attempted with LVN B on 02/18/2025 at 12:18 PM and 02/19/2025 at 2:00 and 02/19/2025 at 2:30 PM was unsuccessful. Record review of Progress Note by LVN B, dated 01/04/2025 at 8:41 PM revealed, [Resident #7] punched nurse. [LVN B] pushed resident away from her. Resident dramatically fell against the wall and slid to the floor. [LVN B] attempted to assist resident. [Resident #7] refused. [Resident #7] then lied down in the supine position. [CNA A] attempted to assist resident. Resident again refused . In interview with CNA A on 02/18/2025 at 2:28 PM, she stated she worked the time of the incident, but she did not recall the exact time the incident occurred. She stated she was not present for the specific incident but arrived afterward the alleged incident to assist Resident #7 from the floor to her bed. She stated she did not suspect any abuse at this time, and stated Resident #7 did not report any allegations during any time after the interaction. Record review of Progress Note by LVN T, dated 01/05/2025 at 11:15 AM revealed: [Resident #7] called nurse to give her pain pill and noticed bruising in her elbow and wrist asked when that happened, she replied 'it happen last night after the dinner in the hallway' doctor, DON, ADON, family notified, as per doctor's order R elbow, hand, skull X-RAY stat ordered. vitals are stable, call button is in place, nurse is monitoring resident closely. Interview attempted with LVN T at 02/18/2025 at 3:25 was unsuccessful. In interview with DON at 2/18/2025 at 3:00 PM, she stated LVN B was a good nurse and denied any complaints or suspicions of abusive conduct prior to the incident. She stated that LVN B reported to her that she specifically witnessed the resident sit on the floor and that was why LVN B did not report the incident as a fall, accident, or abuse. DON stated that once LVN T noticed bruising on Resident #7's wrists and reported to her the incident, she immediately began interventions. She stated she immediately suspended LVN B, contacted law enforcement, and conducted a thorough investigation with facility's Administrator. DON stated while she did not feel LVN B's action was willful or malicious, she stated LVN B was terminated out of an abundance of caution and her license was referred for further review. In interview with Administrator at 02/18/2025 at 12:43 AM, he stated he immediately suspended LVN B pending investigation, contacted law enforcement, and conducted a thorough investigation after LVN T reported the allegation regarding Resident #7. He stated after he completed his investigation, he stated LVN B reported to him that her actions were defensive, and not willful or malicious. Administrator stated that as a result of his investigation, he concluded her actions were out of line and terminated her employment at the facility. Additionally, he stated he referred her license out of an abundance of caution. Following the incident his leadership team conducted safe-surveys with the residents and multiple in-services related to abuse, neglect, exploitation and employee burnout. Review of Facility in-services on 02/18/2025 revealed multiple staff were in-serviced on what Abuse and Neglect consist of, policy, protocol and procedures following any suspected abuse, neglect, and/or exploitation, and specifically whom to report to and the timeframe required. Further review revealed complementary Abuse & Neglect Knowledge Check quiz completed by all staff to ensure comprehension of the in-service information provided. In interview with Administrator, DON, ADON, RN D, CAN E, CNA F, CNA A, LVN Z, LMSW, and Activity Director between 02/18/2024 9:00 AM - 3:00 PM revealed staff were knowledgeable on what abuse and neglect consisted of, facility policy, protocol, and procedures, whom to specifically report suspected abuse, neglect, and/or exploitation to and the timeframe required. Review of Facility safe surveys on 02/18/2025 conducted by Administrator on 01/05/2025 revealed no additional allegations of Abuse, Neglect, and/or Exploitation from the residents at the facility. Review of LVN B's In-services, dated 01/06/2025 at 10:57 AM revealed she was in-serviced on Preventing and De-escalating Crisis Situations, on 12/27/2024 and received a 100% on the post-test. Additional in-services included Knowing the Rights of the Residents, Working with Residents with Substance Use Disorder, Tips on Managing Challenging Behaviors, Effective Communication, Pian Management, Fall Prevention, and Abuse, Neglect and Exploitation all completed on 12/27/2024. Review of LVN B's Termination Form dated 01/06/2025 revealed she was involuntarily terminated due to gross misconduct and additional explanation of termination: conclusion of the investigation, employee did not express regret, no remorse. Termination effective immediately and is not rehire-able. A Past Non Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator on 02/19/2025 at 11:37 AM. The noncompliance began on 01/04/2025 and ended on 01/06/2025. The facility corrected the noncompliance before the investigation began. Record review of Facility Policy, Resident Rights and Protections, dated 12/2014, signed by LVN B on 10/23/2024 revealed Our residents are entitled to . be treated with respect and dignity . be free from verbal, sexual, physical, and mental abuse . have a physician and/or representative notified any time a resident is injured in an accident or needs to see a doctor . Review of Facility Policy, Reporting and Preventing Abuse, Neglect and Mistreatment, dated 12/2014, revealed Any person who observes or becomes aware of an incident of resident/patient abuse, neglect or mistreatment . whether alleged, suspected, or observed, must report the incident to the Administrator . immediately. Record review of Facility Policy, Abuse: Prevention and Prohibition Against, dated 11/2017 revealed each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . Physical abuse includes but is not limited to hitting, slapping, pinching, and kicking.

**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, neglect, misappropriation of resident property, and exploitation for 1 of 11 residents (Resident #1) reviewed for abuse and/or neglect. The facility failed to protect Resident #1, who was not verbal, from sexual abuse when a confidential interviewee provided video footage of the resident trying to cover her breasts and vaginal area with her hands while CNA A was undressing her and when CNA A had her hands between Resident #1's legs and moved her hand in a fast motion inside the vaginal area for eight (8) minutes and two seconds (.02) after changing her. An IJ was identified on 08/07/24. The IJ template was provided to the facility on [DATE] at 1:30 p.m. While the IJ was removed on 08/09/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on abuse and neglect. This failure could place residents at risk of abuse, neglect, humiliation, and psychosocial harm. Findings include: Record review of Resident #1's admission record, dated 07/25/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included, Dysphagia (difficulty swallowing), Cognitive Communication Deficit (trouble reasoning and making decisions while communicating), Dementia (a group of thinking and social symptoms that interferes with daily functioning), Psychotic Disorder with Delusions (an unshakeable belief in something untrue), Paranoid Schizophrenia (a person feels distrustful and suspicious of other people and acts accordingly), Major Depressive Disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and Muscle Weakness (decreased strength in the muscles). Record review of Resident #1's Modified admission MDS assessment, dated 02/12/24 , this was the most recent comprehensive assessment on file, reflected Resident #1 had no speech. She usually understood and comprehended most conversations. Resident #1 had severe cognitive impairment, the BIMS score was not indicated, Resident #1 was unable to participate. Resident #1 was dependent on staff for all activities of daily living and was incontinent of bowel and bladder. Record review of Resident #1's care plan, dated 01/31/24, reflected Resident #1 was incontinent of bowel and bladder. Staff were to provide incontinent care after each episode. The care plan reflected Resident #1 was totally dependent on staff for all her activities of daily living. Observation on 07/25/24 at 10:38 a.m. the State Surveyor received and reviewed the video provided by a confidential interviewee of the alleged incident involving CNA-A and Resident #1. The video revealed the following: Video dated 7/21/24 at (19:30:00) 7:30 PM, CNA-A entered the room with Resident #1, within camera view CNA-A began to remove the clothes off Resident #1, at (19:30:50) 7:30:50 PM the resident's blouse was completely removed, and CNA-A took the resident to her bed by grabbing her by the right arm. CNA-A used her right hand to turn back the cover on the bed. The resident was observed in the video using her left arm to cover her breast while CNA-A was walking her toward the bed. CNA-A stood the resident by the bed and pulled down the resident's pants before laying the resident on the bed, then reached to grab her feet from the floor and placed her feet in the bed. At (19:31:58) 7:30:58 PM CNA-A put the resident in bed and removed her pants leaving on the adult brief, during this time the resident was watching CNA-A while covering her breast with both of her arms. At (19:32:04) 7:32:04 PM CNA-A unfastened the adult brief of Resident #1 and walked away from the bed out of camera view, while the resident was lying on the bed covering her breast with both of her arms and the open adult brief was open exposing her vaginal area. CNA-A returned to the bedside of the resident at (19:32:38) 7:32:38 PM. When CNA-A returned to the bedside of the resident she returned with adult briefs and wipes. CNA-A was observed using the wipes to clean the resident. While CNA-A was cleaning the resident, Resident#1 was observed holding both of her arms in a bent position covering her breast while shaking her hands in a clasped position in front of her. CNA-A then turned the resident toward the wall and removed the soiled adult brief and bed pad. CNA-A stepped away from the bed again to dispose of the soiled items, as she left the resident lying on the bed completely naked. CNA-A returned to the bedside of the resident, and she placed two clean adult briefs under the resident by turning the resident from side to side. Once the open briefs were under Resident #1, CNA-A moved to the head of the bed and repositioned the pillow under the head of the resident before returning to the middle of the bed and grabbed the gown and shook the gown before she placed the gown over the head of the resident and put her arms inside the gown. At (19:35:19) 7:35:19 PM, while the resident's vaginal area was still uncovered CNA-A used her hands to open the bent legs of the resident and placed her hands in the vaginal area. The resident was observed raising up her right forearm and tapping the left arm of CNA-A while grimacing her face. The resident was observed stretching out her right leg and reaching her right hand toward CNA-A while looking at her. CNA-A was observed looking toward the resident while she had her hands in the open vaginal area of the resident. At (19:35:54) 7:35:54 PM Resident #1 was observed placing her shaking left hand in front of her face, while CNA-A was looking toward her. Resident #1 was observed raising her head slightly off the pillow and patting her left foot on the bed. At (19:36:17) 7:36:17 PM CNA-A continued to have her hands in the vaginal area of the resident when the resident raised her right arm and was moving it toward CNA-A, as CNA-A looked toward the resident. At (19:36:22) 7:36:22 PM CNA-A continued to have her hands in the vaginal area of Resident #1 as CNA-A's right arm was observed to be moving in a fast motion until the resident looked toward something behind CNA-A at (19:36:29) 7:36:29 PM. CNA-A then looked behind her, then she continued to keep her hands in the open vaginal area of the resident until the resident looked behind CNA-A again at (19:36:35) 7:36:35 PM. At (19:36:35) 7:36:35 PM CNA-A stood up as if she was talking to Resident #1. At (19:36:46) 7:36:46 PM CNA-A opened the legs of Resident #1 with her vaginal area still uncovered and then she walked away from the bed off camera. During this time Resident #1 used her hands to cover her open vaginal area. CNA-A returned to the bedside of Resident #1 at (19:36:52) 7:36:52 PM and she moved the hands of the resident, CNA-A leaned over and placed her right hand between the still bent legs of the resident at (19:37:02) 7:37:02 PM and the resident looked behind CNA-A and CNA-A looked at the resident. At (19:37:13) 7:37:13 PM the resident was observed moving her hand and looking behind CNA-A while CNA-A continued to have her hand moving it in a fast motion. At (19:37:24) 7:37:24 PM Resident#1's legs were stretched on the bed while CNA-A's hands were still moving fast in her vaginal area. This action continued in the open vaginal area of the resident until (19:37:32) 7:37:32 PM when CNA-A bent Resident #1's right leg back up before returning her hands to the open vaginal area. At (19:37:55) 7:37:55 PM, CNA-A moved her body closer to the head of the bed of the resident exposing her vaginal area more, CNA-A's right hand was observed on the vagina of Resident #1 moving in a fast motion until (19:38:02) 7:38:02 PM when CNA-A reached down and pulled up both adult briefs and fastened them at (19:38:21) 7:38:21 PM. At (19:38:30) 7:38:30 PM, CNA-A pulled down the gown of Resident #1 then repositioned her in bed. At (19:38:43) 7:38:43 PM, CNA-A covered Resident #1 with the bed covers, lowered the resident's bed, and repositioned her pillow at (19:39:26) 7:39:26 PM. A confidential interview revealed it was observed on 07/21/24 in the evening time, the confidential interviewee stated they were not sure of the specific time of the original viewing of the video. The confidential interviewee stated it was observed via video CNA-A was in the bedroom of Resident #1 putting Resident #1 in bed when they touched her inappropriately. The confidential interviewee stated Resident #1 was not verbal. The confidential interviewee stated there was audio on the camera, the interviewee stated when CNA-A entered the room with the resident CNA-A said, Let me lay you down. The confidential interviewee stated there was not much communication after that statement. The confidential interviewee stated after Resident #1's clothes were taken off, and the resident was put on the bed and the incident happened. The confidential interviewee stated the abuse was reported to the Administrator in Training, and law enforcement. The confidential interviewee stated Resident #1 was taken to the hospital for an exam on 07/22/24. The confidential interviewee stated the hospital stated it would take several weeks to receive the results of the exam. The confidential interviewee stated Resident #1 was anxious when her adult brief was changed, and she would grab the hand of the person who was changing her. The confidential interviewee stated it was hard to determine if the incident had caused the resident harm at this time. The confidential interviewee stated the family requested Resident #1 not be visited because she was non-verbal and could not contribute to the investigation. The confidential interviewee they had contacted the police and Resident #1 was removed from the facility on 07/22/24 at 3:50 p.m. The confidential interviewee stated Resident #1 would not be returning to that facility. The confidential interviewee stated the video would be sent via text. In an interview with the Administrator in Training, acting abuse coordinator on 07/25/24 at 9:40 a.m. revealed he was notified of the abuse allegation on 07/22/24 late in the afternoon by the POA of Resident #1 . He stated the POA notified LE prior to coming to the facility. He stated he was told Resident #1 had been abused, he was not given specifics and was told there was a video, but he had not seen the video. He stated while LE and the POA was at the facility they removed Resident #1 from the facility when they left. He stated CNA A last worked 07/21/24 and was suspended on 07/22/24. He stated the facility's investigation was still ongoing at that time. He stated the facility was conducting safe surveys of all the residents and angel rounds (department heads are making rounds on assigned residents) and skin assessments on the two non-verbal residents. He stated the facility conducted an in-service with all staff on 07/22/24. He stated there was not any previous warnings or incidents regarding CNA-A at the facility. He stated CNA-A received the employee of the month for the month of June. He stated several families complimented her work. He stated at that time the facility was not able to verify if the incident had happened because the investigation was still ongoing. He stated the nursing staff was responsible to ensure the CNA's took proper care of the residents, the DON, and then the Administrator. In an interview on 07/24/24 at 12:08 p.m. with Detective from the local PD revealed he went to the facility on [DATE] and he was not provided the information for CNA-A until he returned on 07/23/24. He stated after the facility provided him with the location information of CNA-A an arrest warrant was issued. He stated due to the nature of his investigation he did not want CNA-A to be interviewed by the State Surveyor prior to her arrest. During an interview on 07/25/24 at 12:20 p.m., LVN B said the abuse coordinator should be notified immediately after an allegation of abuse was made. She said she could tell the abuse coordinator, the administrator or administrator in training in person or call them. She said she could also tell the DON of an allegation of abuse. She said she was trained on abuse and neglect several times. She said the abuse policy was a topic that was trained frequently. She said when abuse allegedly occurred she would also need to ensure the resident and other residents were kept safe from the person who allegedly did the abuse. During an interview on 07/25/24 at 1:17 p.m., CNA C said if a resident alleged that they were abused then she would need to ensure the resident was safe, report to the abuse coordinator, the administrator and the DON, keep the resident safe, and prevent the person who allegedly did the abuse away from other residents. She said she was in-serviced on all these principals' multiple times. During an interview on 07/25/24 at 2:47 p.m., CNA-D said she had been in-serviced on the facility abuse policy several times. She said if an allegation of abuse was made, they were to immediately report the allegation to the abuse coordinator, the administrator. She said she could also report to the charge nurse and the DON as well as call the abuse coordinator. She said she would also need to ensure the person who did the abuse did not have access to any resident and have them leave the building. In a follow-up interview with the Administrator in training on 07/25/24 at 3:43 p.m., he stated he interviewed CNA-A prior to the State Surveyor's entrance. He stated, CAN-A described and demonstrated the service she provided to Resident #1 as cleaning her and changing her bed and her brief. She stated she did not have any issues with Resident #1. He stated CAN-A did not provide a written statement of the services she provided to Resident #1. The Administrator in training stated the facility had psych services at the facility and they came and talked to the residents whom CNA-A had provided care . He stated psych services noted no concerns for other residents on Hall 500, where Resident #1 resided. He stated CNA-A would be terminated on 07/25/24, now that he knew the allegation was substantiated. He stated the facility became aware of the incident when the POA and police came to the facility on [DATE]. He stated the facility started in-services on abuse with the facility staff on 07/22/24. He stated their abuse and neglect policy required that all residents be protected after an allegation of abuse. He stated they ensured the protection of residents by conducting the safe surveys and angel rounds. He stated the residents were at risk of having their rights violated, risk of no longer being free from abuse, and risk of trauma. Record review of the facility's in-service, dated 03/26/24, reflected CNA A was in-serviced on the facility abuse policy. Abuse policy educated staff on identifying abuse and neglect as well as timeframes associated with reporting abuse and neglect to the State Agency. Record review of the facility in-service, dated 07/22/24, reflected all staff signed they were in-serviced on facility abuse policy. Record review of residents residing on Hall 500 evaluated by Psych services dated 07/23/24 reflected no change made to medication, the psych evaluation was secondary to an incident that occurred with another resident, the incident included inappropriate touching, the residents were emotionally stable and the recent incident did not affect the resident. Record review of CNA A's Date of Hire-01/10/2023 Background check completed reflected: 01/04/2023-Federal Criminal National-clear, Healthcare Sanctions-clear, Sex Offender-clear 01/04/23-Criminal History Conviction Name Search with Department of Public Safety-No search results found 01/03/23-Texas Health and Human Services Not listed on the EMR, NAR: Active 07/15/23-Employability Status Check Search Results-Not listed on EMR-NAR status: Active; Certification expiration date: 07/03/2025 07/22/2024-Criminal History Conviction Name Search Results-No search results found 07/23/2024-Employability Status Check Search Results-Nurse Record review of CNA A's Counseling/Disciplinary Notice dated 07/22/24 reflected suspension, pending investigation, subject to discharge, reason why counseling/disciplinary action necessary was due to abuse allegation, notified via phone on 07/22/24. Record review of facility Termination Form dated 7/25/24 to CNA A reflected her last day of work was 07/21/24 and she was involuntary terminated for gross misconduct on 7/25/24. Record review of facility Abuse: Prevention of and Prohibition Against dated 11.2017 revised 12.2023 reflected, The facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, exploitation, or use technology that would infringe on the resident's right to personal privacy. Sexual abuse is non-consensual sexual contact of any type with a resident. An IJ was identified on 08/07/24. The IJ template was provided to the Administrator on 08/07/24 at 1:30 p.m. and a Plan of Removal was requested. The POR was accepted on 08/08/24 at 4:23 p.m. The POR revealed the following: Abuse: Per the information provided in the IJ Template given on 8/7/2024, the facility has started but has not completed in-services with all staff as of 07/25/24. The facility received verbal information alleging that a staff member had touched a resident inappropriately. This allegation was given to the facility by the police and by an HHSC surveyor. 1. The Medical Director was notified of the IJ on 08/07/2024 at 2:10 pm. 2. Train the trainer in-servicing was given to the ED, DON, ADON, MDS Nurse and RN/ED Partners by the Clinical Resource. The training included regarding abuse to include resident rights to be free of sexual abuse. Started in-service training on 7/22/2024 on Abuse: Prevention of and Prohibition Against Sexual Assault and Prevention. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This was completed on 8/7 /24. 3. Training and knowledge checks were completed with all staff regarding abuse to include resident rights to be free of sexual abuse. Skills check offs and skin assessments started on pericare [sic] 7/22/2024. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This was completed on 8/7/24. This training was given by the ED, DON, ADON, MDS Nurse Clinical Resource and RN/ED Partners, was initiated on 8/7/24 will be completed on 8/8/24 with all staff prior to the start of their next shift. Staff will not be allowed to work unless they have completed the training and knowledge checks. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. ED, DON and/or Designee will be responsible that all staff are trained before working. 4. An ad hoc (a non-scheduled QA meeting) meeting regarding items in the IJ templates will be completed on 8/7/24. Attendees will include the DON, Medical Director, ADON, Clinical Resource, Executive Director and will include the plan of removal items and interventions. 5. The ED or designee will verify staff knowledge on abuse prevention with 10 staff weekly using the abuse and neglect knowledge checks. This will be completed weekly after the initial training and knowledge checks completed on 8/8/24. 6. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 8/8/24 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring of the facility plan of removal was as follows: In an interview on 08/09/24 at 9:30 a.m. with the Administrator in Training revealed he had been trained on 08/07/24 on how to in-service the staff on Abuse: Prevention of and Prohibition Against a resident by staff and they should report abuse/neglect to the administrator or person in charge of the facility at the time the abuse was observed or suspected. In an interview on 08/09/24 at 9:35 a.m. with the Resource Nurse, revealed she had been trained on 08/07/24 on how to in-service the staff on Abuse: Prevention of and Prohibition Against a resident by staff and they should report abuse/neglect to the administrator or person in charge of the facility at the time the abuse was observed or suspected. In an interview on 08/09/24 at 10:50 a.m. Resident #2 revealed she did feel safe in the facility, she stated a few weeks ago a facility staff came by to ask if there had been any issues with any CNA's and she told her there had not been any issues. She stated she knew she could notify the social worker or the administrator if she did not feel safe or was abused. In an interview on 08/09/24 at 11:23 a.m. with RN E revealed she had been in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident, the administrator was the abuse coordinator and should be notified if abuse was suspected. In an interview on 08/09/24 at 11:36 a.m. with Resident #3 revealed stated she did feel safe in the facility, she stated she had been asked by facility staff if she felt safe and if she had any issues with a CNA. She stated she had not had any issues. She stated if she did not feel safe or if she was abused she would tell her son or the administrator. In an interview on 08/09/24 at 11:41 a.m. with CNA F revealed he had been in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident, and the administrator was the abuse coordinator and should be notified if abuse was suspected. In an interview on 08/09/24 at 11:45 a.m. with MA G revealed she had been in-serviced that abuse was a willful act, it was never appropriate to have sexual contact with a resident, if she suspected abuse she would notify the abuse coordinator, the administrator, or the DON. In an interview on 08/09/24 at 12:07 p.m. with the Housekeeping Supervisor revealed she had been in-serviced on how to in-service the staff on Abuse: Prevention of and Prohibition Against a resident by staff and they should report abuse/neglect to the administrator or person in charge of the facility at the time the abuse was observed or suspected. She stated she would in-service the staff that abuse was a willful act, it was not appropriate for a staff to have sexual contact with a resident. She stated abuse and neglect should be reported to the administrator, as the abuse and neglect coordinator. In an interview on 08/09/24 at 12:16 p.m. with CNA H revealed she was in-serviced that abuse was a willful act, it was not appropriate for an employee to have sexual contact with a resident. She stated if she suspected or saw abuse she should report to the administrator the abuse coordinator. In an interview on 08/09/24 at 12:22 p.m. with CNA I revealed she was in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident. Abuse and neglect should be reported to the abuse coordinator, the administrator. In an interview on 08/09/24 at 12:28 p.m. with RN J revealed she was in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident. Abuse and neglect should be reported to the abuse coordinator, the administrator. In an interview on 08/09/24 at 12:34 p.m. with visiting DON revealed she had been in-serviced on how to in-service the staff on Abuse: Prevention of and Prohibition Against a resident by staff and they should report abuse/neglect to the administrator or person in charge of the facility at the time the abuse was observed or suspected. She stated she would in-service the staff that abuse was a willful act, it was not appropriate for a staff to have sexual contact with a resident. She stated abuse and neglect should be reported to the administrator, as the abuse and neglect coordinator. In an interview on 08/09/24 at 12:51 p.m. with CNA K revealed she was in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident. Abuse and neglect should be reported to the abuse coordinator, the administrator. In an interview on 08/09/24 at 12:57 p.m. with CNA L revealed she was in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident. Abuse and neglect should be reported to the abuse coordinator, the administrator. In an interview on 08/09/24 at 1:02 p.m. with RN M revealed she was in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident. Abuse and neglect should be reported to the abuse coordinator, the administrator. In an interview on 08/09/24 at 1:05 p.m. with the Director of Rehabilitation revealed he had been in-serviced on how to in-service the staff on Abuse: Prevention of and Prohibition Against a resident by staff and they should report abuse/neglect to the administrator or person in charge of the facility at the time the abuse was observed or suspected. He stated he would in-service the staff that abuse was a willful act, it was not appropriate for a staff to have sexual contact with a resident. He stated abuse and neglect should be reported to the administrator, as the abuse and neglect coordinator. In an interview on 08/09/24 at 1:02 p.m. with RN M revealed she was in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident. Abuse and neglect should be reported to the abuse coordinator, the administrator. In an interview on 08/09/24 at 1:15 p.m. with Therapist N revealed she was in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident. Abuse and neglect should be reported to the abuse coordinator, the administrator. In an interview on 08/09/24 at 1:23 p.m. with CNA O revealed she was in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident. Abuse and neglect should be reported to the abuse coordinator, the administrator. In an interview on 08/09/24 at 1:27 p.m. with CNA P revealed she was in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident. Abuse and neglect should be reported to the abuse coordinator, the administrator. In an interview on 08/09/24 at 1:31 p.m. with CNA Q revealed she was in-serviced that abuse was a willful act, it was never appropriate for an employee to have sexual contact with a resident. Abuse and neglect should be reported to the abuse coordinator, the administrator. In an interview on 08/09/24 at 1:35 p.m. with Resident #4 revealed she stated she had not been touched inappropriately by anyone, she stated she received her medication on time. She stated facility staff asked her a few weeks ago if she was safe. She stated she felt safe living at the facility, she stated if she was abused she could tell her family or the administrator. In an interview on 08/09/24 at 1:42 p.m. with Resident #5 revealed she stated she did feel safe at the facility, she stated if she did not feel safe she could tell her family or the social worker. In an interview on 08/09/24 at 1:50 p.m. with Resident #6 revealed she felt safe in the facility, she stated she had not been touched inappropriately. She stated if she was abused she could notify the nurse or the administrator. In an interview on 08/09/24 at 2:30 p.m. with the Administrator revealed she had been trained on 08/07/24 on Prevention of and Prohibition Against Sexual Assault and Prevention. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. She stated the QA team met and discussed they would ensure new staff were in-serviced and current staff would conduct random knowledge test of staff and it would be documented on form. She stated safety assessments had been completed on the residents. She stated Resident #1 had not returned to the facility since she was removed by the POA on 07/22/24. She stated CNA A was suspended 07/22/24 by phone and she was terminated on 07/25/24. Review of Facility train the trainer in-service dated 8/7/24 revealed the management staff had been in serviced on how to train the staff on Abuse: Prevention of and Prohibition Against by staff policy dated 10.2022 Review of Facility abuse and neglect in-service dated 8/7/24 revealed all facility staff had been in serviced on Abuse: Prevention of and Prohibition Against by staff policy dated 10.2022 Record review of Psych services evaluation for Resident's #7, #8, #9, #10, #11, #12, #13, and #14 dated 07/23/14 reflected no change made to medication, the psych evaluation was secondary to an incident that occurred with another resident, the incident included inappropriate touching, the residents were emotionally stable, and the recent incident did not affect the resident. Record review of resident roster provided 08/07/24 reflected Resident #1 was no longer residing at the facility. Record review of Skills checklist-Perineal Care dated 07/22/24 and 07/23/24 reflected CNAs were re-evaluated to ensure they performed proper Perineal Care. Record review of Safe Interviews of facility residents dated 07/22/24 and 07/23/24 reflected residents were assessed for safety. Record review of CNA A's Counseling/Disciplinary Notice dated 07/22/24 reflected suspension, pending investigation, subject to discharge, reason why counseling/disciplinary action necessary was due to abuse allegation, notified via phone on 07/22/24. Record review of facility Termination Form dated 7/25/24 to CNA A reflected her last day of work was 07/21/24 and she was involuntary terminated for gross misconduct on 7/25/24. The administrator was informed the Immediate Jeopardy was removed on 08/09/2024 at 4:23 p.m. the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on abuse and neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 1 of 11 residents (Resident #1) reviewed for abuse. The facility failed to implement policy that prohibited abuse of Resident #1 was sexually abused when a confidential interviewee provided video footage of CNA A undressing Resident #1 as Resident #1used her crossed arms to cover her breast and CNA A inserted her hands between the legs of Resident #1, moved her hands in a fast motion inside the vaginal area for eight (8) minutes and 2 (.02) seconds after the resident's clothes were taken off. An IJ was identified on 08/07/24. The IJ template was provided to the facility on [DATE] at 1:30 p.m. While the IJ was removed on 08/09/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on abuse and neglect. This failure could place residents at risk for physical harm, psychosocial harm, unsafe environment, and further abuse. Findings included: Record review of facility Abuse: Prevention of and Prohibition Against dated 11.2017 revised 12.2023 reflected, The facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, exploitation, or use technology that would infringe on the resident's right to personal privacy. Sexual abuse is non-consensual sexual contact of any type with a resident. Record review of Resident #1's admission record, dated 07/25/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE] Resident #1 had diagnoses which included, Dysphagia (difficulty swallowing), Cognitive Communication Deficit (trouble reasoning and making decisions while communicating), Dementia (a group of thinking and social symptoms that interferes with daily functioning), Psychotic Disorder with Delusions (an unshakeable belief in something untrue), Paranoid Schizophrenia (a person feels distrustful and suspicious of other people and acts accordingly), Major Depressive Disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and Muscle Weakness (decreased strength in the muscles). Record review of Resident #1's Modified admission MDS assessment, dated 02/12/24, reflected Resident #1 had no speech. She usually understood and comprehended most conversations. Resident #1 had severe cognitive impairment, the BIMS was not indicated, Resident #1 was unable to participate. Resident #1 was dependent on staff for all activities of daily living and was incontinent of bowel and bladder. Record review of Resident #1's care plan, dated 01/31/24, reflected Resident #1 was incontinent of bowel and bladder. Staff were to provide incontinent care after each episode. The care plan reflected Resident #1 was totally dependent on staff for all her activities of daily living. Observation on 07/25/24 at 10:38 a.m. the State Surveyor received and reviewed the video provided by a confidential interviewee of the alleged incident involving CNA-A and Resident #1. The video revealed the following: Video dated 7/21/24 at (19:30:00) 7:30 PM, CNA-A entered the room with Resident #1, within camera view CNA-A began to remove the clothes off Resident #1, at (19:30:50) 7:30:50 PM the resident's blouse was completely removed, and CNA-A took the resident to her bed by grabbing her by the right arm. CNA-A used her right hand to turn back the cover on the bed. The resident was observed in the video using her left arm to cover her breast while CNA-A was walking her toward the bed. CNA-A stood the resident by the bed and pulled down the resident's pants before laying the resident on the bed, then reached to grab her feet from the floor and placed her feet in the bed. At (19:31:58) 7:30:58 PM CNA-A put the resident in bed and removed her pants leaving on the adult brief, during this time the resident was watching CNA-A while covering her breast with both of her arms. At (19:32:04) 7:32:04 PM CNA-A unfastened the adult brief of Resident #1 and walked away from the bed out of camera view, while the resident was lying on the bed covering her breast with both of her arms and the open adult brief was open exposing her vaginal area. CNA-A returned to the bedside of the resident at (19:32:38) 7:32:38 PM. When CNA-A returned to the bedside of the resident she returned with adult briefs and wipes. CNA-A was observed using the wipes to clean the resident. While CNA-A was cleaning the resident, Resident#1 was observed holding both of her arms in a bent position covering her breast while shaking her hands in a clasped position in front of her. CNA-A then turned the resident toward the wall and removed the soiled adult brief and bed pad. CNA-A stepped away from the bed again to dispose of the soiled items, as she left the resident lying on the bed completely naked. CNA-A returned to the bedside of the resident, and she placed two clean adult briefs under the resident by turning the resident from side to side. Once the open briefs were under Resident #1, CNA-A moved to the head of the bed and repositioned the pillow under the head of the resident before returning to the middle of the bed and grabbed the gown and shook the gown before she placed the gown over the head of the resident and put her arms inside the gown. At (19:35:19) 7:35:19 PM, while the resident's vaginal area was still uncovered CNA-A used her hands to open the bent legs of the resident and placed her hands in the vaginal area. The resident was observed raising up her right forearm and tapping the left arm of CNA-A while grimacing her face. The resident was observed stretching out her right leg and reaching her right hand toward CNA-A while looking at her. CNA-A was observed looking toward the resident while she had her hands in the open vaginal area of the resident. At (19:35:54) 7:35:54 PM Resident #1 was observed placing her shaking left hand in front of her face, while CNA-A was looking toward her. Resident #1 was observed raising her head slightly off the pillow and patting her left foot on the bed. At (19:36:17) 7:36:17 PM CNA-A continued to have her hands in the vaginal area of the resident when the resident raised her right arm and was moving it toward CNA-A, as CNA-A looked toward the resident. At (19:36:22) 7:36:22 PM CNA-A continued to have her hands in the vaginal area of Resident #1 as CNA-A's right arm was observed to be moving in a fast motion until the resident looked toward something behind CNA-A at (19:36:29) 7:36:29 PM. CNA-A then looked behind her, then she continued to keep her hands in the open vaginal area of the resident until the resident looked behind CNA-A again at (19:36:35) 7:36:35 PM. At (19:36:35) 7:36:35 PM CNA-A stood up as if she was talking to Resident #1. At (19:36:46) 7:36:46 PM CNA-A opened the legs of Resident #1 with her vaginal area still uncovered and then she walked away from the bed off camera. During this time Resident #1 used her hands to cover her open vaginal area. CNA-A returned to the bedside of Resident #1 at (19:36:52) 7:36:52 PM and she moved the hands of the resident, CNA-A leaned over and placed her right hand between the still bent legs of the resident at (19:37:02) 7:37:02 PM and the resident looked behind CNA-A and CNA-A looked at the resident. At (19:37:13) 7:37:13 PM the resident was observed moving her hand and looking behind CNA-A while CNA-A continued to have her hand moving it in a fast motion. At (19:37:24) 7:37:24 PM Resident#1's legs were stretched on the bed while CNA-A's hands were still moving fast in her vaginal area. This action continued in the open vaginal area of the resident until (19:37:32) 7:37:32 PM when CNA-A bent Resident #1's right leg back up before returning her hands to the open vaginal area. At (19:37:55) 7:37:55 PM, CNA-A moved her body closer to the head of the bed of the resident exposing her vaginal area more, CNA-A's right hand was observed on the vagina of Resident #1 moving in a fast motion until (19:38:02) 7:38:02 PM when CNA-A reached down and pulled up both adult briefs and fastened them at (19:38:21) 7:38:21 PM. At (19:38:30) 7:38:30 PM, CNA-A pulled down the gown of Resident #1 then repositioned her in bed. At (19:38:43) 7:38:43 PM, CNA-A covered Resident #1 with the bed covers, lowered the resident's bed, and repositioned her pillow at (19:39:26) 7:39:26 PM. A confidential interview revealed it was observed on 07/21/24 in the evening time, the confidential interviewee stated they were not sure of the specific time of the original viewing of the video. The confidential interviewee stated it was observed via video CNA-A was in the bedroom of Resident #1 putting Resident #1 in bed when they touched her inappropriately. The confidential interviewee stated Resident #1 was not verbal. The confidential interviewee stated there was audio on the camera, the interviewee stated when CNA-A entered the room with the resident CNA-A said, Let me lay you down. The confidential interviewee stated interviewee stated there was not much communication after that statement. The confidential interviewee stated after Resident #1's clothes were taken off, and the resident was put on the bed and the incident happened. The confidential interviewee stated the abuse was reported to the Administrator in Training, and law enforcement. The confidential interviewee stated Resident #1 was taken to the hospital for an exam. The confidential interviewee stated the hospital stated it would take several weeks to receive the results of the exam. The confidential interviewee stated Resident #1 was anxious when her adult brief was changed, and she grabbed the hand of the person who was changing her. The confidential interviewee stated it was hard to determine if the incident had caused the resident harm at this time. The confidential interviewee stated the family requested Resident #1 not be visited because she was non-verbal and could not contribute to the investigation. The confidential interviewee stated the video would be sent via text. In an interview with the Administrator in Training, acting abuse coordinator on 07/25/24 at 9:40 a.m. revealed he was notified of the abuse allegation on 07/22/24 late in the afternoon by the POA of Resident #1 . He stated the POA notified LE prior to coming to the facility. He stated he was told Resident #1 had been abused, he was not given specifics and was told there was a video, but he had not seen the video. He stated while LE and the POA was at the facility they removed Resident #1 from the facility when they left. He stated CNA A last worked 07/21/24 and was suspended on 07/22/24. He stated the facility's investigation was still ongoing at that time. He stated the facility was conducting safe surveys of all the residents and angel rounds (department heads are making rounds on assigned residents) and skin assessments on the two non-verbal residents. He stated the facility conducted an in-service with all staff on 07/22/24. He stated there was not any previous warnings or incidents regarding CNA-A at the facility. He stated CNA-A received the employee of the month for the month of June. He stated several families complimented her work. He stated at that time the facility was not able to verify if the incident had happened because the investigation was still ongoing. He stated the nursing staff was responsible to ensure the CNA's took proper care of the residents, the DON, and then the Administrator. During an interview on 07/25/24 at 12:20 p.m., LVN B said the abuse coordinator should be notified immediately after an allegation of abuse was made. She said she could tell the abuse coordinator, the administrator or administrator in training in person or call them . She said she could also tell the DON of an allegation of abuse. She said she was trained on abuse and neglect several times. She said the abuse policy was a topic that was trained frequently. She said when abuse allegedly occurred she would also need to ensure the resident and other residents were kept safe from the person who allegedly did the abuse. During an interview on 07/25/24 at 1:17 p.m., CNA C said if a resident alleged that they were abused then she would need to ensure the resident was safe, report to the abuse coordinator who was the administrator, and/or the DON . She stated she would keep the resident safe and prevent the person who allegedly did the abuse away from other residents. She said she was in-serviced on all these principals' multiple times. During an interview on 07/25/24 at 2:47 p.m., CNA-D said she had been in-services on the facility abuse policy several times. She said if an allegation of abuse was made, they were to immediately report the allegation to the abuse coordinator , the administrator. She said she could also report to the charge nurse and the DON as well as call the abuse coordinator. She said she would also need to ensure the person who did the abuse did not have access to any resident and have them leave the building. In a follow-up interview with the Administrator in training on 07/25/24 at 3:43 p.m., he stated he interviewed CNA-A prior to the State Surveyor's entrance. He stated, CAN-A described and demonstrated the service she provided to Resident #1 as cleaning her and changing her bed and her brief. She stated she did not have any issues with Resident #1. He stated CAN-A did not provide a written statement of the services she provided to Resident #1. The Administrator in training stated the facility had psych services at the facility and they came and talked to the residents whom CNA-A had provided care . He stated psych services noted no concerns for other residents on Hall 500, where Resident #1 resided. He stated CNA-A would be terminated on 07/25/24, now that he knew the allegation was substantiated. He stated the facility became aware of the incident when the POA and police came to the facility on [DATE]. He stated the facility started in-services on abuse with the facility staff on 07/22/24. He stated their abuse and neglect policy required that all residents be protected after an allegation of abuse. He stated they ensured the protection of residents by conducting the safe surveys and angel rounds. He stated the residents were at risk of having their rights violated, risk of no longer being free from abuse, and risk of trauma. Record review of the facility's in-service, dated 03/26/24, revealed CNA A was in-serviced on the facility abuse policy. Abuse policy educated staff on identifying abuse and neglect as well as timeframes associated with reporting abuse and neglect to the State Agency. Record review of residents by Psych services dated 07/23/14 reflected no change made to medication, the psych evaluation was secondary to an incident that occurred with another resident, the incident included inappropriate touching, the residents were emotionally stable, and the recent incident did not affect the resident. Record review of the facility in-service, dated 07/22/24, reflected all staff signed they were in-serviced on facility abuse policy. Record review of Psych services evaluation for Resident's #7, #8, #9, #10, #11, #12, #13, and #14 dated 07/23/14 reflected no change made to medication, the psych evaluation was secondary to an incident that occurred with another resident, the incident included inappropriate touching, the residents were emotionally stable, and the recent incident did not affect the resident. Record review of CNA A's Background check completed reflected: 01/04/2023-Federal Criminal National-clear, Healthcare Sanctions-clear, Sex Offender-clear 01/04/23-Criminal History Conviction Name Search with Department of Public Safety-No search results found 01/03/23-Texas Health and Human Services Not listed on the EMR, NAR: Active 07/15/23-Employability Status Check Search Results-Not listed on EMR-NAR status: Active; Certification expiration date: 07/03/2025 07/22/2024-Criminal History Conviction Name Search Results-No search results found 07/23/2024-Employability Status Check Search Results-Nurse Record review of CNA A's Counseling/Disciplinary Notice dated 07/22/24 reflected suspension, pending investigation, subject to discharge, reason why counseling/disciplinary action necessary was due to abuse allegation, notified via phone on 07/22/24. An IJ was identified on 08/07/24. The IJ template was provided to the Administrator on 08/07/24 at 1:30 p.m. and a Plan of Removal was requested. The POR was accepted on 08/08/24 at 4:23 p.m. The POR revealed the following: Develop and Implement Policy: Per the information provided in the IJ Template given on 8/7/2024, the facility has started but has not completed in-services with all staff as of 07/25/24. The facility received verbal information alleging that a staff member had touched a resident inappropriately. This allegation was given to the facility by the police and by an HHSC surveyor. The facility has not been given or reviewed the video where the alleged abuse may have occurred. 1. The Medical Director was notified of the IJ on 08/07/2024 at 2:10 pm. 2. Train the trainer in-servicing was given to the ED, DON, ADON, MOS Nurse and RN/ED Partners by the Clinical Resource. The training included regarding abuse to include resident rights to be free of sexual abuse. Started in-service training on 7/22/2024 on Abuse: Prevention of and Prohibition Against Sexual Assault and Prevention. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This was completed on 8/7/24. 3. Training and knowledge checks were completed with all staff regarding abuse to include resident rights to be free of sexual abuse. Skills check offs and skin assessments started on peri care 7/22/2024. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This was completed on 8/7/24. This training was given by the ED, DON, ADON, MOS Nurse Clinical Resource and RN/ED Partners, was initiated on 8/7/24 will be completed on 8/8/24 with all staff prior to the start of their next shift. Staff will not be allowed to work unless they have completed the training and knowledge checks. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. ED, DON and/or Designee will be responsible that all staff are trained before working. 4. An ad hoc (a non-scheduled QA meeting) meeting regarding items in the IJ templates will be completed on 8/7/24. Attendees will include the DON, Medical Director, ADON, Clinical Resource, Executive Director and will include the plan of removal items and interventions. 5. The ED or designee will verify staff knowledge on abuse prevention with 10 staff weekly using the abuse and neglect knowledge checks. This will be completed weekly after the initial training and knowledge checks completed on 8/8/24. 6. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly x 4 weeks beginning 8/8/24 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 7. Monitoring of the facility plan of removal was as follows: In an interview on 08/09/24 at 9:30 a.m. with the Administrator in Training revealed he had been trained on 08/07/24 on Prevention of and Prohibition Against Sexual Assault and Prevention. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. He stated the QA team met and discussed they would ensure new staff were in-serviced and current staff would conduct random knowledge test of staff and it would be documented on form. He stated he was also trained on understanding behavioral symptoms of residents that may increase the risk of abuse was resistance to care, outburst, and difficulty in adjusting to new routines or staff. He stated he had been trained that if abuse or neglect involved an employee he should immediately remove the employee from care of any resident and suspend the employee during the investigation. In an interview on 08/09/24 at 9:35 a.m. with the Resource Nurse, revealed she had been trained on 08/07/24 on Prevention of and Prohibition Against Sexual Assault and Prevention. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. She stated the QA team met and discussed they would ensure new staff were in-serviced and current staff would conduct random knowledge test of staff and it would be documented on form. She stated she was trained to recognize the signs of abuse of physical or psychosocial indicators, to inform staff they could report abuse they could do so without fear of reprisal. She stated she was trained to respond immediately to protect the alleged victim of abuse, and the victim should be examined for any injury, by physical examination or psychosocial assessment. In an interview on 08/09/24 at 11:23 a.m. with RN E revealed she was in-serviced on abuse policy that she should ensure all residents were free from neglect and abuse, to identify and assess behaviors that could indicate a resident had been abused was sexually aggressive behavior and saying sexual things. She sated some indicators of abuse would be sudden or unexplained changes in behaviors or activities, fear of a person providing care. She had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 11:41 a.m. with CNA F revealed his training included identifying and preventing abuse of a resident, how to report abuse and that he could report abuse without fear of retaliation. He sated he was re-in-serviced that they should not take photos of residents. He had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 11:45 a.m. with MA G revealed she stated abuse and neglect policy stated she should intervene in situations of abuse or neglect, she stated signs that a resident had been abused could be the resident acted different around a specific staff, the resident might be withdrawn or act ashamed when staff were providing care. She had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 12:07 p.m. with the Housekeeping Supervisor revealed she had been trained on 08/07/24 on Prevention of and Prohibition Against Sexual Assault and Prevention. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. She stated the QA team met and discussed they would ensure new staff were in-serviced and current staff would conduct random knowledge test of staff and it would be documented on form. She stated abuse prevention policy included verbal aggression, physical aggression, sexual abuse. She stated some signs a resident had been abused would include injuries in an unusual location on the resident, sudden unexplained changes in the resident's behavior such as fear of a person or feeling shame or guilt. In an interview on 08/09/24 at 12:16 p.m. with CNA H revealed she had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. She stated when she received additional in-service on the abuse policy she learned the abused resident should be kept safe from the employee, the resident should receive emotional support and counseling. She stated some signs of abuse would be sudden change in behavior or a resident who would normally participate in activities suddenly did not want to participate. In an interview on 08/09/24 at 12:22 p.m. with CAN I revealed she learned all abuse was not directly observed and possible indicators would be bruises, skin tears, injuries in an unusual location, and unexplained changes in behaviors. She stated she must protect the resident from the perpetrator. she had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 12:28 p.m. with RN J revealed she stated regarding the facility policy on abuse and neglect all personnel, residents, and visitors were encouraged to report incidents and grievances without the fear of retribution, she would supervise the staff to identify and correct any inappropriate or unprofessional behaviors, she stated as a member of the staff she was responsible for ensuring residents were free from abuse, policy indicated that a resident with communication disorders or spoke a different language should be monitored for signs of abuse. She stated she had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 12:34 p.m. with visiting DON revealed she had been trained on 08/09/24 on Prevention of and Prohibition Against Sexual Assault and Prevention. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. She stated the QA team met and discussed they would ensure new staff were in-serviced and current staff would conduct random knowledge test of staff and it would be documented on form. In an interview on 08/09/24 at 12:51 p.m. with CNA K revealed she stated the abuse neglect policy was reviewed with her regarding recognizing signs of abuse, neglect, exploitation such as physical or psychosocial indicators, facility staff were prohibited from taking or keeping photographs of facility residents in any manner that demeaned or humiliated the resident. She stated she should report any reasonable suspicion of a crime against a resident, she should protect the resident. She had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 12:57 p.m. with CNA L revealed she stated she learned from abuse and neglect policy that she should ensure the residents were safe, she stated some types of abuse of a resident would be verbally aggressive behavior, screaming, cursing, insulting to their race, physically aggressive behavior. She stated a resident who has been abuse might also exhibit the same behaviors. she had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 1:02 p.m. with RN M revealed she received additional training on the abuse policy regarding recognizing signs of abuse and neglect such as physical or psychosocial indicators, abuse and neglect should be reported to the administrator without fear of reprisal, she learned the facility staff was responsible for protecting the residents, they should not take or distribute photos of the residents, and that dementia residents are at a greater risk of abuse. She had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 1:05 p.m. with the Director of Rehabilitation revealed he would be responsible to protect all the residents, he stated the abuse and neglect policy indicated all personnel, residents, and visitors should be encouraged to report incidents without the fear of retribution, the facility would act to protect the resident and prevent further abuse, the facility should have structures and processes to provide needed care and services for all residents. Residents who require extensive nursing care or totally dependent on staff for provision of care are most vulnerable. He had been trained on 08/07/24 on Prevention of and Prohibition Against Sexual Assault and Prevention. Train the trainer in-servicing on training and implementation of abuse and neglect policy and procedures. This training will also be included in the new hire orientation and will be included for PRN staff prior to starting work on the floor. These staff will not be allowed to work unless they have received this training and knowledge checks. She stated the QA team met and discussed they would ensure new staff were in-serviced and current staff would conduct random knowledge test of staff and it would be documented on form. In an interview on 08/09/24 at 1:15 p.m. with Therapist N revealed she was re-in-serviced on policy for identification of signs of abuse of a resident that included sudden or unexplained changes in behaviors or activities such as fear of a person or place, learning to identify different types of abuse such as mental/verbal, sexual, and physical, any act that would demean or humiliate a resident. She had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 1:27 p.m. with CNA O revealed she received addition training on how to prevent abuse or neglect of a resident how to recognize signs that a resident had been abused or neglected either physically or mentally. She stated she could report abuse without reprisal, and she should not take photos of any resident or distribute any resident to cause the resident to be demeaned or humiliated. She had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 1:15 p.m. with CNA P revealed she was re-in-serviced on the facility policy of how to recognize signs of abuse and neglect such as physical or psychosocial indicators, abuse and neglect should be reported without fear of retaliation, vulnerable residents usually had dementia or were cognitively impaired. She sated she learned that some residents with behavioral symptoms would be aggressive reactions outburst or yelling difficulty in adjusting to new routines or staff. She had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 1:31 p.m. with CNA Q revealed she had been re-trained on the abuse policy that all staff were encouraged to report incidents and abuse without fear of retribution, how to recognize signs of abuse and neglect which were physical or psychosocial, she should not take photos and distribute them of the residents, she stated she learned that residents with dementia or cognitively impaired residents were at greater risk of abuse. She had been given a knowledge assessment regarding abuse and neglect included to report to the administrator. In an interview on 08/09/24 at 2:30 p.m. with the Administrator revealed she had been trained on 08/07/24 on Prevention of and Prohibition Against Sexual Assault and Prevention. Train the trainer in-servicing on training and implementation of ab[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #4) of five residents reviewed for quality of care. The facility failed to retrieve results of an x-ray order of Resident #4's left hip in a timely manner, which resulted in delayed treatment of a dislocation for a period of approximately 28 hours. Resident #4 was found on the floor on 04/10/23 approximately 9:00 PM, STAT orders (referring to a diagnostic or therapeutic procedure that is to be performed immediately; prioritized in a lab, as the results have a potentially immediate impact on patient management) were submitted on 04/11/23 at approximately 4:56 AM, results retrieved on 04/12/23 at approximately 9:11 AM, by Physician I, and the resident was sent out to the hospital on [DATE] at approximately 11:21 AM. An Immediate Jeopardy was determined to have existed from 04/10/23 through 04/27/23. While the IJ was removed on 04/28/23, the facility remained out of compliance at a scope of actual harm that is not Immediate Jeopardy and a severity level of pattern, due to the facility's need to implement corrective systems. The facility implemented actions that corrected the Immediate Jeopardy prior to re-entering the facility on 05/11/23. The facility Administrator was provided the Immediate Jeopardy Template on 05/11/23 at 3:39 PM. This failure placed residents at risk of a delay in medical evaluation, treatment and decrease in quality of care. Findings included: Review of Resident #4's face sheet dated 04/27/23 revealed the resident was an [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4's diagnosis included non-displaced intertrochanteric of fracture of left femur, unspecified fall, muscle weakness, difficulty in walking, abnormalities of gait and mobility, history of falling, lack of coordination, unsteadiness on feet. aphasia, major depressive disorder, vascular dementia with agitation. Review of Resident #4's quarterly MDS Assessment, dated 03/25/23, revealed Resident #4 was usually understood by others and was usually able to understand others; however, the resident's cognitive assessment/BIMS was not completed. Transferring between bed, chair, wheelchair, and standing position required extensive assistance with one person assist. Locomotion in the room required supervision with two person assist. Review of Resident #4's care plan, undated, revealed Resident #4 had ADL self-care performance deficit related to weakness, dementia, and transient ischemic accident. Goal: will maintain current level of function in transfers, toilet use and personal hygiene, Intervention: Toilet use: requires x1 staff to assist, Transfer requires x1 staff assist with transferring. Resident #4 at risk for falls related to weakness. Goal: will not sustain serious injury. Intervention: 1/1/23 Fall; due to drop in blood pressure, 1/19/23 Fall; educated resident to call for assistance when picking up things off the floor, 02/12/23 Fall; offer bathroom assistance when making rounds, 04/10/23 Fall; fall mat to beside at all times, be sure the call light is within reach and encourage to use it to call for assistance as needed, keep needed items, water, etc. in reach. Resident #4 had an actual fall with minor injury. Goal: Sutures x4 to be removed 02/19/23 will resolve without complication. Intervention: offer bathroom assistance when making rounds, Bed in lowest position, provide activities that promote exercise and strength building where possible. Review of Resident #4's progress notes dated 04/10/23 at 10:11 PM, documented by LVN A reflected: resident was noted sitting on the floor at the end of bed facing the door next to wheelchair. The roommate says she was trying to get out of bed, and she slid out and sat on the floor. Head to toe assessment done. Alert with no signs or symptoms of acute distress, no injuries noted at this time, vitals checked, staff helped back in bed, denies pain at this time. Bed placed in low position, MD, DON, and family notified, will continue to monitor. Review of medication notes dated 04/11/23 at 4:55 AM documented by LVN A reflected: Acetaminophen Tablet 650 mg. Give 1 tablet by mouth every 6 hours as needed for general discomfort. Review of nurse's notes dated 04/11/23 at 4:56 AM documented by LVN A reflected: During routine rounds, this nurse noted Resident #4 holding left hip massaging it. Asked resident if she was in pain and resident nodded her head. Acetaminophen Tablet 650 MG Give 1 tablet by mouth was administered, MD notified, new order left hip x-ray to rule out fracture. X-ray order placed and waiting for the technician. Will continue to monitor. Review of medication notes dated 04/11/23 at 8:00 AM documented by the DON reflected: Acetaminophen Tablet 650 MG. Give 1 tablet by mouth every 6 hours as needed for general discomfort. Follow up: PRN administration was: Effective, Pain scale was: 2. Review of nurse's notes dated 04/11/23 at 9:55 PM documented by LVN A reflected: Follow up follow day 1 of 2, no delayed injury noted, able to move all extremities without difficult. Denies pain to left hip. Bed placed in low position. Will continue to monitor. Review of nurse's notes dated 04/12/23 at 11:21 AM documented by the ADON reflected: Resident complained of pain to right hip. Pain management administered with acetaminophen. X-rays ordered. Results showed fracture to right hip (error in the facility note). Resident sent to hospital via city ambulance by stretcher. Review of Resident #4's lab results dated 04/11/23 at 11:21 AM revealed interpretation: significant findings: left hip x-ray unilateral 2-3 views show a fracture of the left proximal femur at the intertrochanteric region. Impression: Acute fracture of the left proximal femur at the intertrochanteric region. Reviewed by doctor on 04/12/23 9:11 AM. There was a delay (approximately 28 hours) in getting medical treatment for Resident #4 due to the facility not being aware x-ray results (which showed hip fracture) had been received and not promptly notifying the physician of the results. During an observation and interview on 04/27/23 at 11:48 AM with Resident #4 revealed communication was unclear. Resident #4 would nod head when asking her questions. Resident #4 stated she had some pain, she stated she fell, and she went to the hospital. Resident #4 was not able to say how the fall occurred. During an interview on 04/27/23 at 3:15 PM with CNA C revealed she was alerted to Resident #4's room by the roommate engaging the call light. CNA C stated she observed Resident #4 on the floor around 7:00 PM and called for the nurse to enter the room to assess. CNA C stated after the assessment Resident #4 was put in bed. CNA C stated she returned to check on Resident #4 and to complete incontinent care. CNA C stated Resident #4 was fighting with her and did not want me to change her. CNA C stated it was hard to tell if she was fighting or if she was displaying pain and alerted the nurse. CNA C stated Resident #4 usually did not talk too much but during her rounds the next day Resident #4 was crying. CNA C stated she informed the nurse Resident #4 was crying and appeared to be in pain, she stated the nurse then administered pain medication and ordered x-ray. CNA C stated Resident was not in the facility the following day when she arrived to work. During an interview on 04/27/23 at 3:48 PM with RN D revealed she was informed about Resident #4's fall. RN D stated she was not present when resident had fall or when the x-ray was completed. RN D stated it was protocol if a resident had a fall and complained of pain, nurses would contact the doctor, and the doctor would order an x-ray stat. RN D stated the x-ray techs would show up within the hour and would usually have the results returned the same day via fax. Upon the receipt of the result, nurses would send the results to the doctor, and wait on the doctor's new orders if any which could be pain management or send resident out to the hospital. If the doctor was busy the Nurse Practitioner would respond or would reach back out to the doctor if no response within 2-3 hours. It was the responsibility of all nurses to receive the x-ray results and alert the doctor of the results. RN D stated there was not one specific person who received the x-ray results; however, if you know your resident had an x-ray you should be looking for the results to come in so that you can alert the doctor. RN D stated not following up with x-ray results put the resident at risk of prolonged pain and not getting the services needed. On 04/27/23 at 4:10 PM an attempt to interview LVN A was unsuccessful. During an interview on 04/27/23 at 4:10 PM with the ADON revealed she was present on the day Resident #4 had a fall. ADON stated she and LVN A entered the room between 9:00 PM-9:30 PM after noting the call light was on and someone yelling. The ADON stated she found Resident #4 on the floor at the foot of the bed feet facing the door and head towards the wall. The ADON stated Resident #4's bed was observed to be at the lowest position. The ADON stated Resident #4 was assessed and back in the wheelchair. The ADON stated Resident #4 was crying and upset, you could tell she was in pain. According to the ADON, the next morning on 04/11/23 Resident #4 was hurting, in pain and grabbing her left side so she told the nurse to give pain medication and was told x-rays were already ordered. The ADON stated on 04/12/23 Resident #4 was showing signs of pain with crying and yelling. The ADON stated facility protocol would be to call out for mobile x-ray, when necessary, results were received pretty quick in the resident's chart and the nurse will contact the doctor immediately. The ADON stated she was not able to say who received Resident #4's x-ray results. The ADON stated any nurse on duty could review the x-ray results and contact the doctor. There was not one person responsible for following up with the doctor with the results. The ADON stated not getting the x-ray results in a timely manner could place residents at risk of getting proper medical care. On 04/27/23 at 4:48 PM an attempt to interview Physician I was unsuccessful. During an interview on 04/27/23 at 5:07 PM with the DON revealed she was notified by nursing staff on 04/10/23 at 8:00 PM that Resident #4 had a fall with no injuries. The DON stated LVN A stated during rounds he assessed Resident #4 and observed she was rubbing her hip, expressing that she was in pain. The DON stated LVN A contacted the doctor for an x-ray. The DON stated the x-ray was completed on 04/11/23 at 11:21 AM. The DON stated x-rays were returned the same day and were auto-posted into resident file. The DON stated there was no way to know when the results were uploaded to resident charts. The DON stated the charge nurse on duty for that resident would be the person to go into resident files to check for x-ray results, then contact the doctor. The DON stated in this case the doctor was the one that logged in, reviewed the results, and contacted us to send her out on 04/12/23. The DON stated Resident #4 was given Tylenol one time for pain and was sent to the hospital by stretcher. The DON stated without knowing what time the results came in it was hard to know the risk for Resident #4. During an interview on 04/28/23 at 12:26 PM with Physician I revealed he was reviewing all lab results and identified the results himself for Resident #4. Physician I stated he did not receive notification from the facility that the results were in. Physician I stated he notified the facility that Resident #4 needed to be sent out to the hospital right after revealing the results. Physician I stated he spoke to the DON to have the results sent directly to her so that she was aware when the results were in so she could notify the required authorities as soon as possible to prevent risk to the resident. During interview and record review it was revealed LVN A received a STAT order for an X-ray as of 04/11/23 at 4:56 AM. The x-ray was completed on 04/11/23 at 11:21 AM. Resident #4 was sent out to the hospital on [DATE] after the doctor reviewed the results on 04/12/23, he then notified the facility of the results. The ADON stated she did not follow up on the X-ray orders to see if they were received on 04/11/23 after the orders had been completed. ADON stated on 04/12/23 when she asked about orders for the X-ray on 04/12/23, she was notified the resident was being sent out to the hospital. Resident #4 had now been in pain during several shifts (10:00 PM-6:00 AM day 1 of 3, 6:00 AM-2:00 PM, 2:00 PM-10:00 PM, 10:00 PM-6:00 AM day 2 of 3, and 6:00 AM-until sent to the hospital day 3 of 3) according to both LVN A and ADON. Review of the EMAR revealed she was administered pain medication once on 04/11/23 at 4:55 AM throughout all shifts after the fall. Hospital records revealed Resident #4 admitting diagnosis was severe left hip pain, left hip fracture, leukocytosis, acute cystitis without hematuria, fall, dementia. An Immediate Jeopardy was determined to have existed from 04/10/23 through 04/27/23. The IJ was removed on 04/28/23 because the facility implemented actions that corrected the Immediate Jeopardy prior to re-entering the facility on 05/11/23. The facility Administrator was provided the Immediate Jeopardy Template on 05/11/23 at 3:39 PM. The facility submitted the following accepted Plan of Removal on 05/12/23: .Immediate Action: 1. ADON re-education was completed on 4/12/2023 was completed by DON. DON was educated by Clinical Resource .04/27/2023. 2. The Medical Director was notified of IJ on 5/11/2023 at 3:51 PM and read at 3:59 PM . 3. Education was initiated with nurses by DON/ADON/Clinical Resource on 4/28/23 related to: a. Lab results reporting and checking lab and radiology PCC modules every 4 hours during per shift; b. Every shift to complete assessments on residents that have had a fall. Report any complaints of pain to MD immediately; c. Notification to MD of Abnormal Results; Notification to Responsible Party in the clinical record; d. Fall prevention; e. Stop and watch program; f. Abuse, neglect, misappropriation 4. Notified Medical Director of survey results on 4/28/23 and physician wrote a written statement of no harm or significant delay in care that we received on 5/1/23. (Relevance is that there is no harm or significant delay in care per the Medical Director). 5. Immediately notified Xray provider that all Abnormal and Critical Findings are required to be called to the DON if facility staff do not answer facility phone on 4/12/2023. 6. An Ad hoc QA meeting regarding items in IJ template was completed on 5/11/23 at 5:15pm. Attendees included the Administrator, DON, Medical Director and Clinical Resource. The plan of removal items and interventions were developed, reviewed, and agreed upon. Identification of Others Affected: Residents who have ordered diagnostic and radiology services have the potential to be affected. Systemic Change to Prevent Re-occurrence: 1. Education was initiated with nurses by DON/ADON/Clinical Resource on 4/28/23 related to: a. Lab results reporting and checking lab and radiology PCC modules every 4 hours during per shift; b. Every shift to complete assessments on residents that have had a fall. Report any complaints of pain to MD immediately; c. Notification to MD of Abnormal Results; Notification to Responsible Party with a progress note identifying results and notification made; d. Fall prevention; e. Stop and watch program; f. Abuse, neglect, misappropriation 2. Review of all radiology and diagnostic services to ensure completion and follow up with appropriate documentation, daily, in clinical morning meeting, effective 5/1/2023. 3. Immediately notified Xray provider that all Abnormal and Critical Findings are required to be called to the DON if facility staff do not answer facility phone on 4/12/2023. 4. An Ad hoc QA meeting regarding items in IJ template was completed on 5/11/23 at 5:15pm. Attendees included the Administrator, DON, Medical Director and Clinical Resource. The plan of removal items and interventions were developed, reviewed, and agreed upon. Monitoring: 1. Review of all radiology and diagnostic services to ensure completion and follow up with appropriate documentation, daily, in clinical morning meeting, effective 5/1/2023, by Clinical IDT, daily, for 4 weeks, and then routinely monitored through the change of condition process. 2. Weekly clinical meetings will include review of laboratory orders and results. Meeting attendees will include the clinical IDT and the Administrator. Meeting minutes will be reported to monthly QA by DON/ADON/designee. During an interview on 05/11/23 at 4:11 PM with the ADON revealed when she entered the facility on 04/11/23 she received updated information from LVN A and the 24-hour report for Resident #4. The ADON stated she was told an x-ray had been ordered and waiting on x-ray techs arrival. The ADON stated you get busy doing other things and then she realized the next day on 04/12/23, they were sending Resident #4 out to the hospital. The ADON stated since she worked the floor on 04/11/23, she should have followed up with looking for the results by looking in the chart or contacting the x-ray company for results then contacting the physician and the family about Resident #4's results. The ADON stated she completed training and in-services pertaining to labs and radiology services on 04/28/23 the day after the initial HHSC visit on 04/27/23. The ADON stated the facility had implemented daily clinical meetings to review order listing reports and orders from the previous day to be checked by the interdisciplinary team. The ADON stated the team would then reach out to the nurse who created the order or charge nurse on the floor that day to see if they had reviewed orders, reached out to the doctor, and documented in the chart. The ADON stated lab results with significant findings would be sent directly to the DON, the DON would contact the charge nurse and the physician with the findings. The ADON stated the nurses would communicate verbally and through the 24-hour report, whether residents had labs, doctor appointments, anything noted on the 24-hour report, that shift nurse was now responsible to ensure the task was completed, followed-up on and documented in the resident chart. During interview on 05/11/23 at 6:11 PM with the DON revealed she received notification via text from LVN A on 04/10/23 the night of the fall after 9:00 PM. LVN A indicated Resident #4 had no apparent injury and no complaints of pain. The DON stated she returned to the facility on [DATE] about 5:45 AM and was verbally told by LVN A that Resident #4 started complaining of pain, and LVN A contacted the doctor and received an order for x-ray. The DON stated she would have expected x-ray to show up within 4-6 hours. The DON stated since LVN A's shift ended, the 24-hour report would alert the next shift nurse that Resident #4 was to complete x-ray. That shift nurse, which in this case was the ADON should have followed up to ensure the x-ray was completed and results given to the physician. The DON stated in-services were started on 04/28/23 with nurses to check lab results every 4 hours during 12-hour shift. The DON stated the facility had now implemented that after the morning stand-up meeting, the clinical team would review all orders from the previous day, check on the things that needed to be done, go over current orders, care plans, nurses' notes, documentation and calls to doctors and resident representatives. The DON stated she also contacted the imaging company to ensure they would send notification directly to her via text when there were significant findings with lab results. The DON stated the notifications came with a link so that she could access the results. The DON stated she would put in a progress note and notify the doctor, nurse, and resident representative. The DON stated for agency staff or as needed staff there would be a binder with in-services and test to complete to ensure all nursing staff were aware to check for laboratory, radiology, diagnostic result every 4 hours, and to call doctor and resident representatives with results, and to document in the resident chart. During interview on 05/11/23 at 6:46 PM with LVN A revealed the aide alerted him that Resident #4 had fallen on 04/10/23 between 8:00 PM-9:00 PM. LVN A stated when he entered the room Resident #4 was sitting down next to the bed legs straight out, the call light had been initiated by the roommate. LVN A stated the roommate stated Resident #4 was trying to get up off the bed and slid down to the floor. LVN A stated after his assessment her vitals were normal, no findings with range of motion and no indication of pain, Resident #4 was assisted to her bed. LVN A stated during his rounds at 12:00 AM Resident #4 was sleeping, during his rounds at 4:00 AM, Resident #4 was rubbing her left hip continuously. LVN A stated he asked her if she was in pain and the way she replied confirmed she was in pain. LVN A stated he provided her with pain medication which she has an order for use as needed. LVN A stated he contacted the physician and received order for X-ray, contacted the family and notified the DON. LVN A stated when the next shift nurse came, rounds were completed together, completed the 24-hour report so that she could follow up with X-ray. LVN A stated the next day when he entered the facility he completed rounds, Resident #4 was sleep, not showing signs of pain. LVN A stated he thought the results were received and the physician was notified. LVN A stated he did not think to look or ask about the x-ray results, LVN A stated he should have followed up on the results himself. LVN A stated he completed several in-service training about 2 weeks ago covering labs and x-ray results, checking for results every 4 hours during shift and if the results were critical to contact the physician and resident representative immediately, and document. During interview on 05/12/23 at 1:47 PM with Physician I revealed the reason he sent Resident #4 out to the hospital was due to her results of acute fracture of her left hip. Physician I stated Resident #4 did not have an emergency; however, it was urgent, and they needed to act with urgency. Physician I stated he was not sure when the results were sent or received and speaking with the x-ray company, they did not think the hip fracture was considered critical. Physician I stated communication was completed with them to have the understanding to contact the facility through phone call and fax with critical findings. It was discussed with the x-ray company that a hip fracture was a critical result and should have been called to the facility and not just faxed. Physician I stated some things were critical and needed action right away and this was one. Physiciani I stated even if the results came in the same day and she was sent to the hospital that night, the surgery would not have happened until 2-3 days later, and they were still in that window. During interview on 05/12/23 at 3:19 PM with a representative from the x-ray company revealed she had been communicating with the facility a number of ways to alert the facility when results came in. The x-ray company representative stated the results were automatically sent to the same number and emailed whether the findings were significant or not. The x-ray company representative stated after Resident #4's fall more functionality was provided to the alerts and as of 04/17/23 the facility would now be automatically emailed the findings and if there were significant results then the DON would also get a text notifying the DON of the critical result. The x-ray company representative confirmed monitoring and there had not been any further concerns. Review of in-services and interviews on 05/12/23 with nurses, ADON, DON, Clinical Resources revealed the facility implemented in-services on 04/28/23 on the following topics: 1. Notification to MD of abnormal results. Notification to responsible party (RP), progress notes, stating results and notification. 2. Reporting Lab results, check Lab & Radiology Q4 hours during a 12 hour shift. 3. Stop & Watch training with the Nurses, MAs, and CNAs. 4. Response on Resident call lights. Call light in reach of resident. 5. Fall Prevention Review of facility's Nursing Clinical policy and procedure, revised May 2007, reflected the following: Policy- It is the policy of this facility that the resident's attending physician will be notified of the results of diagnostic tests. Procedures: 1. Results of laboratory, radiological, and diagnostic tests shall be reported in writing to the resident's attending physician or to the facility. 2. Should the test results be provided to the facility, the attending physician shall be notified of the results. 3. The Director of Nursing Services, or Charge Nurse receiving the test results, shall be responsible for notifying the physician of such test results .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for one (Resident #4) of five residents reviewed for radiology services. The facility failed to retrieve results of an x-ray order of Resident #4's left hip in a timely manner, which resulted in delayed treatment of a dislocation for a period of approximately 28 hours. Resident #4 was found on the floor on 04/10/23 approximately 9:00 PM, STAT orders (referring to a diagnostic or therapeutic procedure that is to be performed immediately; prioritized in a lab, as the results have a potentially immediate impact on patient management) were submitted on 04/11/23 at approximately 4:56 AM, results retrieved on 04/12/23 at approximately 9:11 AM, by Physician I, and the resident was sent out to the hospital on [DATE] at approximately 11:21 AM. An Immediate Jeopardy was determined to have existed from 04/10/23 through 04/27/23. While the IJ was removed on 04/28/23, the facility remained out of compliance at a scope of potential of actual harm that is not Immediate Jeopardy and a severity level of pattern, due to the facility's need to implement corrective systems. The facility implemented actions that corrected the Immediate Jeopardy prior to re-entering the facility on 05/11/23. The facility Administrator was provided the Immediate Jeopardy Template on 05/11/23 at 3:39 PM. This failure placed residents at risk of a delay in medical evaluation, treatment and decrease in quality of care. Findings included: Review of Resident #4's face sheet dated 04/27/23 revealed the resident was an [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4's diagnosis included non-displaced intertrochanteric of fracture of left femur, unspecified fall, muscle weakness, difficulty in walking, abnormalities of gait and mobility, history of falling, lack of coordination, unsteadiness on feet. aphasia, major depressive disorder, vascular dementia with agitation. Review of Resident #4's quarterly MDS Assessment, dated 03/25/23, revealed Resident #4 was usually understood by others and was usually able to understand others; however, the resident's cognitive assessment/BIMS was not completed. Transferring between bed, chair, wheelchair, and standing position required extensive assistance with one person assist. Locomotion in the room required supervision with two person assist. Review of Resident #4's care plan, undated, revealed Resident #4 had ADL self-care performance deficit related to weakness, dementia, and transient ischemic accident. Goal: will maintain current level of function in transfers, toilet use and personal hygiene, Intervention: Toilet use: requires x1 staff to assist, Transfer requires x1 staff assist with transferring. Resident #4 at risk for falls related to weakness. Goal: will not sustain serious injury. Intervention: 1/1/23 Fall; due to drop in blood pressure, 1/19/23 Fall; educated resident to call for assistance when picking up things off the floor, 02/12/23 Fall; offer bathroom assistance when making rounds, 04/10/23 Fall; fall mat to beside at all times, be sure the call light is within reach and encourage to use it to call for assistance as needed, keep needed items, water, etc. in reach. Resident #4 had an actual fall with minor injury. Goal: Sutures x4 to be removed 02/19/23 will resolve without complication. Intervention: offer bathroom assistance when making rounds, Bed in lowest position, provide activities that promote exercise and strength building where possible. Review of Resident #4's progress notes dated 04/10/23 at 10:11 PM, documented by LVN A reflected: resident was noted sitting on the floor at the end of bed facing the door next to wheelchair. The roommate says she was trying to get out of bed, and she slid out and sat on the floor. Head to toe assessment done. Alert with no signs or symptoms of acute distress, no injuries noted at this time, vitals checked, staff helped back in bed, denies pain at this time. Bed placed in low position, MD, DON, and family notified, will continue to monitor. Review of medication notes dated 04/11/23 at 4:55 AM documented by LVN A reflected: Acetaminophen Tablet 650 mg. Give 1 tablet by mouth every 6 hours as needed for general discomfort. Review of nurse's notes dated 04/11/23 at 4:56 AM documented by LVN A reflected: During routine rounds, this nurse noted Resident #4 holding left hip massaging it. Asked resident if she was in pain and resident nodded her head. Acetaminophen Tablet 650 MG Give 1 tablet by mouth was administered, MD notified, new order left hip x-ray to rule out fracture. X-ray order placed and waiting for the technician. Will continue to monitor. Review of medication notes dated 04/11/23 at 8:00 AM documented by the DON reflected: Acetaminophen Tablet 650 MG. Give 1 tablet by mouth every 6 hours as needed for general discomfort. Follow up: PRN administration was: Effective, Pain scale was: 2. Review of nurse's notes dated 04/11/23 at 9:55 PM documented by LVN A reflected: Follow up follow day 1 of 2, no delayed injury noted, able to move all extremities without difficult. Denies pain to left hip. Bed placed in low position. Will continue to monitor. Review of nurse's notes dated 04/12/23 at 11:21 AM documented by the ADON reflected: Resident complained of pain to right hip. Pain management administered with acetaminophen. X-rays ordered. Results showed fracture to right hip (error in the facility note). Resident sent to hospital via city ambulance by stretcher. Review of Resident #4's lab results dated 04/11/23 at 11:21 AM revealed interpretation: significant findings: left hip x-ray unilateral 2-3 views show a fracture of the left proximal femur at the intertrochanteric region. Impression: Acute fracture of the left proximal femur at the intertrochanteric region. Reviewed by doctor on 04/12/23 9:11 AM. There was a delay (approximately 28 hours) in getting medical treatment for Resident #4 due to the facility not being aware x-ray results (which showed hip fracture) had been received and not promptly notifying the physician of the results. During an observation and interview on 04/27/23 at 11:48 AM with Resident #4 revealed communication was unclear. Resident #4 would nod head when asking her questions. Resident #4 stated she had some pain, she stated she fell, and she went to the hospital. Resident #4 was not able to say how the fall occurred. During an interview on 04/27/23 at 3:15 PM with CNA C revealed she was alerted to Resident #4's room by the roommate engaging the call light. CNA C stated she observed Resident #4 on the floor around 7:00 PM and called for the nurse to enter the room to assess. CNA C stated after the assessment Resident #4 was put in bed. CNA C stated she returned to check on Resident #4 and to complete incontinent care. CNA C stated Resident #4 was fighting with her and did not want me to change her. CNA C stated it was hard to tell if she was fighting or if she was displaying pain and alerted the nurse. CNA C stated Resident #4 usually did not talk too much but during her rounds the next day Resident #4 was crying. CNA C stated she informed the nurse Resident #4 was crying and appeared to be in pain, she stated the nurse then administered pain medication and ordered x-ray. CNA C stated Resident was not in the facility the following day when she arrived to work. During an interview on 04/27/23 at 3:48 PM with RN D revealed she was informed about Resident #4's fall. RN D stated she was not present when resident had fall or when the x-ray was completed. RN D stated it was protocol if a resident had a fall and complained of pain, nurses would contact the doctor, and the doctor would order an x-ray stat. RN D stated the x-ray techs would show up within the hour and would usually have the results returned the same day via fax. Upon the receipt of the result, nurses would send the results to the doctor, and wait on the doctor's new orders if any which could be pain management or send resident out to the hospital. If the doctor was busy the Nurse Practitioner would respond or would reach back out to the doctor if no response within 2-3 hours. It was the responsibility of all nurses to receive the x-ray results and alert the doctor of the results. RN D stated there was not one specific person who received the x-ray results; however, if you know your resident had an x-ray you should be looking for the results to come in so that you can alert the doctor. RN D stated not following up with x-ray results put the resident at risk of prolonged pain and not getting the services needed. On 04/27/23 at 4:10 PM an attempt to interview LVN A was unsuccessful. During an interview on 04/27/23 at 4:10 PM with the ADON revealed she was present on the day Resident #4 had a fall. ADON stated she and LVN A entered the room between 9:00 PM-9:30 PM after noting the call light was on and someone yelling. The ADON stated she found Resident #4 on the floor at the foot of the bed feet facing the door and head towards the wall. The ADON stated Resident #4's bed was observed to be at the lowest position. The ADON stated Resident #4 was assessed and back in the wheelchair. The ADON stated Resident #4 was crying and upset, you could tell she was in pain. According to the ADON, the next morning on 04/11/23 Resident #4 was hurting, in pain and grabbing her left side so she told the nurse to give pain medication and was told x-rays were already ordered. The ADON stated on 04/12/23 Resident #4 was showing signs of pain with crying and yelling. The ADON stated facility protocol would be to call out for mobile x-ray, when necessary, results were received pretty quick in the resident's chart and the nurse will contact the doctor immediately. The ADON stated she was not able to say who received Resident #4's x-ray results. The ADON stated any nurse on duty could review the x-ray results and contact the doctor. There was not one person responsible for following up with the doctor with the results. The ADON stated not getting the x-ray results in a timely manner could place residents at risk of getting proper medical care. On 04/27/23 at 4:48 PM an attempt to interview Physician I was unsuccessful. During an interview on 04/27/23 at 5:07 PM with the DON revealed she was notified by nursing staff on 04/10/23 at 8:00 PM that Resident #4 had a fall with no injuries. The DON stated LVN A stated during rounds he assessed Resident #4 and observed she was rubbing her hip, expressing that she was in pain. The DON stated LVN A contacted the doctor for an x-ray. The DON stated the x-ray was completed on 04/11/23 at 11:21 AM. The DON stated x-rays were returned the same day and were auto-posted into resident file. The DON stated there was no way to know when the results were uploaded to resident charts. The DON stated the charge nurse on duty for that resident would be the person to go into resident files to check for x-ray results, then contact the doctor. The DON stated in this case the doctor was the one that logged in, reviewed the results, and contacted us to send her out on 04/12/23. The DON stated Resident #4 was given Tylenol one time for pain and was sent to the hospital by stretcher. The DON stated without knowing what time the results came in it was hard to know the risk for Resident #4. During an interview on 04/28/23 at 12:26 PM with Physician I revealed he was reviewing all lab results and identified the results himself for Resident #4. Physician I stated he did not receive notification from the facility that the results were in. Physician I stated he notified the facility that Resident #4 needed to be sent out to the hospital right after revealing the results. Physician I stated he spoke to the DON to have the results sent directly to her so that she was aware when the results were in so she could notify the required authorities as soon as possible to prevent risk to the resident. During interview and record review it was revealed LVN A received a STAT order for an X-ray as of 04/11/23 at 4:56 AM. The X-ray was completed on 04/11/23 at 11:21 AM. Resident #4 was sent out to the hospital on [DATE] after the doctor reviewed the results on 04/12/23, he then notified the facility of the results. The ADON stated she did not follow up on the X-ray orders to see if they were received on 04/11/23 after the orders had been completed. ADON stated on 04/12/23 when she asked about orders for the X-ray on 04/12/23, she was notified the resident was being sent out to the hospital. Resident #4 had now been in pain during several shifts (10:00 PM-6:00 AM day 1 of 3, 6:00 AM-2:00 PM, 2:00 PM-10:00 PM, 10:00 PM-6:00 AM day 2 of 3, and 6:00 AM-until sent to the hospital day 3 of 3) according to both LVN A and ADON. Review of the EMAR revealed she was administered pain medication once on 04/11/23 at 4:55 AM throughout all shifts after the fall. Hospital records revealed Resident #4 admitting diagnosis was severe left hip pain, left hip fracture, leukocytosis, acute cystitis without hematuria, fall, dementia. An Immediate Jeopardy was determined to have existed from 04/10/23 through 04/27/23. The IJ was removed on 04/28/23 because the facility implemented actions that corrected the Immediate Jeopardy prior to re-entering the facility on 05/11/23. The facility Administrator was provided the Immediate Jeopardy Template on 05/11/23 at 3:39 PM. The facility submitted the following accepted Plan of Removal on 05/12/23: .Immediate Action: 1. ADON re-education was completed on 4/12/2023 was completed by DON. DON was educated by Clinical Resource .04/27/2023. 2. The Medical Director was notified of IJ on 5/11/2023 at 3:51 PM and read at 3:59 PM . 3. Education was initiated with nurses by DON/ADON/Clinical Resource on 4/28/23 related to: a. Lab results reporting and checking lab and radiology PCC modules every 4 hours during per shift; b. Every shift to complete assessments on residents that have had a fall. Report any complaints of pain to MD immediately; c. Notification to MD of Abnormal Results; Notification to Responsible Party in the clinical record; d. Fall prevention; e. Stop and watch program; f. Abuse, neglect, misappropriation 4. Notified Medical Director of survey results on 4/28/23 and physician wrote a written statement of no harm or significant delay in care that we received on 5/1/23. (Relevance is that there is no harm or significant delay in care per the Medical Director). 5. Immediately notified Xray provider that all Abnormal and Critical Findings are required to be called to the DON if facility staff do not answer facility phone on 4/12/2023. 6. An Ad hoc QA meeting regarding items in IJ template was completed on 5/11/23 at 5:15pm. Attendees included the Administrator, DON, Medical Director and Clinical Resource. The plan of removal items and interventions were developed, reviewed, and agreed upon. Identification of Others Affected: Residents who have ordered diagnostic and radiology services have the potential to be affected. Systemic Change to Prevent Re-occurrence: 1. Education was initiated with nurses by DON/ADON/Clinical Resource on 4/28/23 related to: a. Lab results reporting and checking lab and radiology PCC modules every 4 hours during per shift; b. Every shift to complete assessments on residents that have had a fall. Report any complaints of pain to MD immediately; c. Notification to MD of Abnormal Results; Notification to Responsible Party with a progress note identifying results and notification made; d. Fall prevention; e. Stop and watch program; f. Abuse, neglect, misappropriation 2. Review of all radiology and diagnostic services to ensure completion and follow up with appropriate documentation, daily, in clinical morning meeting, effective 5/1/2023. 3. Immediately notified Xray provider that all Abnormal and Critical Findings are required to be called to the DON if facility staff do not answer facility phone on 4/12/2023. 4. An Ad hoc QA meeting regarding items in IJ template was completed on 5/11/23 at 5:15pm. Attendees included the Administrator, DON, Medical Director and Clinical Resource. The plan of removal items and interventions were developed, reviewed, and agreed upon. Monitoring: 1. Review of all radiology and diagnostic services to ensure completion and follow up with appropriate documentation, daily, in clinical morning meeting, effective 5/1/2023, by Clinical IDT, daily, for 4 weeks, and then routinely monitored through the change of condition process. 2. Weekly clinical meetings will include review of laboratory orders and results. Meeting attendees will include the clinical IDT and the Administrator. Meeting minutes will be reported to monthly QA by DON/ADON/designee. During an interview on 05/11/23 at 4:11 PM with the ADON revealed when she entered the facility on 04/11/23 she received updated information from LVN A and the 24-hour report for Resident #4. The ADON stated she was told an x-ray had been ordered and waiting on x-ray techs arrival. The ADON stated you get busy doing other things and then she realized the next day on 04/12/23, they were sending Resident #4 out to the hospital. The ADON stated since she worked the floor on 04/11/23, she should have followed up with looking for the results by looking in the chart or contacting the x-ray company for results then contacting the physician and the family about Resident #4's results. The ADON stated she completed training and in-services pertaining to labs and radiology services on 04/28/23 the day after the initial HHSC visit on 04/27/23. The ADON stated the facility had implemented daily clinical meetings to review order listing reports and orders from the previous day to be checked by the interdisciplinary team. The ADON stated the team would then reach out to the nurse who created the order or charge nurse on the floor that day to see if they had reviewed orders, reached out to the doctor, and documented in the chart. The ADON stated lab results with significant findings would be sent directly to the DON, the DON would contact the charge nurse and the physician with the findings. The ADON stated the nurses would communicate verbally and through the 24-hour report, whether residents had labs, doctor appointments, anything noted on the 24-hour report, that shift nurse was now responsible to ensure the task was completed, followed-up on and documented in the resident chart. During interview on 05/11/23 at 6:11 PM with the DON revealed she received notification via text from LVN A on 04/10/23 the night of the fall after 9:00 PM. LVN A indicated Resident #4 had no apparent injury and no complaints of pain. The DON stated she returned to the facility on [DATE] about 5:45 AM and was verbally told by LVN A that Resident #4 started complaining of pain, and LVN A contacted the doctor and received an order for x-ray. The DON stated she would have expected x-ray to show up within 4-6 hours. The DON stated since LVN A's shift ended, the 24-hour report would alert the next shift nurse that Resident #4 was to complete x-ray. That shift nurse, which in this case was the ADON should have followed up to ensure the x-ray was completed and results given to the physician. The DON stated in-services were started on 04/28/23 with nurses to check lab results every 4 hours during 12-hour shift. The DON stated the facility had now implemented that after the morning stand-up meeting, the clinical team would review all orders from the previous day, check on the things that needed to be done, go over current orders, care plans, nurses' notes, documentation and calls to doctors and resident representatives. The DON stated she also contacted the imaging company to ensure they would send notification directly to her via text when there were significant findings with lab results. The DON stated the notifications came with a link so that she could access the results. The DON stated she would put in a progress note and notify the doctor, nurse, and resident representative. The DON stated for agency staff or as needed staff there would be a binder with in-services and test to complete to ensure all nursing staff were aware to check for laboratory, radiology, diagnostic result every 4 hours, and to call doctor and resident representatives with results, and to document in the resident chart. During interview on 05/11/23 at 6:46 PM with LVN A revealed the aide alerted him that Resident #4 had fallen on 04/10/23 between 8:00 PM-9:00 PM. LVN A stated when he entered the room Resident #4 was sitting down next to the bed legs straight out, the call light had been initiated by the roommate. LVN A stated the roommate stated Resident #4 was trying to get up off the bed and slid down to the floor. LVN A stated after his assessment her vitals were normal, no findings with range of motion and no indication of pain, Resident #4 was assisted to her bed. LVN A stated during his rounds at 12:00 AM Resident #4 was sleeping, during his rounds at 4:00 AM, Resident #4 was rubbing her left hip continuously. LVN A stated he asked her if she was in pain and the way she replied confirmed she was in pain. LVN A stated he provided her with pain medication which she has an order for use as needed. LVN A stated he contacted the physician and received order for X-ray, contacted the family and notified the DON. LVN A stated when the next shift nurse came, rounds were completed together, completed the 24-hour report so that she could follow up with X-ray. LVN A stated the next day when he entered the facility he completed rounds, Resident #4 was sleep, not showing signs of pain. LVN A stated he thought the results were received and the physician was notified. LVN A stated he did not think to look or ask about the x-ray results, LVN A stated he should have followed up on the results himself. LVN A stated he completed several in-service training about 2 weeks ago covering labs and x-ray results, checking for results every 4 hours during shift and if the results were critical to contact the physician and resident representative immediately, and document. During interview on 05/12/23 at 1:47 PM with Physician I revealed the reason he sent Resident #4 out to the hospital was due to her results of acute fracture of her left hip. Physician I stated Resident #4 did not have an emergency; however, it was urgent, and they needed to act with urgency. Physician I stated he was not sure when the results were sent or received and speaking with the x-ray company, they did not think the hip fracture was considered critical. Physician I stated communication was completed with them to have the understanding to contact the facility through phone call and fax with critical findings. It was discussed with the x-ray company that a hip fracture was a critical result and should have been called to the facility and not just faxed. Physician I stated some things were critical and needed action right away and this was one. Physician I stated even if the results came in the same day and she was sent to the hospital that night, the surgery would not have happened until 2-3 days later, and they were still in that window. During interview on 05/12/23 at 3:19 PM with a representative from the x-ray company revealed she had been communicating with the facility a number of ways to alert the facility when results came in. The x-ray company representative stated the results were automatically sent to the same number and emailed whether the findings were significant or not. The x-ray company representative stated after Resident #4's fall more functionality was provided to the alerts and as of 04/17/23 the facility would now be automatically emailed the findings and if there were significant results then the DON would also get a text notifying the DON of the critical result. The x-ray company representative confirmed monitoring and there had not been any further concerns. Review of in-services and interviews on 05/12/23 with nurses, ADON, DON, Clinical Resources revealed the facility implemented in-services on 04/28/23 on the following topics: 1. Notification to MD of abnormal results. Notification to responsible party (RP), progress notes, stating results and notification. 2. Reporting Lab results, check Lab & Radiology Q4 hours during a 12 hour shift. 3. Stop & Watch training with the Nurses, MAs, and CNAs. 4. Response on Resident call lights. Call light in reach of resident. 5. Fall Prevention Review of facility's Nursing Clinical policy and procedure, revised May 2007, reflected the following: Policy- It is the policy of this facility that the resident's attending physician will be notified of the results of diagnostic tests. Procedures: 1. Results of laboratory, radiological, and diagnostic tests shall be reported in writing to the resident's attending physician or to the facility. 2. Should the test results be provided to the facility, the attending physician shall be notified of the results. 3. The Director of Nursing Services, or Charge Nurse receiving the test results, shall be responsible for notifying the physician of such test results .

**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 from abuse, neglect, misappropriation of resident property, and exploitation for six of 16 residents (Residents #2, #3, #4, #5, #6 and #7) reviewed for abuse. The facility failed to protect Residents #2, #3, #4, #5, #6 and #7 from Resident #1, who had a known history of physical and verbal aggression towards residents. An Immediate Jeopardy (IJ) situation was identified on 01/05/23. The IJ began on 11/04/22 and removed on 12/22/22. While the IJ was removed on 12/22/22, the facility remained out of compliance at a scope of potential for more than minimal harm that is not Immediate Jeopardy and a severity level of pattern, due to the facility's need to implement corrective systems. This failure placed residents at risk of subsequent abuse, mental anguish, and emotional distress. Findings included: Record review of Resident #1's face sheet, dated 12/22/22, revealed the resident was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included alcohol dependence with alcohol induced persisting dementia (brain disorder that causes memory loss), alcoholic polyneuropathy (alcohol induced nerve disorder), aphasia (speech disorder), schizoaffective disorder (psychotic/mood disorder), major depressive disorder (mood disorder), and cognitive communication deficit. Record review of Resident #1's Quarterly MDS assessment, dated 11/28/22, reflected Resident #1 had a diagnosis which included non-Alzheimer's dementia. The resident had a BIMS score of 0, due to the BIMs not being completed due to cognitive deficits. The MDS reflected Resident #1 rarely had the ability to make himself clear and understand others. Resident #1 was severely impaired when it came to making decisions regarding tasks of daily life. The MDS reflected Resident #1 was short-tempered and easily annoyed. Record review of Resident #1's care plan, revised 11/07/22, revealed: Resident #1 was at risk for impaired cognitive function or impaired thought processes r/t dementia. Resident #1 had poor attention span, fidgety, unable to sit for a very long time and was constantly on the move. Goal: resident will maintain current level of cognitive function through review date. Interventions: administer Memantine as ordered, administer Thiamine as ordered, identify self at each interaction, and give step-by-step instructions one at a time as needed to support cognitive function. Resident #1 had the potential for psychosocial well-being problem r/t resident wandering into other residents' spaces, grabs their wrists, their items, food on trays in dining room, then other residents retaliate against him. Goals: resident will have no indications of psychosocial well-being problems through review date. Interventions: 1:1 supervision, monitor for injuries every shift for 3 days, monitor/document resident's feelings relative to the other residents. Resident #1 had the potential to demonstrate physical behaviors r/t Dementia, hitting, kicking at staff, unable to redirect behavior. Resident combative, verbally aggressive, going in and out of resident rooms, upset with redirection, cursing staff, and refusing care. Goals: resident will not harm self or other residents. Interventions: 1:1 supervision, administer Benadryl as ordered, provide physical and verbal cues to alleviate anxiety, document observed behaviors and attempted interventions, and give as many choices as possible regarding care and activities. Record review of Resident #2's face sheet, dated 12/22/22, revealed the resident was a [AGE] year-old female, who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included age-related osteoporosis (weak bones), unspecified dementia without behavioral disturbances (brain disorder that causes memory loss), speech language deficits, and profound intellectual disabilities. Record review of Resident #2's Quarterly MDS assessment, dated 10/21/22, reflected a BIMS score of 06, which indicated severe impairment. Record review of Resident #2's care plan, dated 06/21/22, revealed the resident was to be monitored for re-traumatization r/t assault in 2013. The family complained of poor care at prior living situation. Resident noted to cry a lot, but not abnormal per guardian. Goals: resident will have no evidence of emotional, physical, and psychological problems by review date. Interventions: anticipate and meet needs, document behaviors and resident's response to interventions. Record review of Resident #3's face sheet, dated 12/22/22, revealed the resident was a [AGE] year-old female, who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease), unspecified dementia and essential hypertension (high blood pressure). Record review of Resident #3's Quarterly MDS assessment, dated 12/21/22, reflected a BIMS score of 0, due to the BIMs not being completed, due to cognitive deficits. Record review of Resident #3's care plan, dated 11/04/22, revealed the resident had potential for injury related to another resident hitting her in the chest, monitoring needed for injury. Interventions: Monitor res for pain, bruising chest area q shift. Resident #3 also had potential for pain and inability to communicate. Goal: If or when res shows signs of pain, pain med will be effective. Interventions: Anticipate need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Record review of Resident #4's face sheet, dated 12/22/22, revealed the resident was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease), respiratory failure, anxiety disorder. Record review of Resident 4's Quarterly MDS assessment, dated 10/02/22, reflected the resident had a BIMS of 08, which indicated moderately impaired cognition. Record review of Resident #4's care plan, dated 01/22/20, revealed: Resident #4 had a terminal prognosis related to chronic obstructive pulmonary disease. Goal: to be free of depression and anxiety. Interventions: assess resident coping strategies and respect resident wishes, monitor significant changes in patients physical, mental, social, or emotional status and/or concerns including pain and uncomfortable situations. Record review of Resident #5's face sheet, dated 12/22/22, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease), asthma, abnormalities of gait and mobility and major depressive disorder. Record review of Resident #5's Quarterly MDS assessment, dated 11/15/22, reflected the resident had a BIMS of 12, which indicated moderately impaired cognition. Record review of Resident #5's care plan, dated 04/01/22, revealed: Resident #5 was at risk for Re-traumatization related to history of alleged verbal abuse and history of alleged physical abuse. Goal: have no evidence of emotional, physical, and psychological problems. Interventions: monitoring behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved and situations. Anticipate and meet needs. Record review of Resident #6's electronic face sheet, dated 12/22/22, revealed Resident #6 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included moderate intellectual disabilities, manic episode without psychotic symptoms and cognitive communication deficit. Record review of Resident #6's Quarterly MDS assessment, dated 07/13/22, revealed Resident #6's BIMS score was 0, due to the BIMs not being completed due to cognitive deficits. Record review of Resident #6's care plan, dated 08/04/22, revealed Resident #6 had Anti-anxiety medication use related to anxiety disorder. Goal revealed resident will be free from discomfort or adverse reactions related to anti-anxiety therapy. Interventions included Lorazepam as ordered by physician. 8/3/2022 Increased Dosage. Record review of Resident #7's face sheet, dated 12/22/22, revealed the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease), type II diabetes, aphasia (speech disorder), hemiplegia (severe or complete paralysis), hemiparesis (mild or partial weakness), osteoporosis (weak bones) and dementia (brain disorder that causes memory loss). Record review of Resident #7's Quarterly MDS assessment, dated 12/15/22, reflected the resident had a BIMS of 13, which indicated her cognition was intact. Record review of Resident #7's care plan, dated 06/08/22, revealed: Resident #7 had potential for aggressive behaviors and psychosocial well-being problem related to a resident-to-resident incident. Goal: resident will have no indications of psychosocial well-being problems and will identify coping mechanisms. Interventions: skin assessments, monitor for mood change, separate from other resident in incident, when conflict arises, remove Resident #7 to a calm safe environment and allow to vent/share feelings. Record review of Progress Notes, dated 12/11/2022, regarding Resident #1 revealed Resident was found in another resident's room scooting around. He took her picture frame and threw it and broke it. The other resident was pushing the seat of the wheelchair into his back over and over to scoot him out of her room. Resident removed from her room and avoiding glass on the floor, assisted back into wheelchair. Head to toe assessment shows no apparent injuries. Record review of Progress Notes, dated 12/12/2022, regarding Resident #1 revealed Resident remains on follow up related to resident-to-resident altercation with no other incidents observed or reported . Record review of Progress Notes, dated 12/13/2022, regarding Resident #1 revealed Resident wandering aimless into resident room with re-direction given . Record review of Progress Notes, dated 12/14/2022, regarding Resident #1 revealed Resident wandering aimless into resident room with re-direction given . Record review of Progress Notes, dated 12/21/2022, regarding Resident #1 revealed Resident agitated, moving from room to room waking up residents, resisting care Lorazepam Tablet 0.5 MG . Record review of Incident Report, dated 10/9/2022, regarding Resident #1 revealed Resident wheeled himself into room [ROOM NUMBER] and was found crawling around the floor there. Wheelchair was also knocked over. Left forearm skin tear noted. Range of motion per baseline. No signs of pain. Record review of Incident Report, dated 12/11/2022, regarding Resident #1 revealed Resident was in another residents' room and was bothering her things. He got out of his wheelchair and got onto the floor, found and broke a picture frame. An attempted interview and observation on 12/22/22 at 11:51 AM with Resident #1 revealed he was unable to participate in an interview due to cognitive deficits. When asked a question, the resident did not respond and was not aware of what was being said. Resident #1 was observed self-propelling around the facility in a wheelchair. He was seen entering a resident's room without any intervention. An interview and observation on 12/22/22 at 11:53 AM with RN C revealed she saw Resident #1 enter room [ROOM NUMBER]. RN C stated Resident #1 was always going into other rooms, and it was hard for staff to stop him because he would become angry. RN C stated she did not intervene because there were no residents in room [ROOM NUMBER], although Resident #1 was not supposed to be in that room. RN C proceeded to go into room [ROOM NUMBER] and redirected Resident #1 out. RN C stated Resident #1 went all over the facility and usually did not disturb anyone until he was redirected and unable to do what he wanted. RN C stated staff had been trained to do frequent checks on Resident #1 to prevent him from going into other resident rooms. An interview on 12/22/22 at 11:30 AM with Resident #2 revealed she was sitting in a wheelchair on the 200 Hall near her room. Resident #2 denied being abused or neglected by staff. When asked about other residents, Resident #2 stated she was afraid of Resident #1 and immediately became teary-eyed and hysterical. Resident #2 was so upset she could barely speak, but she was able to state Resident #1 was always coming into her room to take things and curse at her and her roommate. Resident #2 stated she was afraid Resident #1 was going to hurt her and her roommate. Resident #2 continued to cry and stated she had to protect her roommate from Resident #1. An attempted interview on 12/22/22 at 11:15 AM with Resident #3 revealed she was unable to participate in an interview due to cognitive deficits. Resident #3 was dressed and well-groomed with no visible marks or bruises. An interview on 12/22/22 at 11:55 AM with Resident #4 revealed she had recently relocated to another room because of having issues with another resident who she described as Resident #1. Resident #4 stated Resident #1 had just been in her room the previous night going through her personal items. Resident #4 stated Resident #1 liked to get close to her, in her personal space and this made her feel uncomfortable. Resident #4 stated Resident #1 needed to be in a different facility because staff were not able properly care for him because he liked to roam the facility, curse at residents, and cause problems with other residents. Resident #4 stated she always alerted staff to remove him from her room, but it sometimes took a long time to remove him. She stated she would use the saltshaker, telling him it was evil, to get Resident #1 away from her. Resident #4 denied ever being physically harmed by Resident #1 but stated she was afraid of him. An interview on 12/22/22 at 12:33 PM with Resident #5 revealed she had an encounter with Resident #1 while sitting in the dining room. She stated Resident #1 jumped on her. Resident #5 stated she was physically attacked but did not indicate having any pain or injuries from the incident. She stated she was nervous around Resident #1 since then. She stated Resident #1 would always come in her personal space as if he did not understand boundaries. Resident #5 stated when she saw Resident #1 getting too close, she would have to stop him to keep him from grabbing her. She stated he could have become very aggressive. Resident #5 stated Resident #1 needed to be at a different facility, because of the way he treated people and he could harm someone. Resident #5 stated she was scared he would cause harm to her again. An interview on 12/22/22 at 12:42 PM with Resident #6 revealed she was hit in the stomach by Resident #1 in the dining hall during lunch. Resident #6 stated she reported the altercation to the Speech Therapist. Resident #6 did not recall any pain or injuries after the altercation. Resident #6 stated she did not like Resident #1 and he was mean and made her feel uncomfortable. An interview on 12/22/22 at 2:45 PM with the Speech Therapist revealed on 11/07/22, he was walking in the dining area and Resident #6 reported to him she was hit in the stomach. When asked to identify the person who hit her, she pointed out Resident #1. The Speech Therapist stated he saw Resident #1 having aggressive behaviors towards staff and other residents on many occasions. The Speech Therapist stated he was told by several residents they were fearful of Resident #1. Residents stated they have woken to him being in their rooms throughout the night. The Speech Therapist stated he alerted the Administrator about all concerns that were brought to him by residents, and he would try to assist with redirecting Resident #1 as much as possible. An interview on 12/22/22 at 11:41 AM with Resident #7, revealed the only person she was afraid of at the facility was Resident #1. She stated, He's a pain in the butt! Resident #7 stated Resident #1 would always come in her room and take her personal belongings. She stated he was caught in her room about a week ago and when she broke a special picture frame of hers. Resident #7 stated staff would try to keep him out of her room, but he would find a way to get in. She stated she was recently moved to a different room to get away from Resident #1 and now felt safer. She denied ever being physically abused by Resident #1. An interview on 12/22/22 at 1:05 PM with CNA A, revealed she had worked at the facility since 2019. CNA A stated she worked on the 200 Hall with Resident #1. She stated Resident #1 would beat on the staff and other residents periodically since being admitted . CNA A stated he would sneak into other resident rooms and if staff were unable to catch him in a timely manner, he would grab or hit the residents. She stated if Resident #1 was seen going into another resident's room, staff would redirect and guide him out immediately. CNA A stated she last witnessed Resident #1 hit another resident about a month ago; however, he was constantly cursing and yelling at everyone. She stated Resident #1 was placed on 1:1 supervision after this incident, but she believed it was discontinued because he would attack the staff who were supervising him, and staff started refusing to work with him. This incident was reported and investigated on this date. CNA A stated Resident #1 was able to be redirected sometimes but most times he could not be due to his cognition. CNA A stated staff could not reason with Resident #1 or help him understand why he was unable to wander in other rooms or intrude on the space of other residents. She stated staff were told to check on Resident #1 more frequently, but it was hard to do so and care for all other residents. She stated most residents on the 200 Hall were afraid of Resident #1, and some had even been moved to different halls to get away from him. CNA A stated staff were trained on abuse, neglect and handling aggressive behaviors with the last training being about a month ago. An interview on 12/22/22 at 1:25 PM with RN B, revealed she had worked at the facility since 2017. RN B stated she worked on the 200 Hall with Resident #1. She stated Resident #1 was a difficult resident with aggressive behaviors. RN B stated most of the residents were afraid of him. She stated there were interventions in place to check on him every 15 mins and sometimes he was placed on 1:1 supervision. RN B stated she tried to keep Resident #1 close to her station, but it was hard because he liked to wander and go into other resident rooms. RN B stated Resident #1 had been on psychotropic medications to help control his behaviors; however, the family would have them adjusted or discontinued. RN B stated the medications Resident #1 was currently on, was not helping him. She stated the other residents were not safe with Resident #1 in the facility and she felt he belonged in a psychiatric hospital. An interview on 12/22/22 at 2:14 PM with the COTA revealed she worked at the facility for 5 months. She stated she witnessed a physical altercation between Resident #1 and Resident #3 on 11/4/22. The COTA stated she was standing in the dining room when she heard groans coming from the table where Resident #3 was sitting. The COTA stated she turned and saw Resident #1 trying to take food from one of the trays and when staff intervened, he became angry. The COTA stated Resident #1 was able to ball up his fist and reach across to punch Resident #3 in the chest twice before staff were able to pull him away. The COTA stated Resident #3 was assessed by the nurse and did not sustain any injuries to her knowledge. The COTA stated she saw Resident #1 become verbally aggressive and knock over things, but she denied ever seeing him physically harm any residents prior to that incident. The COTA stated the Administrator was immediately notified about the incident. An interview on 12/22/22 at 5:45 PM with the DON revealed she had been employed at the facility for about 5 months. The DON stated shortly after starting at the facility, she recommended Resident #1 be transferred to a memory care facility. However, he was Medicaid pending and the family would not provide the necessary documents for the application to be approved. The DON stated Resident #1 was not receiving proper care at their facility because he needed a more structured environment with staff who were trained to better handle his behaviors. The DON stated Resident #1 was in an advanced stage of dementia and his cognitive deficits was beyond what the facility was capable of managing. The DON stated Resident #1 would wander around the entire facility, going in other residents' rooms causing them to become upset. She stated there were incidents where Resident #1 would become physically aggressive towards other residents, break their personal items, and use profanity. She stated the physical aggression had not happened in about a month; however, the wandering and verbal aggression was continuous. The DON stated she was concerned with the safety of all residents but more so for Resident #1 because of his unawareness and the conflict he would cause. The DON stated she was concerned he would wander into another confused or aggressive resident's room. The DON stated Resident #1 was also physically and verbally aggressive towards staff, especially when care was being provided. The DON stated the MD placed Resident #1 on 1:1 supervision for about 2 weeks then discontinued after there were no new incidents. The DON stated he was then placed on 15-minute checks. The DON stated she could not say the interventions were effective, because Resident #1 was not suitable for the facility. She stated Resident #1 was previously on psychotropic medications that seemed to be working. However, the family decided to take him off and refused any other psychiatric services. The DON stated she was able to convince them to consent to low dose PRN psychotropic medications that were not as effective. The DON stated Resident #1's family would threaten to sue the facility if they transferred him or sent him out to be evaluated at a psychiatric hospital. The DON stated she was not sure what other options they had to protect everyone's safety and rights. Interview on 12/22/22 at 6:05 PM with the Administrator, revealed she had been employed at the facility since 12/01/22. The Administrator stated she was not yet familiar with all of Resident #1's history. However, he had presented many challenges since the start of her employment. She described Resident #1 as having extreme mood swings, presenting very friendly and happy at times and then frustrated and aggressive at other times. The Administrator stated Resident #1 was not easily redirected, and staff would have a hard time keeping him content. The Administrator stated Resident #1 required a higher level of care the facility could not provide due to not having a secured unit and because Resident #1's family would not consent to any psychiatric services, which included psychotropic medications and/or evaluations at a psychiatric hospital. The Administrator stated Resident #1's family also would not cooperate in providing documents to get him Medicare so he could be transferred to a more appropriate facility. She also stated Resident #1 had a balance of $60,000 owed to their facility, which made it even more difficult to find appropriate placement. The Administrator stated it was her responsibility to ensure the proper care and safety of all residents in the facility. However, she felt like there was not a simple solution and either way she would face a dilemma. The Administrator stated she knew it was best for Resident #1 to be discharged from the facility, but with his family not giving consent for him to be transferred or sent out to a psychiatric hospital, she would be at risk for an inappropriate discharge tag. The Administrator stated her hands were tied. She stated the facility had interventions in place for Resident #1's behaviors such as frequent redirection, checks every 15 minutes, and allowing him to self-redirect and have self-determination as much as possible; however, these interventions were not always effective. The Administrator stated the facility had decided to discharge Resident #1 to a psychiatric hospital and was in the process of doing so on this date. The Administrator stated keeping Resident #1 at the facility where he was not receiving the proper treatment was a risk to his safety as well as others; however, she did not know what else to do. Interview on 01/05/23 at 11:43 AM with CNA D revealed she had worked at the facility for 8 years and worked with Resident #1 until he was discharged on 12/22/22. CNA D stated Resident #1 was a wanderer and was verbally and physically aggressive towards staff and other residents. CNA D stated she had not witnessed any incidents where Resident #1 was physically aggressive towards other residents; however, she witnessed him go throughout the halls yelling and cursing. CNA D stated residents were annoyed by Resident #1 and did not like for him to be in their space. CNA D stated she witnessed Resident #2 become visibly shaken and tearful in the presence of Resident #1. CNA D stated Resident #2's family informed staff Resident #1 resembled Resident #2's father, who abused her as a child, and Resident #1 triggered her post traumatic stress disorder. Interview on 01/05/23 at 12:10 PM with the Administrator and the DON revealed there were currently no other residents in the facility who exhibited similar aggressive behaviors as Resident #1. The DON stated Resident #1 was discharged from the facility on 12/22/22 and the facility put measures in place to prevent further abuse from occurring. The Administrator stated the facility already had interventions in place that would have been effective for Resident #1 had the family been cooperative and would still be effective for other residents who might exhibit similar aggressive behaviors. The DON further stated they hit many brick walls with the family by not allowing Resident #1 to get the assistance he required. The DON stated the family had requested Resident #1 be taken off all psychotropic medications 09/12/22 because they thought the resident appeared to be more confused. Two other nursing facilities had agreed to accept Resident #1, but only if they had the Medicaid application pending, but the POA was not assisting with the Medicaid application process by failing to produce the required documentation. They had also contacted the local ombudsman for assistance and the family kept making promises they would get the necessary paperwork for the Medicaid application, but they never received them. The Administrator stated that management had been in-serviced on the processes of discharges and transfers. The DON stated clinicals for potential residents would be screened closer for keywords such as agitation, aggression, and confusion to prevent the facility from admitting residents who may not receive appropriate services. The DON stated for current residents, the facility would continue to monitor for changes in conditions and a new onset of aggressive behaviors so appropriate interventions could be put in place immediately. The Administrator stated if interventions proved to be ineffective, the facility would meet with the resident and family to begin the process of discharge. Review of Resident #1's IDT meeting notes dated 12/23/22 reflected the following: Note Text: Discussed initial patient behaviors upon admission compared to most recent behaviors. The patient's behaviors have progressed to an increasingly difficult to manage level. POA previously requested termination of all pharmacological psychotropic interventions, which were initially prescribed to address diagnosis of dementia with agitation, schizoaffective disorder, alcohol induced persisting amnestic disorder, Wernicke's Korsakoff's syndrome, and major depression disorder. Team discussed how termination of psych meds has contributed to progressively increased behaviors and a higher risk of harm to self or others. Prior discussions have been had with POA regarding cooperative efforts needed to find alternative placement considering increased behaviors. POA and family continue to appear to be in denial regarding resident's disease process, resulting in unproductive discussions. Current non-pharmacological interventions currently in place: - Distract resident from wandering of offering pleasant diversions, structured activities, food, conversation, television, book. - Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. - Monitor resident and redirect from entering other resident rooms. - Intervene as necessary to protect the rights and safety of others. - Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. - Give as many choices as possible about care and activities. - Q15 minute checks - D/t the increase progression of negative behaviors and barriers related to current POA allowed interventions becoming increasingly ineffective resident was transferred to an acute care hospital for higher level of care and assessment. Acute care hospital case manager advised that hospital has identified two facilities with memory care units that can provide increased level of care not available at this facility. Interview on 01/05/23 at 1:23 PM with the Physician revealed Resident #1 was under her care while he was at the facility. She stated when the resident was taken off of his psych medications, per family request, and it had a big impact on Resident #1's increased behaviors. The Physician said the facility kept in communication with her regarding his behaviors and the family later agreed for the resident to begin taking Zoloft and lorazepam because he was hitting staff and throwing things. She further stated she had given an order for Resident #1 to begin psych services but upon reading the psych notes, the resident remained agitated and combative. The Physician said there was nothing else the facility could do other than discharge him from the facility. Record review of the facility's policy titled Abuse: Prevention of and Prohibition Against, revised 10/2022, revealed the following: Policy: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation . Definitions: Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances on abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish . Prevention: .2. The Facility will act to protect and prevent abuse and neglect from occurring within the Facility by: -Identifying, assessing, care planning for appropriate interventions, and[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe environment free from abuse for 4 (Resident #3, #12, #13, and #14) of 14 residents reviewed for abuse. The facility failed to protect and assure the safety of Residents #3, #12, #13, and #14 when verbal abuse was reported on 10/19/22 and 10/20/22. Resident #3 was verbally abused by staff (recorded on video footage) and Residents #12, #13, and #14 said they were verbally abused by CNA E. These failures placed residents, who resided in the facility, at risk of abuse, and mental anguish caused by fear. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 10/24/22. While the IJ was removed on 10/29/22, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. Findings included: In an interview, with the DON and Administrator on 10/20/22 at 9:15 AM, the DON said staff found a camera hidden in a Halloween decoration in Resident #3's room. The DON said she received the call from staff on 10/19/22 round 2:00 AM staff regarding the camera. She said the staff texted her a picture of the Halloween decoration and the camera in it. The DON had staff unplug the camera because it was plugged into an un-approved extension cord. The DON said she was not surprised to find the hidden camera in the room, because the resident's family disagreed with an abuse investigation, conducted on 09/15/22, that did not reveal any abuse. The Administrator said Resident #3's family did not contact the facility regarding the camera, and they had not reported any concerns. The Administrator said he was going to have the Social Worker contact Resident #3's family regarding the camera to get to sign an Electronic Monitoring Form, but he did not know if the Social Worker had contacted them yet. The Administrator and DON said they had not heard anything from the family regarding the camera and no abuse or care issues had been reported to them. On 10/20/22 at 10:43 AM, a video was received from Resident #3's responsible party. The video was recorded on 10/19/22 at 1:58 AM, it showed a female staff person (LVN C) taking Resident #3 to his room in his wheelchair. She pulled him backwards into the room in his wheelchair. LVN C, once in the resident's room, she faced the resident and said, there you go, she pointed her right finger at the resident and said, you stop it, then she pulled her right hand in a fist, the fist does not touch the resident, but her left hand came down on something that cannot be seen in frame and a pop was heard, at the same time LVN C was heard again saying, you stop it, the resident told LVN C, fuck you, LVN C turned towards the door and it appeared the resident attempted to continue the altercation, but the images are obscured by the Halloween decoration. LVN C asked the resident, are you fighting me?', then she said angrily, at the door, you stay there and then shuts the door. On 10/20/22 at 11:08 AM, a video was received from Resident #3's responsible party, it was recorded on 10/16/22 at 12:09 AM, it showed a male staff person (CNA D) enter the resident's room the resident was in bed. CNA D picked up the bed sheet but the resident tugs on the sheet, and CNA D lets go of the sheet. The resident says, get off me, you mother fucker, and throws the sheet at CNA D. CNA D walked to the foot of the resident's bed and told he resident, I'm going to kick your ass. The resident responds but his response could not be understood on the video. In a telephone interview on 10/20/22 at 11:25 AM, Resident #3's responsible party said she had a previous complaint regarding staff treatment of the resident, which she believed to be abuse, that was investigated and found to be unsubstantiated on 09/15/22. She said she disagreed with the findings of the facility's investigation and felt the facility was covering up abuse and/or mistreatment of Resident #3. She said a former employee, Housekeeper F, informed her she believed Resident #3 was being mistreated and told her she should place a camera in his room, because reports to the Administrator and DON of mistreatment were not being acted on. She said Housekeeper F was terminated for telling her about the mistreatment of Resident #3 for not reporting the abuse allegations to the Administrator. She said based on her experience with the facility; she decided to place a hidden camera in the resident's room. She said the resident did not have a roommate and it was not violating any other resident's privacy. She said when she saw the abuse recorded on the camera, she came to the facility to check on Resident #3 but did not alert the facility to the hidden camera. She said the videos showed Resident #3 was being abused by the staff. She said on 10/19/22 around 2:00 AM she could see on the camera that staff discovered the camera was in the room. She said she could see several staff members looking at the camera before it was unplugged. She said, staff from the facility just called her a few minutes ago, she did not know who, to tell her the camera was not approved and that she would need to sign a consent for its use. She said she asked the person that called if they were concerned about what the camera revealed and the person did not answer the question, and just told her she needed to sign the form in order for the camera to be approved. She said she informed the staff she had already removed the camera from the room and took it home. She said no one reached out to her about the camera prior to the phone call today, after the investigator entered the facility. She said there was one additional video that she had not sent yet, but she would send it. She said she wanted to move the resident to another facility but had to wait for his Medicaid to be approved before her facility of choice would accept him. She said she feels stuck because she cannot move him but cannot trust that he won't be harmed at the facility. On 10/20/22 at 12:04 PM, the Administrator and DON were shown the above videos for staff identification purposes. They said both videos showed abuse of Resident #3. They identified LVN C as the staff in the first video and CNA D in the second video. The DON said there had been no reports or concerns regarding the employees' care and treatment of the residents. She said the employees would be notified and suspended pending the outcome of the investigation. On 10/20/22 at 12:38 PM, the third and final video was received from Resident #3's responsible party, it was recorded on 10/13/22 at 7:36 PM, it showed two staff (LVN C and CNA E) providing care to the resident while he was in bed. LVN C was at the head of the resident's bed encouraging him to allow care but he was saying don't do that, CNA E was observed getting some wipes, she joined LVN C at the resident's bedside. The resident could be heard saying, God dammit, at that point, LVN C's left hand went up with her hand open, while she leaned forward and told the resident to stop it, she does not hit the resident, but it appeared to be a gesture like she was going to slap the resident. On 10/20/22 at 12:45 PM, the Administrator and DON said the third video was LVN C who appeared to raise her hand to Resident #3. They said the other staff was CNA E. Record Review of Resident #3's admission Record dated 10/20/22 indicated the [AGE] year-old male resident was re-admitted to the facility on [DATE] with diagnoses which included dementia and major depressive disorder. Record Review of Resident #3's quarterly MDS dated [DATE] indicated the resident had short and long-term memory problems. He was severely cognitively impaired. He had no behaviors. Record Review of Resident #3's un-dated Care Plan indicated he had behaviors which included, combativeness, physical and verbal aggression with staff. The interventions included to provide physical and verbal cues to alleviate the resident's anxiety and give positive feedback. If the resident resists care, reassure the resident, leave, and return 5-10 minutes later and try again. In an observation on 10/20/22 at 1:34 PM, Resident #3 was propelling himself in his wheelchair. He was not able to answer any direct questions. In an interview on 10/20/22 at 2:44 PM, CNA E watched third video. She said she did not think LVN C was raising her hand to the resident, but she was not paying attention, at the time. She said she thought maybe LVN C was reaching to roll the resident over. She said she had never seen any staff being abusive or mistreating the resident. She said around 10:00 PM yesterday, 10/19/22, the resident's responsible party asked her if she was aware there had been a camera in the room. She said she told her she was not aware. She said the resident's responsible party told her she put the camera in the room because the resident was being abused by the staff. She said she told the resident's responsible party she did not believe that would happen at the facility. She said she did not tell anyone the resident's responsible party reported the resident had been abused. She said LVN C overheard her talking with the resident's responsible party and knew about the allegation. She said she was supposed to inform the Administrator of any abuse allegations; however, she did not report it. In an interview on 10/20/22 at 4:21 PM, with the DON present, LVN C said on 10/19/22 Resident #3 was awake around 2:00 AM and staff got him up in his wheelchair and assisted him to the nurses' station for monitoring. She said the resident became combative, threw things off the nurses' station, and tried to hit, kick and bite staff. She said the video showed her pulling him in his room backwards because he was being combative. She said her right hand was in a fist and pulled back because she thought he was going to grab or bite her. She said she did not make physical contact with the resident. She said the slap sound on the video was when she slapped her own leg. She said she did not feel she was being abusive to the resident. She said she was speaking loudly but it was because the resident was hard of hearing. She said she did tell the resident to stay in his room and closed the door, but it was only for approximately 5 minutes until she could get a CNA to assist her to put the resident back to bed. She denied ever threatening or hitting the resident. She said staff discovered the camera after 2:00 AM and let the DON know. She said she did hear CNA E speaking to Resident #3's responsible party but she did not hear the allegation of abuse. She later said that maybe CNA E told her something about the allegation, but she did not remember, and she was busy at the time. She said she would report abuse to the DON, she was not aware the Administrator was the Abuse Coordinator. She said she should not have raised her voice to the resident. She said Resident #3 tried to kick her as she was leaving the room and that was why she asked him if he was trying to fight her. She said she never raised her hand to hit the resident. The DON informed her she was suspended pending the outcome of the investigation and was not to return to the facility until further notice. In a telephone interview on 10/20/22 at 3:35 PM, with the DON present, CNA D said if the resident was too combative, he was supposed to get another CNA to assist him, but he did not feel the resident was being that aggressive on 10/16/22. He said the resident tugged on the sheet and he let go, he said he did not know, at the time, the camera was in the room. He said he did tell the resident he was going to kick his ass because he was under pressure, but he would not have physically hurt the resident because it was not in his heart to do so. He said what he said was abuse. He said he was frustrated and tired of the resident being so mean. He said he had not seen or heard any other staff be mean or aggressive with the resident. He said he apologized dearly for his actions and would never hurt the residents. The DON informed him he could not report to work and was under investigation. In an interview on 10/20/22 at 5:00 PM, the Administrator said staff knew he was the Abuse Coordinator because they had all been in-serviced and it was posted in the facility. He said it was his expectation that staff would notify him immediately of any allegations of abuse or mistreatment. He said the facility would investigate, and notify the police and State Agency. In a telephone interview on 10/20/22 at 5:42 PM, Resident #3's responsible party said on 10/19/22 she spoke to CNA E regarding her abuse concerns and why she installed the camera. She said she asked if she could show CNA E the videos of the abuse, but the CNA told her her eyesight was not good and she did not think she could see the videos. She said she believed CNA E did not wish to see the videos because she would have to report the abuse to the Administrator. She said it further showed how staff wanted to turn a blind eye to reports of abuse. In a telephone interview on 10/20/22 at 6:07 PM, Former Housekeeper F said she was the housekeeper on Resident #3's hall and she felt staff were not caring for the resident appropriately. She said she believed the staff were not assisting him with meals, were abrupt and discourteous to him. She said she spoke with the Administrator and DON about her concerns, but she believed they were not addressed. She said she spoke to the resident's responsible party regarding her concerns and told her she should put a camera in the resident's room because she believed he was being mistreated by staff. She said when the facility found out she told the resident's responsible party she suspected abuse, the DON called her on 09/10/22, to question her if she knew who the Abuse Coordinator was, and she told her it was the Administrator. She said the Administrator wanted to meet with her in the next day 09/11/22, in his office, but she did not meet with him for fear she would be terminated. She said her last day of employment was 09/11/22. She said the facility's inaction regarding allegations made employees not want to report anything. She said other facility employees knew about things but don't report it. She would not give the investigator the names of the other employees. She said there were employees, still working at the facility, who abused residents. She named CNA E, as an abuser. In an observation on 10/24/22 at 9:30 AM, Resident #3 was propelling himself in his wheelchair. He was smiling and appeared to be in a good mood. He was not able to answer questions appropriately. In an interview on 10/24/22 at 9:43 AM, the Administrator and DON said the videos showed, based on their investigation, verbal abuse, and included intimidation and seclusion. They said they were going to terminate LVN C and CNA D for abuse. They said CNA E would be terminated for not reporting the allegation of abuse to the Administrator. The Administrator and DON said Former Housekeeper F never reported any abuse, neglect, or mistreatment of Resident #3 to them. The Administrator and DON said in-service training was provided orally and written for all staff on all three shifts, after the abuse allegation regarding Resident #3 on 09/15/22. On 10/24/22 at 12:43 PM the Administrator and DON were informed of an Immediate Jeopardy. On 10/25/22 at 3:58 PM Safe Surveys (interviews with residents regarding abuse and/or mistreatment) were received from the Administrator. On 10/25/22 at 4:18 PM the Immediate Jeopardy Plan of Removal was accepted. In an interview on 10/26/22 at 10:04 AM, the Social Worker said Medical Records had completed Safe Surveys with residents on 10/20/22. Record Review of the Safe Surveys, provided by the Administrator, on 10/25/22 at 3:58 PM, did not include any completed by Medical Records. Record Review of the Resident Council Minutes dated 10/17/22 indicated resident said they needed more customer service and respect from the staff. No staff was named and the number of residents who voiced this was not identified. In an interview on 10/26/22 at 10:27 AM, the AD said the Resident Council did bring up, in the meeting on 10/17/22, that they would like staff to be more respectful, but no abuse was alleged. In an interview on 10/26/22 at 11:05 AM, Medical Records said she conducted safe surveys on 10/20/22. She said during the surveys on 10/20/22, Resident #13 said CNA E yelled at her and was pointing her finger at her so close to her she thought the aide was going to hit her, but she did not. She said Resident 13's roommate, Resident #14 said she put on the light again for a different reason, to ask a question, and CNA E yelled at them again and stated, why are you on the light again? What's your problem? I was just in here!. She said Resident #14 was the Resident Council President and told her that they just tried not to bother CNA E after that. She said Resident #14 told Resident #13 they needed to speak up to get it to stop. She said Residents #13 and #14 told her they were verbally abused by CNA E. She said the interviews were between 9:00 AM -11:00 AM on Thursday, 10/20/22. She said she told the Administrator and DON immediately on 10/20/22. She said the residents told her the verbal abuse occurred on Monday, 10/17/22 on the 2:00 PM - 10:00 PM shift. She said, after she reported the allegation of abuse to the Administrator and DON, she interviewed Resident #12 on 10/20/22 between 11:00 AM -12:00 PM and the resident told her CNA E had verbally abused her too by yelling at her. She said once again she immediately informed the Administrator and DON of the verbal abuse allegation on 10/20/22. On 10/26/22 at 12:10 PM the investigator sent the Administrator an email requesting any additional safe surveys and if the facility had any new allegations of abuse. Record Review of Resident #13's admission Record dated 10/29/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included, chronic obstructive pulmonary disease and bipolar disorder (a mental illness). Record Review of Resident #13's quarterly MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated no cognitive impairment). In an observation and interview on 10/26/22 at 1:22 PM, Resident #13 was in her room in her wheelchair. She said on 10/17/22, her roommate, Resident #14, had the call light and CNA E came in the room and was screaming, upset, that the call light was on. She said CNA E came over to her while she was in her bed and was screaming and pointing her finger so close to her; she was afraid she was going to hit her. She said CNA E was mad that her roommate had turned on the call light. She said she was shocked, she felt threatened and scared by CNA E's outburst. She said she later, the same evening, wanted to just ask a question, she put the call light on, and CNA E came in yelling again and asked why they were on the light again after she had just been in there. She said CNA E verbally abused her on 10/17/22. She said the only person she told, about the abuse, was the Medical Records person on 10/20/22. Record Review of Resident #12's admission Record dated 10/29/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses of mild cognitive impairment, mild intellectual disabilities, depression and, the need for assistance with personal care. Record Review of Resident #12's quarterly MDS dated [DATE] indicated the resident was moderately cognitively impaired with a BIMS score of 10 (a score of 8-12 indicated moderate cognitive impairment). In an observation and interview on 10/26/22 at 1:46 PM, Resident #12 was in her wheelchair. She said about two or three weeks ago, CNA E came in her room and was going to assist with her incontinent care. She said CNA E started yelling at her, saying the resident could help more with the care. She said she was unable to physically help more, and she started crying. She said she was verbally abused by CNA E and was a little scared of her. She said it was on a weekend, and she told a lady working the 500 Hall, she did not know the lady's name, and the DON was called. She said she told the DON what happened with CNA E. She said the DON told her they would do some additional training with staff. She said she felt like she received the silent treatment from CNA E after she reported her. She said she reported the incident again on 10/20/22 to the Medical Records person. At 10/26/22 at 2:41 PM, there was no response from the Administrator regarding the email sent at 12:10 PM. In an interview on 10/26/22 at 2:58 PM, the Administrator said Medical Records conducted some Safe Surveys on 10/20/22. He said she did not notify him of the verbal abuse allegations reported by Residents #12, #13, and #14. He said staff conducting the Safe Surveys were told to immediately report any allegations of abuse and/or mistreatment to him immediately. He said he would look for the Safe Surveys conducted by Medical Records on 10/20/22. In an interview on 10/26/22 at 3:12 PM, the DON said she was not aware of the new allegations regarding CNA E. She said she was not contacted on a weekend regarding an incident between Resident #12 and CNA E. She said she would immediately tell the Administrator of any allegations regarding abuse. She said CNA E was terminated on Monday, 10/24/22 for not reporting Resident #3's responsible party's allegation of abuse to the Administrator. Record Review of Resident #14's admission Record dated 10/29/22 indicated the [AGE] year-old female resident was re-admitted to the facility on [DATE] with diagnoses which included mild cognitive impairment and anxiety. Record Review of Resident #14's quarterly MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated no cognitive impairment). In an observation and interview on 10/26/22 at 4:04 PM, Resident #14 was in bed in her room. She said she had been the Resident Council President about a month. She said, in the Resident Council Meeting in October 2022 it was discussed how the staff were speaking to the residents, at times. She said the residents perceived some of the staff to be snotty and argumentative, at times, like when a resident needed something the staff acted like they were doing the resident a favor instead of the fact that the staff worked for the residents. She said this was discussed in the council because staffs' attitudes towards the residents were getting worse not better. She said Medical Records came in and asked her, last week on 10/20/22 about her treatment in the facility. She said she told her about an incident on Monday 10/17/22 around 5:00 PM, she requested to be transferred from her wheelchair to bed and provided incontinent care. She said CNA E told her go to room and get in position. She said she followed instructions and waited over an hour and then put the call light on. She said CNA E came into the room yelling and screaming that the resident should not have put the call light on and that she had to just wait her turn for assistance. She said she told CNA E she was going to report her, and CNA E told her to go ahead because she did not have to answer to the resident. She said CNA E was screaming over her and pointing her finger. She said CNA E then went to her roommate's (Resident #13) side of the bed, the roommate was in bed, CNA E was standing over Resident #13, still yelling, and pointing her finger but was directed at her (Resident #14) and not the roommate (Resident #13). She said Resident #13 became afraid CNA E was going to hit her and Resident #13 started crying. She said she told Resident #13 not to cry because CNA E was mad at her (Resident #14). She said CNA E left the room, and Resident #13, who does not cuss, said Holy Shit!. She said about an hour later, the same evening, Resident #13 just wanted to ask a question, so she put the call light on, and CNA E came in the room screaming again. She said CNA E asked them What is your problem why is the call light on again?. She said Resident #13 apologized and said she just wanted to ask the AD something. She said she had been a resident at the facility for 5 years and CNA E had always had a temper. She said CNA E had an attitude like she was invincible because nothing ever happened to her, and she felt like she would not get fired. She said CNA E had always had a bad temper, but it had never been like this before. She said she did not tell anyone about the incident until the Medical Records person asked her about abuse on 10/20/22. She said she was verbally abused and intimidated by CNA E on 10/17/22. In an interview on 10/26/22 at 4:47 PM, the DON and the Clinical Resource RN said Medical Records had the Safe Surveys dated 10/20/22, on her person, for Residents #12, #13, and #14. She said Medical Records reported them verbally to the Administrator on 10/20/22 but did not give him the forms. They said the Administrator and Medical Records were suspended pending the outcome of the investigation. Record Review of Safe Surveys dated 10/20/22, not timed, indicated the question, Do you feel that you have been intentionally injured by a team member? -Resident #12 - verbal abuse -Resident #13 - verbal abuse with violently yelling and afraid CNA E would hit her on Monday (10/17/22) -Resident #14 - verbally abused with attitude - CNA E Record Review revealed Medical Records completed the three above Safe Surveys again on 10/20/22, not timed, and all three residents' answers to Do you feel you have been intentionally injured by a team member? were changed to, No. In an interview on 10/27/22 at 10:02 AM, the Clinical Resource RN and DON said the facility began in-services with all staff on the types of abuse, with a written quiz. The DON was made the Abuse Prevention Coordinator. The facility began interview with staff to see if any abuse allegations had been reported to the Administrator that were not acted upon. The facility began a root cause analysis. She said the Safe Surveys conducted on 10/20/22 with Residents #12, #13, and #14 revealed verbal abuse by CNA E. The DON said CNA E worked on 10/21/22, after the allegations of verbal abuse were reported to the Administrator on 10/20/22. She said CNA E did not work after 10/21/22. She said CNA E was terminated on 10/24/22 for not reporting the allegation of abuse made by Resident #3's responsible party, but not related to the allegations of verbal abuse. Record Review of CNA E's time sheet dated 10/27/22 indicated she worked on 10/21/22 from 2:24 PM - 9:48 PM, 7.4 hours. Attempts were made to interview CNA E on 10/28/22 at 5:23 PM, 7:24 PM, and 10/29/22 at 12:19 PM, there was no answer to the phone call and messages, a text was also sent on 10/29/22 at 12:20 PM requesting an interview, no return call was received prior to the exit on 10/29/22 at 1:00 PM. In a telephone interview on 10/27/22 at 5:26 PM, Medical Records said she told the Administrator immediately about each of the allegations of verbal abuse on 10/20/22. She said she told him after each allegation was made. She said the DON was also present, during the discussion with the Administrator. She said the administrator told her to shred Resident #12, #13, #14's Safe Surveys that revealed verbal abuse. She said he told her State was not looking at verbal abuse as being intentionally injured. She said the Administrator, then gave her new forms to complete with the same residents again. She said on 10/26/22, after the investigator asked about the Safe Surveys, she got the three original Safe Surveys for Resident #12, #13, and #14 out of the shred bin to give to the Administrator. She said the Administrator understood on 10/20/22 Residents #12, #13, and #14 had alleged they were verbally abused by CNA E. In an interview on 10/27/22 at 5:41 PM, the DON said she was not involved in the conversation regarding the abuse, as stated above, on 10/20/22. She said she was not aware of abuse being reported on the three residents (Residents #12, #13, and #14) in question. In a telephone interview on 10/27/22 at 5:45 PM, the Administrator said DON was not in the room when Medical Records discussed the verbal abuse allegations. He said Medical Records did notify him on 10/20/22 of the verbal abuse allegations. He said with everything going on the verbal abuse allegations did not cross his mind again. He said yesterday (10/26/22) Medical Records did get the Safe Surveys out of the shred bin, but he did not tell her to shred them. He told her to set them aside in his office. He said he did ask her to conduct new Safe Surveys on Resident #12, #13, and #14 because he did not believe verbal abuse was applicable to the question, Do you feel that you have been intentionally injured by a team member?. He said he was aware of the facility abuse policy and reporting requirements. In an interview on 10/27/22 at 6:35 PM, Resident #14 said she was having increased anxiety related to the verbal abuse from CNA E and just a combination of things. She said she might need an increase in her anti-anxiety medication. Record Review of the facility's Abuse: Prevention of and Prohibition Against dated October 2022 indicated verbal abuse included the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representative, or within their hearing distance, regardless of their [NAME], ability to comprehend, or disability. Prevention included - all staff, residents and visitors are encouraged to report incidents and grievances without the fear of retribution. Supervising staff to identify and correct any inappropriate or unprofessional behaviors. Identifying, correcting, and intervening in situations in which abuse is more likely to occur. Investigation included - all identified events are reported to the Administrator immediately. After receiving the allegation, during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm. Protection included - immediately removing the employee from the care of any resident when an allegation of abuse is reported. Reporting included - all allegations of abuse she be reported immediately to the Administrator. Allegations of abuse will be reported to the appropriate State Agency in the applicable timeframes, as per the policy and applicable regulations. The Administrator and DON were notified of the Immediate Jeopardy on 10/24/22 at 12:43 PM, a Plan of Removal was requested and the Immediate Jeopardy template was provided. The Plan of Removal was accepted on 10/25/22 at 4:18 PM. [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse of residents for 4 (Resident #3, #12, #13, and #14) of 14 residents reviewed for abuse. The facility failed to implement a policy and process for immediately investigating, protecting the residents, and reporting allegations of abuse when: 1. Resident #3's responsible party made allegations of abuse to CNA E on 10/19/22 and she did not report it to the Administrator and the facility did not investigate or implement measures to protect the resident from further abuse; and 2. Resident #12, #13, and #14 reported on 10/20/22 that CNA E verbally abused them, and the facility did not investigate or implement measures to protect the residents from further abuse. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 10/24/22. While the IJ was removed on 10/29/22, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. Findings included: Record Review of the facility's Abuse: Prevention of and Prohibition Against dated October 2022 indicated verbal abuse included the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representative, or within their hearing distance, regardless of their [NAME], ability to comprehend, or disability. Prevention included - all staff, residents and visitors are encouraged to report incidents and grievances without the fear of retribution. Supervising staff to identify and correct any inappropriate or unprofessional behaviors. Identifying, correcting, and intervening in situations in which abuse is more likely to occur. Investigation included - all identified events are reported to the Administrator immediately. After receiving the allegation, during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm. Protection included - immediately removing the employee from the care of any resident when an allegation of abuse is reported. Reporting included - all allegations of abuse she be reported immediately to the Administrator. Allegations of abuse will be reported to the appropriate State Agency in the applicable timeframes, as per the policy and applicable regulations. In an interview, with the DON and Administrator on 10/20/22 at 9:15 AM, the DON said staff found a camera hidden in a Halloween decoration in Resident #3's room. The DON said she received the call from staff on 10/19/22 round 2:00 AM staff regarding the camera. She said the staff texted her a picture of the Halloween decoration and the camera in it. The DON had staff unplug the camera because it was plugged into an un-approved extension cord. The DON said she was not surprised to find the hidden camera in the room, because the resident's family disagreed with an abuse investigation, conducted on 09/15/22, that did not reveal any abuse. The Administrator said Resident #3's family did not contact the facility regarding the camera, and they had not reported any concerns. The Administrator said he was going to have the Social Worker contact Resident #3's family regarding the camera to get to sign an Electronic Monitoring Form, but he did not know if the Social Worker had contacted them yet. The Administrator and DON said they had not heard anything from the family regarding the camera and no abuse or care issues had been reported to them. On 10/20/22 at 10:43 AM, a video was received from Resident #3's responsible party. The video was recorded on 10/19/22 at 1:58 AM, it showed a female staff person (LVN C) taking Resident #3 to his room in his wheelchair. She pulled him backwards into the room in his wheelchair. LVN C, once in the resident's room, she faced the resident and said, there you go, she pointed her right finger at the resident and said, you stop it, then she pulled her right hand in a fist, the fist does not touch the resident, but her left hand came down on something that cannot be seen in frame and a pop was heard, at the same time LVN C was heard again saying, you stop it, the resident told LVN C, fuck you, LVN C turned towards the door and it appeared the resident attempted to continue the altercation, but the images are obscured by the Halloween decoration. LVN C asked the resident, are you fighting me?', then she said angrily, at the door, you stay there and then shuts the door. On 10/20/22 at 11:08 AM, a video was received from Resident #3's responsible party, it was recorded on 10/16/22 at 12:09 AM, it showed a male staff person (CNA D) enter the resident's room the resident was in bed. CNA D picked up the bed sheet but the resident tugs on the sheet, and CNA D lets go of the sheet. The resident says, get off me, you mother fucker, and throws the sheet at CNA D. CNA D walked to the foot of the resident's bed and told he resident, I'm going to kick your ass. The resident responds but his response could not be understood on the video. In a telephone interview on 10/20/22 at 11:25 AM, Resident #3's responsible party said she had a previous complaint regarding staff treatment of the resident, which she believed to be abuse, that was investigated and found to be unsubstantiated on 09/15/22. She said she disagreed with the findings of the facility's investigation and felt the facility was covering up abuse and/or mistreatment of Resident #3. She said a former employee, Housekeeper F, informed her she believed Resident #3 was being mistreated and told her she should place a camera in his room, because reports to the Administrator and DON of mistreatment were not being acted on. She said Housekeeper F was terminated for telling her about the mistreatment of Resident #3 for not reporting the abuse allegations to the Administrator. She said based on her experience with the facility; she decided to place a hidden camera in the resident's room. She said the resident did not have a roommate and it was not violating any other resident's privacy. She said when she saw the abuse recorded on the camera, she came to the facility to check on Resident #3 but did not alert the facility to the hidden camera. She said the videos showed Resident #3 was being abused by the staff. She said on 10/19/22 around 2:00 AM she could see on the camera that staff discovered the camera was in the room. She said she could see several staff members looking at the camera before it was unplugged. She said, staff from the facility just called her a few minutes ago, she did not know who, to tell her the camera was not approved and that she would need to sign a consent for its use. She said she asked the person that called if they were concerned about what the camera revealed and the person did not answer the question, and just told her she needed to sign the form in order for the camera to be approved. She said she informed the staff she had already removed the camera from the room and took it home. She said no one reached out to her about the camera prior to the phone call today, after the investigator entered the facility. She said there was one additional video that she had not sent yet, but she would send it. She said she wanted to move the resident to another facility but had to wait for his Medicaid to be approved before her facility of choice would accept him. She said she feels stuck because she cannot move him but cannot trust that he won't be harmed at the facility. On 10/20/22 at 12:04 PM, the Administrator and DON were shown the above videos for staff identification purposes. They said both videos showed abuse of Resident #3. They identified LVN C as the staff in the first video and CNA D in the second video. The DON said there had been no reports or concerns regarding the employees' care and treatment of the residents. She said the employees would be notified and suspended pending the outcome of the investigation. On 10/20/22 at 12:38 PM, the third and final video was received from Resident #3's responsible party, it was recorded on 10/13/22 at 7:36 PM, it showed two staff (LVN C and CNA E) providing care to the resident while he was in bed. LVN C was at the head of the resident's bed encouraging him to allow care but he was saying don't do that, CNA E was observed getting some wipes, she joined LVN C at the resident's bedside. The resident could be heard saying, God dammit, at that point, LVN C's left hand went up with her hand open, while she leaned forward and told the resident to stop it, she does not hit the resident, but it appeared to be a gesture like she was going to slap the resident. On 10/20/22 at 12:45 PM, the Administrator and DON said the third video was LVN C who appeared to raise her hand to Resident #3. They said the other staff was CNA E. Record Review of Resident #3's admission Record dated 10/20/22 indicated the [AGE] year-old male resident was re-admitted to the facility on [DATE] with diagnoses which included dementia and major depressive disorder. Record Review of Resident #3's quarterly MDS dated [DATE] indicated the resident had short and long-term memory problems. He was severely cognitively impaired. He had no behaviors. Record Review of Resident #3's un-dated Care Plan indicated he had behaviors which included, combativeness, physical and verbal aggression with staff. The interventions included to provide physical and verbal cues to alleviate the resident's anxiety and give positive feedback. If the resident resists care, reassure the resident, leave, and return 5-10 minutes later and try again. In an observation on 10/20/22 at 1:34 PM, Resident #3 was propelling himself in his wheelchair. He was not able to answer any direct questions. In an interview on 10/20/22 at 2:44 PM, CNA E watched third video. She said she did not think LVN C was raising her hand to the resident, but she was not paying attention, at the time. She said she thought maybe LVN C was reaching to roll the resident over. She said she had never seen any staff being abusive or mistreating the resident. She said around 10:00 PM yesterday, 10/19/22, the resident's responsible party asked her if she was aware there had been a camera in the room. She said she told her she was not aware. She said the resident's responsible party told her she put the camera in the room because the resident was being abused by the staff. She said she told the resident's responsible party she did not believe that would happen at the facility. She said she did not tell anyone the resident's responsible party reported the resident had been abused. She said LVN C overheard her talking with the resident's responsible party and knew about the allegation. She said she was supposed to inform the Administrator of any abuse allegations; however, she did not report it. In an interview on 10/20/22 at 4:21 PM, with the DON present, LVN C said on 10/19/22 Resident #3 was awake around 2:00 AM and staff got him up in his wheelchair and assisted him to the nurses' station for monitoring. She said the resident became combative, threw things off the nurses' station, and tried to hit, kick and bite staff. She said the video showed her pulling him in his room backwards because he was being combative. She said her right hand was in a fist and pulled back because she thought he was going to grab or bite her. She said she did not make physical contact with the resident. She said the slap sound on the video was when she slapped her own leg. She said she did not feel she was being abusive to the resident. She said she was speaking loudly but it was because the resident was hard of hearing. She said she did tell the resident to stay in his room and closed the door, but it was only for approximately 5 minutes until she could get a CNA to assist her to put the resident back to bed. She denied ever threatening or hitting the resident. She said staff discovered the camera after 2:00 AM and let the DON know. She said she did hear CNA E speaking to Resident #3's responsible party but she did not hear the allegation of abuse. She later said that maybe CNA E told her something about the allegation, but she did not remember, and she was busy at the time. She said she would report abuse to the DON, she was not aware the Administrator was the Abuse Coordinator. She said she should not have raised her voice to the resident. She said Resident #3 tried to kick her as she was leaving the room and that was why she asked him if he was trying to fight her. She said she never raised her hand to hit the resident. The DON informed her she was suspended pending the outcome of the investigation and was not to return to the facility until further notice. In a telephone interview on 10/20/22 at 3:35 PM, with the DON present, CNA D said if the resident was too combative, he was supposed to get another CNA to assist him, but he did not feel the resident was being that aggressive on 10/16/22. He said the resident tugged on the sheet and he let go, he said he did not know, at the time, the camera was in the room. He said he did tell the resident he was going to kick his ass because he was under pressure, but he would not have physically hurt the resident because it was not in his heart to do so. He said what he said was abuse. He said he was frustrated and tired of the resident being so mean. He said he had not seen or heard any other staff be mean or aggressive with the resident. He said he apologized dearly for his actions and would never hurt the residents. The DON informed him he could not report to work and was under investigation. In an interview on 10/20/22 at 5:00 PM, the Administrator said staff knew he was the Abuse Coordinator because they had all been in-serviced and it was posted in the facility. He said it was his expectation that staff would notify him immediately of any allegations of abuse or mistreatment. He said the facility would investigate, and notify the police and State Agency. In a telephone interview on 10/20/22 at 5:42 PM, Resident #3's responsible party said on 10/19/22 she spoke to CNA E regarding her abuse concerns and why she installed the camera. She said she asked if she could show CNA E the videos of the abuse, but the CNA told her her eyesight was not good and she did not think she could see the videos. She said she believed CNA E did not wish to see the videos because she would have to report the abuse to the Administrator. She said it further showed how staff wanted to turn a blind eye to reports of abuse. In a telephone interview on 10/20/22 at 6:07 PM, Former Housekeeper F said she was the housekeeper on Resident #3's hall and she felt staff were not caring for the resident appropriately. She said she believed the staff were not assisting him with meals, were abrupt and discourteous to him. She said she spoke with the Administrator and DON about her concerns, but she believed they were not addressed. She said she spoke to the resident's responsible party regarding her concerns and told her she should put a camera in the resident's room because she believed he was being mistreated by staff. She said when the facility found out she told the resident's responsible party she suspected abuse, the DON called her on 09/10/22, to question her if she knew who the Abuse Coordinator was, and she told her it was the Administrator. She said the Administrator wanted to meet with her in the next day 09/11/22, in his office, but she did not meet with him for fear she would be terminated. She said her last day of employment was 09/11/22. She said the facility's inaction regarding allegations made employees not want to report anything. She said other facility employees knew about things but don't report it. She would not give the investigator the names of the other employees. She said there were employees, still working at the facility, who abused residents. She named CNA E, as an abuser. In an observation on 10/24/22 at 9:30 AM, Resident #3 was propelling himself in his wheelchair. He was smiling and appeared to be in a good mood. He was not able to answer questions appropriately. In an interview on 10/24/22 at 9:43 AM, the Administrator and DON said the videos showed, based on their investigation, verbal abuse, and included intimidation and seclusion. They said they were going to terminate LVN C and CNA D for abuse. They said CNA E would be terminated for not reporting the allegation of abuse to the Administrator. The Administrator and DON said Former Housekeeper F never reported any abuse, neglect, or mistreatment of Resident #3 to them. The Administrator and DON said in-service training was provided orally and written for all staff on all three shifts, after the abuse allegation regarding Resident #3 on 09/15/22. On 10/24/22 at 12:43 PM the Administrator and DON were informed of an Immediate Jeopardy. On 10/25/22 at 3:58 PM Safe Surveys (interviews with residents regarding abuse and/or mistreatment) were received from the Administrator. On 10/25/22 at 4:18 PM the Immediate Jeopardy Plan of Removal was accepted. In an interview on 10/26/22 at 10:04 AM, the Social Worker said Medical Records had completed Safe Surveys with residents on 10/20/22. Record Review of the Safe Surveys, provided by the Administrator, on 10/25/22 at 3:58 PM, did not include any completed by Medical Records. Record Review of the Resident Council Minutes dated 10/17/22 indicated resident said they needed more customer service and respect from the staff. No staff was named and the number of residents who voiced this was not identified. In an interview on 10/26/22 at 10:27 AM, the AD said the Resident Council did bring up, in the meeting on 10/17/22, that they would like staff to be more respectful, but no abuse was alleged. In an interview on 10/26/22 at 11:05 AM, Medical Records said she conducted safe surveys on 10/20/22. She said during the surveys on 10/20/22, Resident #13 said CNA E yelled at her and was pointing her finger at her so close to her she thought the aide was going to hit her, but she did not. She said Resident 13's roommate, Resident #14 said she put on the light again for a different reason, to ask a question, and CNA E yelled at them again and stated, why are you on the light again? What's your problem? I was just in here!. She said Resident #14 was the Resident Council President and told her that they just tried not to bother CNA E after that. She said Resident #14 told Resident #13 they needed to speak up to get it to stop. She said Residents #13 and #14 told her they were verbally abused by CNA E. She said the interviews were between 9:00 AM -11:00 AM on Thursday, 10/20/22. She said she told the Administrator and DON immediately on 10/20/22. She said the residents told her the verbal abuse occurred on Monday, 10/17/22 on the 2:00 PM - 10:00 PM shift. She said, after she reported the allegation of abuse to the Administrator and DON, she interviewed Resident #12 on 10/20/22 between 11:00 AM -12:00 PM and the resident told her CNA E had verbally abused her too by yelling at her. She said once again she immediately informed the Administrator and DON of the verbal abuse allegation on 10/20/22. On 10/26/22 at 12:10 PM the investigator sent the Administrator an email requesting any additional safe surveys and if the facility had any new allegations of abuse. Record Review of Resident #13's admission Record dated 10/29/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included, chronic obstructive pulmonary disease and bipolar disorder (a mental illness). Record Review of Resident #13's quarterly MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated no cognitive impairment). In an observation and interview on 10/26/22 at 1:22 PM, Resident #13 was in her room in her wheelchair. She said on 10/17/22, her roommate, Resident #14, had the call light and CNA E came in the room and was screaming, upset, that the call light was on. She said CNA E came over to her while she was in her bed and was screaming and pointing her finger so close to her; she was afraid she was going to hit her. She said CNA E was mad that her roommate had turned on the call light. She said she was shocked, she felt threatened and scared by CNA E's outburst. She said she later, the same evening, wanted to just ask a question, she put the call light on, and CNA E came in yelling again and asked why they were on the light again after she had just been in there. She said CNA E verbally abused her on 10/17/22. She said the only person she told, about the abuse, was the Medical Records person on 10/20/22. Record Review of Resident #12's admission Record dated 10/29/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses of mild cognitive impairment, mild intellectual disabilities, depression and, the need for assistance with personal care. Record Review of Resident #12's quarterly MDS dated [DATE] indicated the resident was moderately cognitively impaired with a BIMS score of 10 (a score of 8-12 indicated moderate cognitive impairment). In an observation and interview on 10/26/22 at 1:46 PM, Resident #12 was in her wheelchair. She said about two or three weeks ago, CNA E came in her room and was going to assist with her incontinent care. She said CNA E started yelling at her, saying the resident could help more with the care. She said she was unable to physically help more, and she started crying. She said she was verbally abused by CNA E and was a little scared of her. She said it was on a weekend, and she told a lady working the 500 Hall, she did not know the lady's name, and the DON was called. She said she told the DON what happened with CNA E. She said the DON told her they would do some additional training with staff. She said she felt like she received the silent treatment from CNA E after she reported her. She said she reported the incident again on 10/20/22 to the Medical Records person. At 10/26/22 at 2:41 PM, there was no response from the Administrator regarding the email sent at 12:10 PM. In an interview on 10/26/22 at 2:58 PM, the Administrator said Medical Records conducted some Safe Surveys on 10/20/22. He said she did not notify him of the verbal abuse allegations reported by Residents #12, #13, and #14. He said staff conducting the Safe Surveys were told to immediately report any allegations of abuse and/or mistreatment to him immediately. He said he would look for the Safe Surveys conducted by Medical Records on 10/20/22. In an interview on 10/26/22 at 3:12 PM, the DON said she was not aware of the new allegations regarding CNA E. She said she was not contacted on a weekend regarding an incident between Resident #12 and CNA E. She said she would immediately tell the Administrator of any allegations regarding abuse. She said CNA E was terminated on Monday, 10/24/22 for not reporting Resident #3's responsible party's allegation of abuse to the Administrator. Record Review of Resident #14's admission Record dated 10/29/22 indicated the [AGE] year-old female resident was re-admitted to the facility on [DATE] with diagnoses which included mild cognitive impairment and anxiety. Record Review of Resident #14's quarterly MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated no cognitive impairment). In an observation and interview on 10/26/22 at 4:04 PM, Resident #14 was in bed in her room. She said she had been the Resident Council President about a month. She said, in the Resident Council Meeting in October 2022 it was discussed how the staff were speaking to the residents, at times. She said the residents perceived some of the staff to be snotty and argumentative, at times, like when a resident needed something the staff acted like they were doing the resident a favor instead of the fact that the staff worked for the residents. She said this was discussed in the council because staffs' attitudes towards the residents were getting worse not better. She said Medical Records came in and asked her, last week on 10/20/22 about her treatment in the facility. She said she told her about an incident on Monday 10/17/22 around 5:00 PM, she requested to be transferred from her wheelchair to bed and provided incontinent care. She said CNA E told her go to room and get in position. She said she followed instructions and waited over an hour and then put the call light on. She said CNA E came into the room yelling and screaming that the resident should not have put the call light on and that she had to just wait her turn for assistance. She said she told CNA E she was going to report her, and CNA E told her to go ahead because she did not have to answer to the resident. She said CNA E was screaming over her and pointing her finger. She said CNA E then went to her roommate's (Resident #13) side of the bed, the roommate was in bed, CNA E was standing over Resident #13, still yelling, and pointing her finger but was directed at her (Resident #14) and not the roommate (Resident #13). She said Resident #13 became afraid CNA E was going to hit her and Resident #13 started crying. She said she told Resident #13 not to cry because CNA E was mad at her (Resident #14). She said CNA E left the room, and Resident #13, who does not cuss, said Holy Shit!. She said about an hour later, the same evening, Resident #13 just wanted to ask a question, so she put the call light on, and CNA E came in the room screaming again. She said CNA E asked them What is your problem why is the call light on again?. She said Resident #13 apologized and said she just wanted to ask the AD something. She said she had been a resident at the facility for 5 years and CNA E had always had a temper. She said CNA E had an attitude like she was invincible because nothing ever happened to her, and she felt like she would not get fired. She said CNA E had always had a bad temper, but it had never been like this before. She said she did not tell anyone about the incident until the Medical Records person asked her about abuse on 10/20/22. She said she was verbally abused and intimidated by CNA E on 10/17/22. In an interview on 10/26/22 at 4:47 PM, the DON and the Clinical Resource RN said Medical Records had the Safe Surveys dated 10/20/22, on her person, for Residents #12, #13, and #14. She said Medical Records reported them verbally to the Administrator on 10/20/22 but did not give him the forms. They said the Administrator and Medical Records were suspended pending the outcome of the investigation. Record Review of Safe Surveys dated 10/20/22, not timed, indicated the question, Do you feel that you have been intentionally injured by a team member? -Resident #12 - verbal abuse -Resident #13 - verbal abuse with violently yelling and afraid CNA E would hit her on Monday (10/17/22) -Resident #14 - verbally abused with attitude - CNA E Record Review revealed Medical Records completed the three above Safe Surveys again on 10/20/22, not timed, and all three residents' answers to Do you feel you have been intentionally injured by a team member? were changed to, No. In an interview on 10/27/22 at 10:02 AM, the Clinical Resource RN and DON said the facility began in-services with all staff on the types of abuse, with a written quiz. The DON was made the Abuse Prevention Coordinator. The facility began interview with staff to see if any abuse allegations had been reported to the Administrator that were not acted upon. The facility began a root cause analysis. She said the Safe Surveys conducted on 10/20/22 with Residents #12, #13, and #14 revealed verbal abuse by CNA E. The DON said CNA E worked on 10/21/22, after the allegations of verbal abuse were reported to the Administrator on 10/20/22. She said CNA E did not work after 10/21/22. She said CNA E was terminated on 10/24/22 for not reporting the allegation of abuse made by Resident #3's responsible party, but not related to the allegations of verbal abuse. Record Review of CNA E's time sheet dated 10/27/22 indicated she worked on 10/21/22 from 2:24 PM - 9:48 PM, 7.4 hours. Attempts were made to interview CNA E on 10/28/22 at 5:23 PM, 7:24 PM, and 10/29/22 at 12:19 PM, there was no answer to the phone call and messages, a text was also sent on 10/29/22 at 12:20 PM requesting an interview, no return call was received prior to the exit on 10/29/22 at 1:00 PM. In a telephone interview on 10/27/22 at 5:26 PM, Medical Records said she told the Administrator immediately about each of the allegations of verbal abuse on 10/20/22. She said she told him after each allegation was made. She said the DON was also present, during the discussion with the Administrator. She said the administrator told her to shred Resident #12, #13, #14's Safe Surveys that revealed verbal abuse. She said he told her State was not looking at verbal abuse as being intentionally injured. She said the Administrator, then gave her new forms to complete with the same residents again. She said on 10/26/22, after the investigator asked about the Safe Surveys, she got the three original Safe Surveys for Resident #12, #13, and #14 out of the shred bin to give to the Administrator. She said the Administrator understood on 10/20/22 Residents #12, #13, and #14 had alleged they were verbally abused by CNA E. In an interview on 10/27/22 at 5:41 PM, the DON said she was not involved in the conversation regarding the abuse, as stated above, on 10/20/22. She said she was not aware of abuse being reported on the three residents (Residents #12, #13, and #14) in question. In a telephone interview on 10/27/22 at 5:45 PM, the Administrator said DON was not in the room when Medical Records discussed the verbal abuse allegations. He said Medical Records did notify him on 10/20/22 of the verbal abuse allegations. He said with everything going on the verbal abuse allegations did not cross his mind again. He said yesterday (10/26/22) Medical Records did get the Safe Surveys out of the shred bin, but he did not tell her to shred them. He told her to set them aside in his office. He said he did ask her to conduct new Safe Surveys on Resident #12, #13, and #14 because he did not believe verbal abuse was applicable to the question, Do you feel that you have been intentionally injured by a team member?. He said he was aware of the facility abuse policy and reporting requirements. In an interview on 10/27/22 at 6:35 PM, Resident #14 said she was having increased anxiety related to the verbal abuse from CNA E and just a combination of things. She [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse or mistreatment, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, including the State Agency, in accordance with State law through established procedures for 4 (Residents #3, #12, #13, and #14) of 14 residents reviewed for abuse. 1) CNA E failed to report Resident #3's responsible party's allegation of abuse to the Administrator on 10/19/22. 2) The Administrator failed to report Resident #12, #13, and #14's allegations of verbal abuse on 10/20/22 to the State Agency; due to not reporting the residents continued to be exposed to the staff that had verbally abused them. These failures could place all the residents, who resided in the facility, at risk for abuse and mental anguish. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 11/14/22. While the IJ was removed on 11/14/22, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. Findings included: In an interview, with the DON and Administrator on 10/20/22 at 9:15 AM, the DON said staff found a camera hidden in a Halloween decoration in Resident #3's room. The DON said she received the call from staff on 10/19/22 round 2:00 AM staff regarding the camera. She said the staff texted her a picture of the Halloween decoration and the camera in it. The DON had staff unplug the camera because it was plugged into an un-approved extension cord. The DON said she was not surprised to find the hidden camera in the room, because the resident's family disagreed with an abuse investigation, conducted on 09/15/22, that did not reveal any abuse. The Administrator said Resident #3's family did not contact the facility regarding the camera, and they had not reported any concerns. The Administrator said he was going to have the Social Worker contact Resident #3's family regarding the camera to get to sign an Electronic Monitoring Form, but he did not know if the Social Worker had contacted them yet. The Administrator and DON said they had not heard anything from the family regarding the camera and no abuse or care issues had been reported to them. On 10/20/22 at 10:43 AM, a video was received from Resident #3's responsible party. The video was recorded on 10/19/22 at 1:58 AM, it showed a female staff person (LVN C) taking Resident #3 to his room in his wheelchair. She pulled him backwards into the room in his wheelchair. LVN C, once in the resident's room, she faced the resident and said, there you go, she pointed her right finger at the resident and said, you stop it, then she pulled her right hand in a fist, the fist does not touch the resident, but her left hand came down on something that cannot be seen in frame and a pop was heard, at the same time LVN C was heard again saying, you stop it, the resident told LVN C, fuck you, LVN C turned towards the door and it appeared the resident attempted to continue the altercation, but the images are obscured by the Halloween decoration. LVN C asked the resident, are you fighting me?', then she said angrily, at the door, you stay there and then shuts the door. On 10/20/22 at 11:08 AM, a video was received from Resident #3's responsible party, it was recorded on 10/16/22 at 12:09 AM, it showed a male staff person (CNA D) enter the resident's room the resident was in bed. CNA D picked up the bed sheet but the resident tugs on the sheet, and CNA D lets go of the sheet. The resident says, get off me, you mother fucker, and throws the sheet at CNA D. CNA D walked to the foot of the resident's bed and told he resident, I'm going to kick your ass. The resident responds but his response could not be understood on the video. In a telephone interview on 10/20/22 at 11:25 AM, Resident #3's responsible party said she had a previous complaint regarding staff treatment of the resident, which she believed to be abuse, that was investigated and found to be unsubstantiated on 09/15/22. She said she disagreed with the findings of the facility's investigation and felt the facility was covering up abuse and/or mistreatment of Resident #3. She said a former employee, Housekeeper F, informed her she believed Resident #3 was being mistreated and told her she should place a camera in his room, because reports to the Administrator and DON of mistreatment were not being acted on. She said Housekeeper F was terminated for telling her about the mistreatment of Resident #3 for not reporting the abuse allegations to the Administrator. She said based on her experience with the facility; she decided to place a hidden camera in the resident's room. She said the resident did not have a roommate and it was not violating any other resident's privacy. She said when she saw the abuse recorded on the camera, she came to the facility to check on Resident #3 but did not alert the facility to the hidden camera. She said the videos showed Resident #3 was being abused by the staff. She said on 10/19/22 around 2:00 AM she could see on the camera that staff discovered the camera was in the room. She said she could see several staff members looking at the camera before it was unplugged. She said, staff from the facility just called her a few minutes ago, she did not know who, to tell her the camera was not approved and that she would need to sign a consent for its use. She said she asked the person that called if they were concerned about what the camera revealed and the person did not answer the question, and just told her she needed to sign the form in order for the camera to be approved. She said she informed the staff she had already removed the camera from the room and took it home. She said no one reached out to her about the camera prior to the phone call today, after the investigator entered the facility. She said there was one additional video that she had not sent yet, but she would send it. She said she wanted to move the resident to another facility but had to wait for his Medicaid to be approved before her facility of choice would accept him. She said she feels stuck because she cannot move him but cannot trust that he won't be harmed at the facility. On 10/20/22 at 12:04 PM, the Administrator and DON were shown the above videos for staff identification purposes. They said both videos showed abuse of Resident #3. They identified LVN C as the staff in the first video and CNA D in the second video. The DON said there had been no reports or concerns regarding the employees' care and treatment of the residents. She said the employees would be notified and suspended pending the outcome of the investigation. On 10/20/22 at 12:38 PM, the third and final video was received from Resident #3's responsible party, it was recorded on 10/13/22 at 7:36 PM, it showed two staff (LVN C and CNA E) providing care to the resident while he was in bed. LVN C was at the head of the resident's bed encouraging him to allow care but he was saying don't do that, CNA E was observed getting some wipes, she joined LVN C at the resident's bedside. The resident could be heard saying, God dammit, at that point, LVN C's left hand went up with her hand open, while she leaned forward and told the resident to stop it, she does not hit the resident, but it appeared to be a gesture like she was going to slap the resident. On 10/20/22 at 12:45 PM, the Administrator and DON said the third video was LVN C who appeared to raise her hand to Resident #3. They said the other staff was CNA E. Record Review of Resident #3's admission Record dated 10/20/22 indicated the [AGE] year-old male resident was re-admitted to the facility on [DATE] with diagnoses which included dementia and major depressive disorder. Record Review of Resident #3's quarterly MDS dated [DATE] indicated the resident had short and long-term memory problems. He was severely cognitively impaired. He had no behaviors. Record Review of Resident #3's un-dated Care Plan indicated he had behaviors which included, combativeness, physical and verbal aggression with staff. The interventions included to provide physical and verbal cues to alleviate the resident's anxiety and give positive feedback. If the resident resists care, reassure the resident, leave, and return 5-10 minutes later and try again. In an observation on 10/20/22 at 1:34 PM, Resident #3 was propelling himself in his wheelchair. He was not able to answer any direct questions. In an interview on 10/20/22 at 2:44 PM, CNA E watched third video. She said she did not think LVN C was raising her hand to the resident, but she was not paying attention, at the time. She said she thought maybe LVN C was reaching to roll the resident over. She said she had never seen any staff being abusive or mistreating the resident. She said around 10:00 PM yesterday, 10/19/22, the resident's responsible party asked her if she was aware there had been a camera in the room. She said she told her she was not aware. She said the resident's responsible party told her she put the camera in the room because the resident was being abused by the staff. She said she told the resident's responsible party she did not believe that would happen at the facility. She said she did not tell anyone the resident's responsible party reported the resident had been abused. She said LVN C overheard her talking with the resident's responsible party and knew about the allegation. She said she was supposed to inform the Administrator of any abuse allegations; however, she did not report it. In an interview on 10/20/22 at 4:21 PM, with the DON present, LVN C said on 10/19/22 Resident #3 was awake around 2:00 AM and staff got him up in his wheelchair and assisted him to the nurses' station for monitoring. She said the resident became combative, threw things off the nurses' station, and tried to hit, kick and bite staff. She said the video showed her pulling him in his room backwards because he was being combative. She said her right hand was in a fist and pulled back because she thought he was going to grab or bite her. She said she did not make physical contact with the resident. She said the slap sound on the video was when she slapped her own leg. She said she did not feel she was being abusive to the resident. She said she was speaking loudly but it was because the resident was hard of hearing. She said she did tell the resident to stay in his room and closed the door, but it was only for approximately 5 minutes until she could get a CNA to assist her to put the resident back to bed. She denied ever threatening or hitting the resident. She said staff discovered the camera after 2:00 AM and let the DON know. She said she did hear CNA E speaking to Resident #3's responsible party but she did not hear the allegation of abuse. She later said that maybe CNA E told her something about the allegation, but she did not remember, and she was busy at the time. She said she would report abuse to the DON, she was not aware the Administrator was the Abuse Coordinator. She said she should not have raised her voice to the resident. She said Resident #3 tried to kick her as she was leaving the room and that was why she asked him if he was trying to fight her. She said she never raised her hand to hit the resident. The DON informed her she was suspended pending the outcome of the investigation and was not to return to the facility until further notice. In a telephone interview on 10/20/22 at 3:35 PM, with the DON present, CNA D said if the resident was too combative, he was supposed to get another CNA to assist him, but he did not feel the resident was being that aggressive on 10/16/22. He said the resident tugged on the sheet and he let go, he said he did not know, at the time, the camera was in the room. He said he did tell the resident he was going to kick his ass because he was under pressure, but he would not have physically hurt the resident because it was not in his heart to do so. He said what he said was abuse. He said he was frustrated and tired of the resident being so mean. He said he had not seen or heard any other staff be mean or aggressive with the resident. He said he apologized dearly for his actions and would never hurt the residents. The DON informed him he could not report to work and was under investigation. In an interview on 10/20/22 at 5:00 PM, the Administrator said staff knew he was the Abuse Coordinator because they had all been in-serviced and it was posted in the facility. He said it was his expectation that staff would notify him immediately of any allegations of abuse or mistreatment. He said the facility would investigate, and notify the police and State Agency. In a telephone interview on 10/20/22 at 5:42 PM, Resident #3's responsible party said on 10/19/22 she spoke to CNA E regarding her abuse concerns and why she installed the camera. She said she asked if she could show CNA E the videos of the abuse, but the CNA told her her eyesight was not good and she did not think she could see the videos. She said she believed CNA E did not wish to see the videos because she would have to report the abuse to the Administrator. She said it further showed how staff wanted to turn a blind eye to reports of abuse. In a telephone interview on 10/20/22 at 6:07 PM, Former Housekeeper F said she was the housekeeper on Resident #3's hall and she felt staff were not caring for the resident appropriately. She said she believed the staff were not assisting him with meals, were abrupt and discourteous to him. She said she spoke with the Administrator and DON about her concerns, but she believed they were not addressed. She said she spoke to the resident's responsible party regarding her concerns and told her she should put a camera in the resident's room because she believed he was being mistreated by staff. She said when the facility found out she told the resident's responsible party she suspected abuse, the DON called her on 09/10/22, to question her if she knew who the Abuse Coordinator was, and she told her it was the Administrator. She said the Administrator wanted to meet with her in the next day 09/11/22, in his office, but she did not meet with him for fear she would be terminated. She said her last day of employment was 09/11/22. She said the facility's inaction regarding allegations made employees not want to report anything. She said other facility employees knew about things but don't report it. She would not give the investigator the names of the other employees. She said there were employees, still working at the facility, who abused residents. She named CNA E, as an abuser. In an observation on 10/24/22 at 9:30 AM, Resident #3 was propelling himself in his wheelchair. He was smiling and appeared to be in a good mood. He was not able to answer questions appropriately. In an interview on 10/24/22 at 9:43 AM, the Administrator and DON said the videos showed, based on their investigation, verbal abuse, and included intimidation and seclusion. They said they were going to terminate LVN C and CNA D for abuse. They said CNA E would be terminated for not reporting the allegation of abuse to the Administrator. The Administrator and DON said Former Housekeeper F never reported any abuse, neglect, or mistreatment of Resident #3 to them. The Administrator and DON said in-service training was provided orally and written for all staff on all three shifts, after the abuse allegation regarding Resident #3 on 09/15/22. On 10/24/22 at 12:43 PM the Administrator and DON were informed of an Immediate Jeopardy. On 10/25/22 at 3:58 PM Safe Surveys (interviews with residents regarding abuse and/or mistreatment) were received from the Administrator. On 10/25/22 at 4:18 PM the Immediate Jeopardy Plan of Removal was accepted. In an interview on 10/26/22 at 10:04 AM, the Social Worker said Medical Records had completed Safe Surveys with residents on 10/20/22. Record Review of the Safe Surveys, provided by the Administrator, on 10/25/22 at 3:58 PM, did not include any completed by Medical Records. Record Review of the Resident Council Minutes dated 10/17/22 indicated resident said they needed more customer service and respect from the staff. No staff was named and the number of residents who voiced this was not identified. In an interview on 10/26/22 at 10:27 AM, the AD said the Resident Council did bring up, in the meeting on 10/17/22, that they would like staff to be more respectful, but no abuse was alleged. In an interview on 10/26/22 at 11:05 AM, Medical Records said she conducted safe surveys on 10/20/22. She said during the surveys on 10/20/22, Resident #13 said CNA E yelled at her and was pointing her finger at her so close to her she thought the aide was going to hit her, but she did not. She said Resident 13's roommate, Resident #14 said she put on the light again for a different reason, to ask a question, and CNA E yelled at them again and stated, why are you on the light again? What's your problem? I was just in here!. She said Resident #14 was the Resident Council President and told her that they just tried not to bother CNA E after that. She said Resident #14 told Resident #13 they needed to speak up to get it to stop. She said Residents #13 and #14 told her they were verbally abused by CNA E. She said the interviews were between 9:00 AM -11:00 AM on Thursday, 10/20/22. She said she told the Administrator and DON immediately on 10/20/22. She said the residents told her the verbal abuse occurred on Monday, 10/17/22 on the 2:00 PM - 10:00 PM shift. She said, after she reported the allegation of abuse to the Administrator and DON, she interviewed Resident #12 on 10/20/22 between 11:00 AM -12:00 PM and the resident told her CNA E had verbally abused her too by yelling at her. She said once again she immediately informed the Administrator and DON of the verbal abuse allegation on 10/20/22. On 10/26/22 at 12:10 PM the investigator sent the Administrator an email requesting any additional safe surveys and if the facility had any new allegations of abuse. Record Review of Resident #13's admission Record dated 10/29/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included, chronic obstructive pulmonary disease and bipolar disorder (a mental illness). Record Review of Resident #13's quarterly MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated no cognitive impairment). In an observation and interview on 10/26/22 at 1:22 PM, Resident #13 was in her room in her wheelchair. She said on 10/17/22, her roommate, Resident #14, had the call light and CNA E came in the room and was screaming, upset, that the call light was on. She said CNA E came over to her while she was in her bed and was screaming and pointing her finger so close to her; she was afraid she was going to hit her. She said CNA E was mad that her roommate had turned on the call light. She said she was shocked, she felt threatened and scared by CNA E's outburst. She said she later, the same evening, wanted to just ask a question, she put the call light on, and CNA E came in yelling again and asked why they were on the light again after she had just been in there. She said CNA E verbally abused her on 10/17/22. She said the only person she told, about the abuse, was the Medical Records person on 10/20/22. Record Review of Resident #12's admission Record dated 10/29/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses of mild cognitive impairment, mild intellectual disabilities, depression and, the need for assistance with personal care. Record Review of Resident #12's quarterly MDS dated [DATE] indicated the resident was moderately cognitively impaired with a BIMS score of 10 (a score of 8-12 indicated moderate cognitive impairment). In an observation and interview on 10/26/22 at 1:46 PM, Resident #12 was in her wheelchair. She said about two or three weeks ago, CNA E came in her room and was going to assist with her incontinent care. She said CNA E started yelling at her, saying the resident could help more with the care. She said she was unable to physically help more, and she started crying. She said she was verbally abused by CNA E and was a little scared of her. She said it was on a weekend, and she told a lady working the 500 Hall, she did not know the lady's name, and the DON was called. She said she told the DON what happened with CNA E. She said the DON told her they would do some additional training with staff. She said she felt like she received the silent treatment from CNA E after she reported her. She said she reported the incident again on 10/20/22 to the Medical Records person. At 10/26/22 at 2:41 PM, there was no response from the Administrator regarding the email sent at 12:10 PM. In an interview on 10/26/22 at 2:58 PM, the Administrator said Medical Records conducted some Safe Surveys on 10/20/22. He said she did not notify him of the verbal abuse allegations reported by Residents #12, #13, and #14. He said staff conducting the Safe Surveys were told to immediately report any allegations of abuse and/or mistreatment to him immediately. He said he would look for the Safe Surveys conducted by Medical Records on 10/20/22. In an interview on 10/26/22 at 3:12 PM, the DON said she was not aware of the new allegations regarding CNA E. She said she was not contacted on a weekend regarding an incident between Resident #12 and CNA E. She said she would immediately tell the Administrator of any allegations regarding abuse. She said CNA E was terminated on Monday, 10/24/22 for not reporting Resident #3's responsible party's allegation of abuse to the Administrator. Record Review of Resident #14's admission Record dated 10/29/22 indicated the [AGE] year-old female resident was re-admitted to the facility on [DATE] with diagnoses which included mild cognitive impairment and anxiety. Record Review of Resident #14's quarterly MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated no cognitive impairment). In an observation and interview on 10/26/22 at 4:04 PM, Resident #14 was in bed in her room. She said she had been the Resident Council President about a month. She said, in the Resident Council Meeting in October 2022 it was discussed how the staff were speaking to the residents, at times. She said the residents perceived some of the staff to be snotty and argumentative, at times, like when a resident needed something the staff acted like they were doing the resident a favor instead of the fact that the staff worked for the residents. She said this was discussed in the council because staffs' attitudes towards the residents were getting worse not better. She said Medical Records came in and asked her, last week on 10/20/22 about her treatment in the facility. She said she told her about an incident on Monday 10/17/22 around 5:00 PM, she requested to be transferred from her wheelchair to bed and provided incontinent care. She said CNA E told her go to room and get in position. She said she followed instructions and waited over an hour and then put the call light on. She said CNA E came into the room yelling and screaming that the resident should not have put the call light on and that she had to just wait her turn for assistance. She said she told CNA E she was going to report her, and CNA E told her to go ahead because she did not have to answer to the resident. She said CNA E was screaming over her and pointing her finger. She said CNA E then went to her roommate's (Resident #13) side of the bed, the roommate was in bed, CNA E was standing over Resident #13, still yelling, and pointing her finger but was directed at her (Resident #14) and not the roommate (Resident #13). She said Resident #13 became afraid CNA E was going to hit her and Resident #13 started crying. She said she told Resident #13 not to cry because CNA E was mad at her (Resident #14). She said CNA E left the room, and Resident #13, who does not cuss, said Holy Shit!. She said about an hour later, the same evening, Resident #13 just wanted to ask a question, so she put the call light on, and CNA E came in the room screaming again. She said CNA E asked them What is your problem why is the call light on again?. She said Resident #13 apologized and said she just wanted to ask the AD something. She said she had been a resident at the facility for 5 years and CNA E had always had a temper. She said CNA E had an attitude like she was invincible because nothing ever happened to her, and she felt like she would not get fired. She said CNA E had always had a bad temper, but it had never been like this before. She said she did not tell anyone about the incident until the Medical Records person asked her about abuse on 10/20/22. She said she was verbally abused and intimidated by CNA E on 10/17/22. In an interview on 10/26/22 at 4:47 PM, the DON and the Clinical Resource RN said Medical Records had the Safe Surveys dated 10/20/22, on her person, for Residents #12, #13, and #14. She said Medical Records reported them verbally to the Administrator on 10/20/22 but did not give him the forms. They said the Administrator and Medical Records were suspended pending the outcome of the investigation. Record Review of Safe Surveys dated 10/20/22, not timed, indicated the question, Do you feel that you have been intentionally injured by a team member? -Resident #12 - verbal abuse -Resident #13 - verbal abuse with violently yelling and afraid CNA E would hit her on Monday (10/17/22) -Resident #14 - verbally abused with attitude - CNA E Record Review revealed Medical Records completed the three above Safe Surveys again on 10/20/22, not timed, and all three residents' answers to Do you feel you have been intentionally injured by a team member? were changed to, No. In an interview on 10/27/22 at 10:02 AM, the Clinical Resource RN and DON said the facility began in-services with all staff on the types of abuse, with a written quiz. The DON was made the Abuse Prevention Coordinator. The facility began interview with staff to see if any abuse allegations had been reported to the Administrator that were not acted upon. The facility began a root cause analysis. She said the Safe Surveys conducted on 10/20/22 with Residents #12, #13, and #14 revealed verbal abuse by CNA E. The DON said CNA E worked on 10/21/22, after the allegations of verbal abuse were reported to the Administrator on 10/20/22. She said CNA E did not work after 10/21/22. She said CNA E was terminated on 10/24/22 for not reporting the allegation of abuse made by Resident #3's responsible party, but not related to the allegations of verbal abuse. Record Review of CNA E's time sheet dated 10/27/22 indicated she worked on 10/21/22 from 2:24 PM - 9:48 PM, 7.4 hours. Attempts were made to interview CNA E on 10/28/22 at 5:23 PM, 7:24 PM, and 10/29/22 at 12:19 PM, there was no answer to the phone call and messages, a text was also sent on 10/29/22 at 12:20 PM requesting an interview, no return call was received prior to the exit on 10/29/22 at 1:00 PM. In a telephone interview on 10/27/22 at 5:26 PM, Medical Records said she told the Administrator immediately about each of the allegations of verbal abuse on 10/20/22. She said she told him after each allegation was made. She said the DON was also present, during the discussion with the Administrator. She said the administrator told her to shred Resident #12, #13, #14's Safe Surveys that revealed verbal abuse. She said he told her State was not looking at verbal abuse as being intentionally injured. She said the Administrator, then gave her new forms to complete with the same residents again. She said on 10/26/22, after the investigator asked about the Safe Surveys, she got the three original Safe Surveys for Resident #12, #13, and #14 out of the shred bin to give to the Administrator. She said the Administrator understood on 10/20/22 Residents #12, #13, and #14 had alleged they were verbally abused by CNA E. In an interview on 10/27/22 at 5:41 PM, the DON said she was not involved in the conversation regarding the abuse, as stated above, on 10/20/22. She said she was not aware of abuse being reported on the three residents (Residents #12, #13, and #14) in question. In a telephone interview on 10/27/22 at 5:45 PM, the Administrator said DON was not in the room when Medical Records discussed the verbal abuse allegations. He said Medical Records did notify him on 10/20/22 of the verbal abuse allegations. He said with everything going on the verbal abuse allegations did not cross his mind again. He said yesterday (10/26/22) Medical Records did get the Safe Surveys out of the shred bin, but he did not tell her to shred them. He told her to set them aside in his office. He said he did ask her to conduct new Safe Surveys on Resident #12, #13, and #14 because he did not believe verbal abuse was applicable to the question, Do you feel that you have been intentionally injured by a team member?. He said he was aware of the facility abuse policy and reporting requirements. In an interview on 10/27/22 at 6:35 PM, Resident #14 said she was having increased anxiety related to the verbal abuse from CNA E and just a combination of things. She said she might need an increase in her anti-anxiety medication. Record Review of the facility's Abuse: Prevention of and Prohibition Against dated October 2022 indicated verbal abuse included the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representative, or within their hearing distance, regardless of their [NAME], ability to comprehend, or disability. Prevention included - all staff, residents and visitors are encouraged to report incidents and grievances without the fear of retribution. Supervising staff to identify and correct any inappropriate or unprofessional behaviors. Identifying, correcting, and intervening in situations in which abuse is more likely to occur. Investigation included - all identified events are reported to the Administrator immediately. After receiving the allegation, during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm. Protection included - immediately removing the employee from the care of

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record reviews the facility failed to ensure allegations of abuse were thoroughly investigated, prevent further potential abuse, and mistreatment while the investigation was in process, and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 4 (Residents #3, #12, #13, and #14) of 14 residents reviewed for abuse. The facility failed to immediately investigate, protect the residents, and report allegations of abuse when: 1. Resident #3's responsible party made allegations of abuse to CNA E on 10/19/22 and she did not report it to the Administrator and the facility did not investigate or implement measures to protect the resident from further abuse; and 2. Resident #12, #13, and #14 reported on 10/20/22 that CNA E verbally abused them, and the facility did not investigate or implement measures to protect the residents from further abuse. These failures place all the residents, residing in the facility, at risk of abuse and mental anguish. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 10/24/22. While the IJ was removed on 10/29/22, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. Findings included: In an interview, with the DON and Administrator on 10/20/22 at 9:15 AM, the DON said staff found a camera hidden in a Halloween decoration in Resident #3's room. The DON said she received the call from staff on 10/19/22 round 2:00 AM staff regarding the camera. She said the staff texted her a picture of the Halloween decoration and the camera in it. The DON had staff unplug the camera because it was plugged into an un-approved extension cord. The DON said she was not surprised to find the hidden camera in the room, because the resident's family disagreed with an abuse investigation, conducted on 09/15/22, that did not reveal any abuse. The Administrator said Resident #3's family did not contact the facility regarding the camera, and they had not reported any concerns. The Administrator said he was going to have the Social Worker contact Resident #3's family regarding the camera to get to sign an Electronic Monitoring Form, but he did not know if the Social Worker had contacted them yet. The Administrator and DON said they had not heard anything from the family regarding the camera and no abuse or care issues had been reported to them. On 10/20/22 at 10:43 AM, a video was received from Resident #3's responsible party. The video was recorded on 10/19/22 at 1:58 AM, it showed a female staff person (LVN C) taking Resident #3 to his room in his wheelchair. She pulled him backwards into the room in his wheelchair. LVN C, once in the resident's room, she faced the resident and said, there you go, she pointed her right finger at the resident and said, you stop it, then she pulled her right hand in a fist, the fist does not touch the resident, but her left hand came down on something that cannot be seen in frame and a pop was heard, at the same time LVN C was heard again saying, you stop it, the resident told LVN C, fuck you, LVN C turned towards the door and it appeared the resident attempted to continue the altercation, but the images are obscured by the Halloween decoration. LVN C asked the resident, are you fighting me?', then she said angrily, at the door, you stay there and then shuts the door. On 10/20/22 at 11:08 AM, a video was received from Resident #3's responsible party, it was recorded on 10/16/22 at 12:09 AM, it showed a male staff person (CNA D) enter the resident's room the resident was in bed. CNA D picked up the bed sheet but the resident tugs on the sheet, and CNA D lets go of the sheet. The resident says, get off me, you mother fucker, and throws the sheet at CNA D. CNA D walked to the foot of the resident's bed and told he resident, I'm going to kick your ass. The resident responds but his response could not be understood on the video. In a telephone interview on 10/20/22 at 11:25 AM, Resident #3's responsible party said she had a previous complaint regarding staff treatment of the resident, which she believed to be abuse, that was investigated and found to be unsubstantiated on 09/15/22. She said she disagreed with the findings of the facility's investigation and felt the facility was covering up abuse and/or mistreatment of Resident #3. She said a former employee, Housekeeper F, informed her she believed Resident #3 was being mistreated and told her she should place a camera in his room, because reports to the Administrator and DON of mistreatment were not being acted on. She said Housekeeper F was terminated for telling her about the mistreatment of Resident #3 for not reporting the abuse allegations to the Administrator. She said based on her experience with the facility; she decided to place a hidden camera in the resident's room. She said the resident did not have a roommate and it was not violating any other resident's privacy. She said when she saw the abuse recorded on the camera, she came to the facility to check on Resident #3 but did not alert the facility to the hidden camera. She said the videos showed Resident #3 was being abused by the staff. She said on 10/19/22 around 2:00 AM she could see on the camera that staff discovered the camera was in the room. She said she could see several staff members looking at the camera before it was unplugged. She said, staff from the facility just called her a few minutes ago, she did not know who, to tell her the camera was not approved and that she would need to sign a consent for its use. She said she asked the person that called if they were concerned about what the camera revealed and the person did not answer the question, and just told her she needed to sign the form in order for the camera to be approved. She said she informed the staff she had already removed the camera from the room and took it home. She said no one reached out to her about the camera prior to the phone call today, after the investigator entered the facility. She said there was one additional video that she had not sent yet, but she would send it. She said she wanted to move the resident to another facility but had to wait for his Medicaid to be approved before her facility of choice would accept him. She said she feels stuck because she cannot move him but cannot trust that he won't be harmed at the facility. On 10/20/22 at 12:04 PM, the Administrator and DON were shown the above videos for staff identification purposes. They said both videos showed abuse of Resident #3. They identified LVN C as the staff in the first video and CNA D in the second video. The DON said there had been no reports or concerns regarding the employees' care and treatment of the residents. She said the employees would be notified and suspended pending the outcome of the investigation. On 10/20/22 at 12:38 PM, the third and final video was received from Resident #3's responsible party, it was recorded on 10/13/22 at 7:36 PM, it showed two staff (LVN C and CNA E) providing care to the resident while he was in bed. LVN C was at the head of the resident's bed encouraging him to allow care but he was saying don't do that, CNA E was observed getting some wipes, she joined LVN C at the resident's bedside. The resident could be heard saying, God dammit, at that point, LVN C's left hand went up with her hand open, while she leaned forward and told the resident to stop it, she does not hit the resident, but it appeared to be a gesture like she was going to slap the resident. On 10/20/22 at 12:45 PM, the Administrator and DON said the third video was LVN C who appeared to raise her hand to Resident #3. They said the other staff was CNA E. Record Review of Resident #3's admission Record dated 10/20/22 indicated the [AGE] year-old male resident was re-admitted to the facility on [DATE] with diagnoses which included dementia and major depressive disorder. Record Review of Resident #3's quarterly MDS dated [DATE] indicated the resident had short and long-term memory problems. He was severely cognitively impaired. He had no behaviors. Record Review of Resident #3's un-dated Care Plan indicated he had behaviors which included, combativeness, physical and verbal aggression with staff. The interventions included to provide physical and verbal cues to alleviate the resident's anxiety and give positive feedback. If the resident resists care, reassure the resident, leave, and return 5-10 minutes later and try again. In an observation on 10/20/22 at 1:34 PM, Resident #3 was propelling himself in his wheelchair. He was not able to answer any direct questions. In an interview on 10/20/22 at 2:44 PM, CNA E watched third video. She said she did not think LVN C was raising her hand to the resident, but she was not paying attention, at the time. She said she thought maybe LVN C was reaching to roll the resident over. She said she had never seen any staff being abusive or mistreating the resident. She said around 10:00 PM yesterday, 10/19/22, the resident's responsible party asked her if she was aware there had been a camera in the room. She said she told her she was not aware. She said the resident's responsible party told her she put the camera in the room because the resident was being abused by the staff. She said she told the resident's responsible party she did not believe that would happen at the facility. She said she did not tell anyone the resident's responsible party reported the resident had been abused. She said LVN C overheard her talking with the resident's responsible party and knew about the allegation. She said she was supposed to inform the Administrator of any abuse allegations; however, she did not report it. In an interview on 10/20/22 at 4:21 PM, with the DON present, LVN C said on 10/19/22 Resident #3 was awake around 2:00 AM and staff got him up in his wheelchair and assisted him to the nurses' station for monitoring. She said the resident became combative, threw things off the nurses' station, and tried to hit, kick and bite staff. She said the video showed her pulling him in his room backwards because he was being combative. She said her right hand was in a fist and pulled back because she thought he was going to grab or bite her. She said she did not make physical contact with the resident. She said the slap sound on the video was when she slapped her own leg. She said she did not feel she was being abusive to the resident. She said she was speaking loudly but it was because the resident was hard of hearing. She said she did tell the resident to stay in his room and closed the door, but it was only for approximately 5 minutes until she could get a CNA to assist her to put the resident back to bed. She denied ever threatening or hitting the resident. She said staff discovered the camera after 2:00 AM and let the DON know. She said she did hear CNA E speaking to Resident #3's responsible party but she did not hear the allegation of abuse. She later said that maybe CNA E told her something about the allegation, but she did not remember, and she was busy at the time. She said she would report abuse to the DON, she was not aware the Administrator was the Abuse Coordinator. She said she should not have raised her voice to the resident. She said Resident #3 tried to kick her as she was leaving the room and that was why she asked him if he was trying to fight her. She said she never raised her hand to hit the resident. The DON informed her she was suspended pending the outcome of the investigation and was not to return to the facility until further notice. In a telephone interview on 10/20/22 at 3:35 PM, with the DON present, CNA D said if the resident was too combative, he was supposed to get another CNA to assist him, but he did not feel the resident was being that aggressive on 10/16/22. He said the resident tugged on the sheet and he let go, he said he did not know, at the time, the camera was in the room. He said he did tell the resident he was going to kick his ass because he was under pressure, but he would not have physically hurt the resident because it was not in his heart to do so. He said what he said was abuse. He said he was frustrated and tired of the resident being so mean. He said he had not seen or heard any other staff be mean or aggressive with the resident. He said he apologized dearly for his actions and would never hurt the residents. The DON informed him he could not report to work and was under investigation. In an interview on 10/20/22 at 5:00 PM, the Administrator said staff knew he was the Abuse Coordinator because they had all been in-serviced and it was posted in the facility. He said it was his expectation that staff would notify him immediately of any allegations of abuse or mistreatment. He said the facility would investigate, and notify the police and State Agency. In a telephone interview on 10/20/22 at 5:42 PM, Resident #3's responsible party said on 10/19/22 she spoke to CNA E regarding her abuse concerns and why she installed the camera. She said she asked if she could show CNA E the videos of the abuse, but the CNA told her her eyesight was not good and she did not think she could see the videos. She said she believed CNA E did not wish to see the videos because she would have to report the abuse to the Administrator. She said it further showed how staff wanted to turn a blind eye to reports of abuse. In a telephone interview on 10/20/22 at 6:07 PM, Former Housekeeper F said she was the housekeeper on Resident #3's hall and she felt staff were not caring for the resident appropriately. She said she believed the staff were not assisting him with meals, were abrupt and discourteous to him. She said she spoke with the Administrator and DON about her concerns, but she believed they were not addressed. She said she spoke to the resident's responsible party regarding her concerns and told her she should put a camera in the resident's room because she believed he was being mistreated by staff. She said when the facility found out she told the resident's responsible party she suspected abuse, the DON called her on 09/10/22, to question her if she knew who the Abuse Coordinator was, and she told her it was the Administrator. She said the Administrator wanted to meet with her in the next day 09/11/22, in his office, but she did not meet with him for fear she would be terminated. She said her last day of employment was 09/11/22. She said the facility's inaction regarding allegations made employees not want to report anything. She said other facility employees knew about things but don't report it. She would not give the investigator the names of the other employees. She said there were employees, still working at the facility, who abused residents. She named CNA E, as an abuser. In an observation on 10/24/22 at 9:30 AM, Resident #3 was propelling himself in his wheelchair. He was smiling and appeared to be in a good mood. He was not able to answer questions appropriately. In an interview on 10/24/22 at 9:43 AM, the Administrator and DON said the videos showed, based on their investigation, verbal abuse, and included intimidation and seclusion. They said they were going to terminate LVN C and CNA D for abuse. They said CNA E would be terminated for not reporting the allegation of abuse to the Administrator. The Administrator and DON said Former Housekeeper F never reported any abuse, neglect, or mistreatment of Resident #3 to them. The Administrator and DON said in-service training was provided orally and written for all staff on all three shifts, after the abuse allegation regarding Resident #3 on 09/15/22. On 10/24/22 at 12:43 PM the Administrator and DON were informed of an Immediate Jeopardy. On 10/25/22 at 3:58 PM Safe Surveys (interviews with residents regarding abuse and/or mistreatment) were received from the Administrator. On 10/25/22 at 4:18 PM the Immediate Jeopardy Plan of Removal was accepted. In an interview on 10/26/22 at 10:04 AM, the Social Worker said Medical Records had completed Safe Surveys with residents on 10/20/22. Record Review of the Safe Surveys, provided by the Administrator, on 10/25/22 at 3:58 PM, did not include any completed by Medical Records. Record Review of the Resident Council Minutes dated 10/17/22 indicated resident said they needed more customer service and respect from the staff. No staff was named and the number of residents who voiced this was not identified. In an interview on 10/26/22 at 10:27 AM, the AD said the Resident Council did bring up, in the meeting on 10/17/22, that they would like staff to be more respectful, but no abuse was alleged. In an interview on 10/26/22 at 11:05 AM, Medical Records said she conducted safe surveys on 10/20/22. She said during the surveys on 10/20/22, Resident #13 said CNA E yelled at her and was pointing her finger at her so close to her she thought the aide was going to hit her, but she did not. She said Resident 13's roommate, Resident #14 said she put on the light again for a different reason, to ask a question, and CNA E yelled at them again and stated, why are you on the light again? What's your problem? I was just in here!. She said Resident #14 was the Resident Council President and told her that they just tried not to bother CNA E after that. She said Resident #14 told Resident #13 they needed to speak up to get it to stop. She said Residents #13 and #14 told her they were verbally abused by CNA E. She said the interviews were between 9:00 AM -11:00 AM on Thursday, 10/20/22. She said she told the Administrator and DON immediately on 10/20/22. She said the residents told her the verbal abuse occurred on Monday, 10/17/22 on the 2:00 PM - 10:00 PM shift. She said, after she reported the allegation of abuse to the Administrator and DON, she interviewed Resident #12 on 10/20/22 between 11:00 AM -12:00 PM and the resident told her CNA E had verbally abused her too by yelling at her. She said once again she immediately informed the Administrator and DON of the verbal abuse allegation on 10/20/22. On 10/26/22 at 12:10 PM the investigator sent the Administrator an email requesting any additional safe surveys and if the facility had any new allegations of abuse. Record Review of Resident #13's admission Record dated 10/29/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included, chronic obstructive pulmonary disease and bipolar disorder (a mental illness). Record Review of Resident #13's quarterly MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated no cognitive impairment). In an observation and interview on 10/26/22 at 1:22 PM, Resident #13 was in her room in her wheelchair. She said on 10/17/22, her roommate, Resident #14, had the call light and CNA E came in the room and was screaming, upset, that the call light was on. She said CNA E came over to her while she was in her bed and was screaming and pointing her finger so close to her; she was afraid she was going to hit her. She said CNA E was mad that her roommate had turned on the call light. She said she was shocked, she felt threatened and scared by CNA E's outburst. She said she later, the same evening, wanted to just ask a question, she put the call light on, and CNA E came in yelling again and asked why they were on the light again after she had just been in there. She said CNA E verbally abused her on 10/17/22. She said the only person she told, about the abuse, was the Medical Records person on 10/20/22. Record Review of Resident #12's admission Record dated 10/29/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses of mild cognitive impairment, mild intellectual disabilities, depression and, the need for assistance with personal care. Record Review of Resident #12's quarterly MDS dated [DATE] indicated the resident was moderately cognitively impaired with a BIMS score of 10 (a score of 8-12 indicated moderate cognitive impairment). In an observation and interview on 10/26/22 at 1:46 PM, Resident #12 was in her wheelchair. She said about two or three weeks ago, CNA E came in her room and was going to assist with her incontinent care. She said CNA E started yelling at her, saying the resident could help more with the care. She said she was unable to physically help more, and she started crying. She said she was verbally abused by CNA E and was a little scared of her. She said it was on a weekend, and she told a lady working the 500 Hall, she did not know the lady's name, and the DON was called. She said she told the DON what happened with CNA E. She said the DON told her they would do some additional training with staff. She said she felt like she received the silent treatment from CNA E after she reported her. She said she reported the incident again on 10/20/22 to the Medical Records person. At 10/26/22 at 2:41 PM, there was no response from the Administrator regarding the email sent at 12:10 PM. In an interview on 10/26/22 at 2:58 PM, the Administrator said Medical Records conducted some Safe Surveys on 10/20/22. He said she did not notify him of the verbal abuse allegations reported by Residents #12, #13, and #14. He said staff conducting the Safe Surveys were told to immediately report any allegations of abuse and/or mistreatment to him immediately. He said he would look for the Safe Surveys conducted by Medical Records on 10/20/22. In an interview on 10/26/22 at 3:12 PM, the DON said she was not aware of the new allegations regarding CNA E. She said she was not contacted on a weekend regarding an incident between Resident #12 and CNA E. She said she would immediately tell the Administrator of any allegations regarding abuse. She said CNA E was terminated on Monday, 10/24/22 for not reporting Resident #3's responsible party's allegation of abuse to the Administrator. Record Review of Resident #14's admission Record dated 10/29/22 indicated the [AGE] year-old female resident was re-admitted to the facility on [DATE] with diagnoses which included mild cognitive impairment and anxiety. Record Review of Resident #14's quarterly MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated no cognitive impairment). In an observation and interview on 10/26/22 at 4:04 PM, Resident #14 was in bed in her room. She said she had been the Resident Council President about a month. She said, in the Resident Council Meeting in October 2022 it was discussed how the staff were speaking to the residents, at times. She said the residents perceived some of the staff to be snotty and argumentative, at times, like when a resident needed something the staff acted like they were doing the resident a favor instead of the fact that the staff worked for the residents. She said this was discussed in the council because staffs' attitudes towards the residents were getting worse not better. She said Medical Records came in and asked her, last week on 10/20/22 about her treatment in the facility. She said she told her about an incident on Monday 10/17/22 around 5:00 PM, she requested to be transferred from her wheelchair to bed and provided incontinent care. She said CNA E told her go to room and get in position. She said she followed instructions and waited over an hour and then put the call light on. She said CNA E came into the room yelling and screaming that the resident should not have put the call light on and that she had to just wait her turn for assistance. She said she told CNA E she was going to report her, and CNA E told her to go ahead because she did not have to answer to the resident. She said CNA E was screaming over her and pointing her finger. She said CNA E then went to her roommate's (Resident #13) side of the bed, the roommate was in bed, CNA E was standing over Resident #13, still yelling, and pointing her finger but was directed at her (Resident #14) and not the roommate (Resident #13). She said Resident #13 became afraid CNA E was going to hit her and Resident #13 started crying. She said she told Resident #13 not to cry because CNA E was mad at her (Resident #14). She said CNA E left the room, and Resident #13, who does not cuss, said Holy Shit!. She said about an hour later, the same evening, Resident #13 just wanted to ask a question, so she put the call light on, and CNA E came in the room screaming again. She said CNA E asked them What is your problem why is the call light on again?. She said Resident #13 apologized and said she just wanted to ask the AD something. She said she had been a resident at the facility for 5 years and CNA E had always had a temper. She said CNA E had an attitude like she was invincible because nothing ever happened to her, and she felt like she would not get fired. She said CNA E had always had a bad temper, but it had never been like this before. She said she did not tell anyone about the incident until the Medical Records person asked her about abuse on 10/20/22. She said she was verbally abused and intimidated by CNA E on 10/17/22. In an interview on 10/26/22 at 4:47 PM, the DON and the Clinical Resource RN said Medical Records had the Safe Surveys dated 10/20/22, on her person, for Residents #12, #13, and #14. She said Medical Records reported them verbally to the Administrator on 10/20/22 but did not give him the forms. They said the Administrator and Medical Records were suspended pending the outcome of the investigation. Record Review of Safe Surveys dated 10/20/22, not timed, indicated the question, Do you feel that you have been intentionally injured by a team member? -Resident #12 - verbal abuse -Resident #13 - verbal abuse with violently yelling and afraid CNA E would hit her on Monday (10/17/22) -Resident #14 - verbally abused with attitude - CNA E Record Review revealed Medical Records completed the three above Safe Surveys again on 10/20/22, not timed, and all three residents' answers to Do you feel you have been intentionally injured by a team member? were changed to, No. In an interview on 10/27/22 at 10:02 AM, the Clinical Resource RN and DON said the facility began in-services with all staff on the types of abuse, with a written quiz. The DON was made the Abuse Prevention Coordinator. The facility began interview with staff to see if any abuse allegations had been reported to the Administrator that were not acted upon. The facility began a root cause analysis. She said the Safe Surveys conducted on 10/20/22 with Residents #12, #13, and #14 revealed verbal abuse by CNA E. The DON said CNA E worked on 10/21/22, after the allegations of verbal abuse were reported to the Administrator on 10/20/22. She said CNA E did not work after 10/21/22. She said CNA E was terminated on 10/24/22 for not reporting the allegation of abuse made by Resident #3's responsible party, but not related to the allegations of verbal abuse. Record Review of CNA E's time sheet dated 10/27/22 indicated she worked on 10/21/22 from 2:24 PM - 9:48 PM, 7.4 hours. Attempts were made to interview CNA E on 10/28/22 at 5:23 PM, 7:24 PM, and 10/29/22 at 12:19 PM, there was no answer to the phone call and messages, a text was also sent on 10/29/22 at 12:20 PM requesting an interview, no return call was received prior to the exit on 10/29/22 at 1:00 PM. In a telephone interview on 10/27/22 at 5:26 PM, Medical Records said she told the Administrator immediately about each of the allegations of verbal abuse on 10/20/22. She said she told him after each allegation was made. She said the DON was also present, during the discussion with the Administrator. She said the administrator told her to shred Resident #12, #13, #14's Safe Surveys that revealed verbal abuse. She said he told her State was not looking at verbal abuse as being intentionally injured. She said the Administrator, then gave her new forms to complete with the same residents again. She said on 10/26/22, after the investigator asked about the Safe Surveys, she got the three original Safe Surveys for Resident #12, #13, and #14 out of the shred bin to give to the Administrator. She said the Administrator understood on 10/20/22 Residents #12, #13, and #14 had alleged they were verbally abused by CNA E. In an interview on 10/27/22 at 5:41 PM, the DON said she was not involved in the conversation regarding the abuse, as stated above, on 10/20/22. She said she was not aware of abuse being reported on the three residents (Residents #12, #13, and #14) in question. In a telephone interview on 10/27/22 at 5:45 PM, the Administrator said DON was not in the room when Medical Records discussed the verbal abuse allegations. He said Medical Records did notify him on 10/20/22 of the verbal abuse allegations. He said with everything going on the verbal abuse allegations did not cross his mind again. He said yesterday (10/26/22) Medical Records did get the Safe Surveys out of the shred bin, but he did not tell her to shred them. He told her to set them aside in his office. He said he did ask her to conduct new Safe Surveys on Resident #12, #13, and #14 because he did not believe verbal abuse was applicable to the question, Do you feel that you have been intentionally injured by a team member?. He said he was aware of the facility abuse policy and reporting requirements. In an interview on 10/27/22 at 6:35 PM, Resident #14 said she was having increased anxiety related to the verbal abuse from CNA E and just a combination of things. She said she might need an increase in her anti-anxiety medication. Record Review of the facility's Abuse: Prevention of and Prohibition Against dated October 2022 indicated verbal abuse included the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representative, or within their hearing distance, regardless of their [NAME], ability to comprehend, or disability. Prevention included - all staff, residents and visitors are encouraged to report incidents and grievances without the fear of retribution. Supervising staff to identify and correct any inappropriate or unprofessional behaviors. Identifying, correcting, and intervening in situations in which abuse is more likely to occur. Investigation included - all identified events are reported to the Administrator immediately. After receiving the allegatio[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 4 (Residents #3, #12, #13, and #14) of 14 residents reviewed for abuse. 1) CNA E failed to report Resident #3's responsible party's allegation of abuse to the Administrator on 10/19/22. 2) The Administrator (the Abuse Coordinator) failed the residents by not implementing the Abuse Policy when he was informed, on 10/20/22, of Resident #12, #13, and #14's allegations that CNA E verbally abused them. CNA E continued to work after the Administrator was notified of the abuse. Safe Surveys conducted on 10/20/22, identified abuse and indicated additional residents were being abused. The Safe Surveys were not provided to the investigator until repeated inquiry and were found in the shred bin. These failures could place all the residents, who resided in the facility, at risk for abuse and mental anguish. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 11/14/22. While the IJ was removed on 11/14/22, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. Findings included: In an interview, with the DON and Administrator on 10/20/22 at 9:15 AM, the DON said staff found a camera hidden in a Halloween decoration in Resident #3's room. The DON said she received the call from staff on 10/19/22 round 2:00 AM staff regarding the camera. She said the staff texted her a picture of the Halloween decoration and the camera in it. The DON had staff unplug the camera because it was plugged into an un-approved extension cord. The DON said she was not surprised to find the hidden camera in the room, because the resident's family disagreed with an abuse investigation, conducted on 09/15/22, that did not reveal any abuse. The Administrator said Resident #3's family did not contact the facility regarding the camera, and they had not reported any concerns. The Administrator said he was going to have the Social Worker contact Resident #3's family regarding the camera to get to sign an Electronic Monitoring Form, but he did not know if the Social Worker had contacted them yet. The Administrator and DON said they had not heard anything from the family regarding the camera and no abuse or care issues had been reported to them. On 10/20/22 at 10:43 AM, a video was received from Resident #3's responsible party. The video was recorded on 10/19/22 at 1:58 AM, it showed a female staff person (LVN C) taking Resident #3 to his room in his wheelchair. She pulled him backwards into the room in his wheelchair. LVN C, once in the resident's room, she faced the resident and said, there you go, she pointed her right finger at the resident and said, you stop it, then she pulled her right hand in a fist, the fist does not touch the resident, but her left hand came down on something that cannot be seen in frame and a pop was heard, at the same time LVN C was heard again saying, you stop it, the resident told LVN C, fuck you, LVN C turned towards the door and it appeared the resident attempted to continue the altercation, but the images are obscured by the Halloween decoration. LVN C asked the resident, are you fighting me?', then she said angrily, at the door, you stay there and then shuts the door. On 10/20/22 at 11:08 AM, a video was received from Resident #3's responsible party, it was recorded on 10/16/22 at 12:09 AM, it showed a male staff person (CNA D) enter the resident's room the resident was in bed. CNA D picked up the bed sheet but the resident tugs on the sheet, and CNA D lets go of the sheet. The resident says, get off me, you mother fucker, and throws the sheet at CNA D. CNA D walked to the foot of the resident's bed and told he resident, I'm going to kick your ass. The resident responds but his response could not be understood on the video. In a telephone interview on 10/20/22 at 11:25 AM, Resident #3's responsible party said she had a previous complaint regarding staff treatment of the resident, which she believed to be abuse, that was investigated and found to be unsubstantiated on 09/15/22. She said she disagreed with the findings of the facility's investigation and felt the facility was covering up abuse and/or mistreatment of Resident #3. She said a former employee, Housekeeper F, informed her she believed Resident #3 was being mistreated and told her she should place a camera in his room, because reports to the Administrator and DON of mistreatment were not being acted on. She said Housekeeper F was terminated for telling her about the mistreatment of Resident #3 for not reporting the abuse allegations to the Administrator. She said based on her experience with the facility; she decided to place a hidden camera in the resident's room. She said the resident did not have a roommate and it was not violating any other resident's privacy. She said when she saw the abuse recorded on the camera, she came to the facility to check on Resident #3 but did not alert the facility to the hidden camera. She said the videos showed Resident #3 was being abused by the staff. She said on 10/19/22 around 2:00 AM she could see on the camera that staff discovered the camera was in the room. She said she could see several staff members looking at the camera before it was unplugged. She said, staff from the facility just called her a few minutes ago, she did not know who, to tell her the camera was not approved and that she would need to sign a consent for its use. She said she asked the person that called if they were concerned about what the camera revealed and the person did not answer the question, and just told her she needed to sign the form in order for the camera to be approved. She said she informed the staff she had already removed the camera from the room and took it home. She said no one reached out to her about the camera prior to the phone call today, after the investigator entered the facility. She said there was one additional video that she had not sent yet, but she would send it. She said she wanted to move the resident to another facility but had to wait for his Medicaid to be approved before her facility of choice would accept him. She said she feels stuck because she cannot move him but cannot trust that he won't be harmed at the facility. On 10/20/22 at 12:04 PM, the Administrator and DON were shown the above videos for staff identification purposes. They said both videos showed abuse of Resident #3. They identified LVN C as the staff in the first video and CNA D in the second video. The DON said there had been no reports or concerns regarding the employees' care and treatment of the residents. She said the employees would be notified and suspended pending the outcome of the investigation. On 10/20/22 at 12:38 PM, the third and final video was received from Resident #3's responsible party, it was recorded on 10/13/22 at 7:36 PM, it showed two staff (LVN C and CNA E) providing care to the resident while he was in bed. LVN C was at the head of the resident's bed encouraging him to allow care but he was saying don't do that, CNA E was observed getting some wipes, she joined LVN C at the resident's bedside. The resident could be heard saying, God dammit, at that point, LVN C's left hand went up with her hand open, while she leaned forward and told the resident to stop it, she does not hit the resident, but it appeared to be a gesture like she was going to slap the resident. On 10/20/22 at 12:45 PM, the Administrator and DON said the third video was LVN C who appeared to raise her hand to Resident #3. They said the other staff was CNA E. Record Review of Resident #3's admission Record dated 10/20/22 indicated the [AGE] year-old male resident was re-admitted to the facility on [DATE] with diagnoses which included dementia and major depressive disorder. Record Review of Resident #3's quarterly MDS dated [DATE] indicated the resident had short and long-term memory problems. He was severely cognitively impaired. He had no behaviors. Record Review of Resident #3's un-dated Care Plan indicated he had behaviors which included, combativeness, physical and verbal aggression with staff. The interventions included to provide physical and verbal cues to alleviate the resident's anxiety and give positive feedback. If the resident resists care, reassure the resident, leave, and return 5-10 minutes later and try again. In an observation on 10/20/22 at 1:34 PM, Resident #3 was propelling himself in his wheelchair. He was not able to answer any direct questions. In an interview on 10/20/22 at 2:44 PM, CNA E watched third video. She said she did not think LVN C was raising her hand to the resident, but she was not paying attention, at the time. She said she thought maybe LVN C was reaching to roll the resident over. She said she had never seen any staff being abusive or mistreating the resident. She said around 10:00 PM yesterday, 10/19/22, the resident's responsible party asked her if she was aware there had been a camera in the room. She said she told her she was not aware. She said the resident's responsible party told her she put the camera in the room because the resident was being abused by the staff. She said she told the resident's responsible party she did not believe that would happen at the facility. She said she did not tell anyone the resident's responsible party reported the resident had been abused. She said LVN C overheard her talking with the resident's responsible party and knew about the allegation. She said she was supposed to inform the Administrator of any abuse allegations; however, she did not report it. In an interview on 10/20/22 at 4:21 PM, with the DON present, LVN C said on 10/19/22 Resident #3 was awake around 2:00 AM and staff got him up in his wheelchair and assisted him to the nurses' station for monitoring. She said the resident became combative, threw things off the nurses' station, and tried to hit, kick and bite staff. She said the video showed her pulling him in his room backwards because he was being combative. She said her right hand was in a fist and pulled back because she thought he was going to grab or bite her. She said she did not make physical contact with the resident. She said the slap sound on the video was when she slapped her own leg. She said she did not feel she was being abusive to the resident. She said she was speaking loudly but it was because the resident was hard of hearing. She said she did tell the resident to stay in his room and closed the door, but it was only for approximately 5 minutes until she could get a CNA to assist her to put the resident back to bed. She denied ever threatening or hitting the resident. She said staff discovered the camera after 2:00 AM and let the DON know. She said she did hear CNA E speaking to Resident #3's responsible party but she did not hear the allegation of abuse. She later said that maybe CNA E told her something about the allegation, but she did not remember, and she was busy at the time. She said she would report abuse to the DON, she was not aware the Administrator was the Abuse Coordinator. She said she should not have raised her voice to the resident. She said Resident #3 tried to kick her as she was leaving the room and that was why she asked him if he was trying to fight her. She said she never raised her hand to hit the resident. The DON informed her she was suspended pending the outcome of the investigation and was not to return to the facility until further notice. In a telephone interview on 10/20/22 at 3:35 PM, with the DON present, CNA D said if the resident was too combative, he was supposed to get another CNA to assist him, but he did not feel the resident was being that aggressive on 10/16/22. He said the resident tugged on the sheet and he let go, he said he did not know, at the time, the camera was in the room. He said he did tell the resident he was going to kick his ass because he was under pressure, but he would not have physically hurt the resident because it was not in his heart to do so. He said what he said was abuse. He said he was frustrated and tired of the resident being so mean. He said he had not seen or heard any other staff be mean or aggressive with the resident. He said he apologized dearly for his actions and would never hurt the residents. The DON informed him he could not report to work and was under investigation. In an interview on 10/20/22 at 5:00 PM, the Administrator said staff knew he was the Abuse Coordinator because they had all been in-serviced and it was posted in the facility. He said it was his expectation that staff would notify him immediately of any allegations of abuse or mistreatment. He said the facility would investigate, and notify the police and State Agency. In a telephone interview on 10/20/22 at 5:42 PM, Resident #3's responsible party said on 10/19/22 she spoke to CNA E regarding her abuse concerns and why she installed the camera. She said she asked if she could show CNA E the videos of the abuse, but the CNA told her her eyesight was not good and she did not think she could see the videos. She said she believed CNA E did not wish to see the videos because she would have to report the abuse to the Administrator. She said it further showed how staff wanted to turn a blind eye to reports of abuse. In a telephone interview on 10/20/22 at 6:07 PM, Former Housekeeper F said she was the housekeeper on Resident #3's hall and she felt staff were not caring for the resident appropriately. She said she believed the staff were not assisting him with meals, were abrupt and discourteous to him. She said she spoke with the Administrator and DON about her concerns, but she believed they were not addressed. She said she spoke to the resident's responsible party regarding her concerns and told her she should put a camera in the resident's room because she believed he was being mistreated by staff. She said when the facility found out she told the resident's responsible party she suspected abuse, the DON called her on 09/10/22, to question her if she knew who the Abuse Coordinator was, and she told her it was the Administrator. She said the Administrator wanted to meet with her in the next day 09/11/22, in his office, but she did not meet with him for fear she would be terminated. She said her last day of employment was 09/11/22. She said the facility's inaction regarding allegations made employees not want to report anything. She said other facility employees knew about things but don't report it. She would not give the investigator the names of the other employees. She said there were employees, still working at the facility, who abused residents. She named CNA E, as an abuser. In an observation on 10/24/22 at 9:30 AM, Resident #3 was propelling himself in his wheelchair. He was smiling and appeared to be in a good mood. He was not able to answer questions appropriately. In an interview on 10/24/22 at 9:43 AM, the Administrator and DON said the videos showed, based on their investigation, verbal abuse, and included intimidation and seclusion. They said they were going to terminate LVN C and CNA D for abuse. They said CNA E would be terminated for not reporting the allegation of abuse to the Administrator. The Administrator and DON said Former Housekeeper F never reported any abuse, neglect, or mistreatment of Resident #3 to them. The Administrator and DON said in-service training was provided orally and written for all staff on all three shifts, after the abuse allegation regarding Resident #3 on 09/15/22. On 10/24/22 at 12:43 PM the Administrator and DON were informed of an Immediate Jeopardy. On 10/25/22 at 3:58 PM Safe Surveys (interviews with residents regarding abuse and/or mistreatment) were received from the Administrator. On 10/25/22 at 4:18 PM the Immediate Jeopardy Plan of Removal was accepted. In an interview on 10/26/22 at 10:04 AM, the Social Worker said Medical Records had completed Safe Surveys with residents on 10/20/22. Record Review of the Safe Surveys, provided by the Administrator, on 10/25/22 at 3:58 PM, did not include any completed by Medical Records. Record Review of the Resident Council Minutes dated 10/17/22 indicated resident said they needed more customer service and respect from the staff. No staff was named and the number of residents who voiced this was not identified. In an interview on 10/26/22 at 10:27 AM, the AD said the Resident Council did bring up, in the meeting on 10/17/22, that they would like staff to be more respectful, but no abuse was alleged. In an interview on 10/26/22 at 11:05 AM, Medical Records said she conducted safe surveys on 10/20/22. She said during the surveys on 10/20/22, Resident #13 said CNA E yelled at her and was pointing her finger at her so close to her she thought the aide was going to hit her, but she did not. She said Resident 13's roommate, Resident #14 said she put on the light again for a different reason, to ask a question, and CNA E yelled at them again and stated, why are you on the light again? What's your problem? I was just in here!. She said Resident #14 was the Resident Council President and told her that they just tried not to bother CNA E after that. She said Resident #14 told Resident #13 they needed to speak up to get it to stop. She said Residents #13 and #14 told her they were verbally abused by CNA E. She said the interviews were between 9:00 AM -11:00 AM on Thursday, 10/20/22. She said she told the Administrator and DON immediately on 10/20/22. She said the residents told her the verbal abuse occurred on Monday, 10/17/22 on the 2:00 PM - 10:00 PM shift. She said, after she reported the allegation of abuse to the Administrator and DON, she interviewed Resident #12 on 10/20/22 between 11:00 AM -12:00 PM and the resident told her CNA E had verbally abused her too by yelling at her. She said once again she immediately informed the Administrator and DON of the verbal abuse allegation on 10/20/22. On 10/26/22 at 12:10 PM the investigator sent the Administrator an email requesting any additional safe surveys and if the facility had any new allegations of abuse. Record Review of Resident #13's admission Record dated 10/29/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses which included, chronic obstructive pulmonary disease and bipolar disorder (a mental illness). Record Review of Resident #13's quarterly MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated no cognitive impairment). In an observation and interview on 10/26/22 at 1:22 PM, Resident #13 was in her room in her wheelchair. She said on 10/17/22, her roommate, Resident #14, had the call light and CNA E came in the room and was screaming, upset, that the call light was on. She said CNA E came over to her while she was in her bed and was screaming and pointing her finger so close to her; she was afraid she was going to hit her. She said CNA E was mad that her roommate had turned on the call light. She said she was shocked, she felt threatened and scared by CNA E's outburst. She said she later, the same evening, wanted to just ask a question, she put the call light on, and CNA E came in yelling again and asked why they were on the light again after she had just been in there. She said CNA E verbally abused her on 10/17/22. She said the only person she told, about the abuse, was the Medical Records person on 10/20/22. Record Review of Resident #12's admission Record dated 10/29/22 indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with diagnoses of mild cognitive impairment, mild intellectual disabilities, depression and, the need for assistance with personal care. Record Review of Resident #12's quarterly MDS dated [DATE] indicated the resident was moderately cognitively impaired with a BIMS score of 10 (a score of 8-12 indicated moderate cognitive impairment). In an observation and interview on 10/26/22 at 1:46 PM, Resident #12 was in her wheelchair. She said about two or three weeks ago, CNA E came in her room and was going to assist with her incontinent care. She said CNA E started yelling at her, saying the resident could help more with the care. She said she was unable to physically help more, and she started crying. She said she was verbally abused by CNA E and was a little scared of her. She said it was on a weekend, and she told a lady working the 500 Hall, she did not know the lady's name, and the DON was called. She said she told the DON what happened with CNA E. She said the DON told her they would do some additional training with staff. She said she felt like she received the silent treatment from CNA E after she reported her. She said she reported the incident again on 10/20/22 to the Medical Records person. At 10/26/22 at 2:41 PM, there was no response from the Administrator regarding the email sent at 12:10 PM. In an interview on 10/26/22 at 2:58 PM, the Administrator said Medical Records conducted some Safe Surveys on 10/20/22. He said she did not notify him of the verbal abuse allegations reported by Residents #12, #13, and #14. He said staff conducting the Safe Surveys were told to immediately report any allegations of abuse and/or mistreatment to him immediately. He said he would look for the Safe Surveys conducted by Medical Records on 10/20/22. In an interview on 10/26/22 at 3:12 PM, the DON said she was not aware of the new allegations regarding CNA E. She said she was not contacted on a weekend regarding an incident between Resident #12 and CNA E. She said she would immediately tell the Administrator of any allegations regarding abuse. She said CNA E was terminated on Monday, 10/24/22 for not reporting Resident #3's responsible party's allegation of abuse to the Administrator. Record Review of Resident #14's admission Record dated 10/29/22 indicated the [AGE] year-old female resident was re-admitted to the facility on [DATE] with diagnoses which included mild cognitive impairment and anxiety. Record Review of Resident #14's quarterly MDS dated [DATE] indicated the resident was cognitively intact with a BIMS score of 15 (a score of 13-15 indicated no cognitive impairment). In an observation and interview on 10/26/22 at 4:04 PM, Resident #14 was in bed in her room. She said she had been the Resident Council President about a month. She said, in the Resident Council Meeting in October 2022 it was discussed how the staff were speaking to the residents, at times. She said the residents perceived some of the staff to be snotty and argumentative, at times, like when a resident needed something the staff acted like they were doing the resident a favor instead of the fact that the staff worked for the residents. She said this was discussed in the council because staffs' attitudes towards the residents were getting worse not better. She said Medical Records came in and asked her, last week on 10/20/22 about her treatment in the facility. She said she told her about an incident on Monday 10/17/22 around 5:00 PM, she requested to be transferred from her wheelchair to bed and provided incontinent care. She said CNA E told her go to room and get in position. She said she followed instructions and waited over an hour and then put the call light on. She said CNA E came into the room yelling and screaming that the resident should not have put the call light on and that she had to just wait her turn for assistance. She said she told CNA E she was going to report her, and CNA E told her to go ahead because she did not have to answer to the resident. She said CNA E was screaming over her and pointing her finger. She said CNA E then went to her roommate's (Resident #13) side of the bed, the roommate was in bed, CNA E was standing over Resident #13, still yelling, and pointing her finger but was directed at her (Resident #14) and not the roommate (Resident #13). She said Resident #13 became afraid CNA E was going to hit her and Resident #13 started crying. She said she told Resident #13 not to cry because CNA E was mad at her (Resident #14). She said CNA E left the room, and Resident #13, who does not cuss, said Holy Shit!. She said about an hour later, the same evening, Resident #13 just wanted to ask a question, so she put the call light on, and CNA E came in the room screaming again. She said CNA E asked them What is your problem why is the call light on again?. She said Resident #13 apologized and said she just wanted to ask the AD something. She said she had been a resident at the facility for 5 years and CNA E had always had a temper. She said CNA E had an attitude like she was invincible because nothing ever happened to her, and she felt like she would not get fired. She said CNA E had always had a bad temper, but it had never been like this before. She said she did not tell anyone about the incident until the Medical Records person asked her about abuse on 10/20/22. She said she was verbally abused and intimidated by CNA E on 10/17/22. In an interview on 10/26/22 at 4:47 PM, the DON and the Clinical Resource RN said Medical Records had the Safe Surveys dated 10/20/22, on her person, for Residents #12, #13, and #14. She said Medical Records reported them verbally to the Administrator on 10/20/22 but did not give him the forms. They said the Administrator and Medical Records were suspended pending the outcome of the investigation. Record Review of Safe Surveys dated 10/20/22, not timed, indicated the question, Do you feel that you have been intentionally injured by a team member? -Resident #12 - verbal abuse -Resident #13 - verbal abuse with violently yelling and afraid CNA E would hit her on Monday (10/17/22) -Resident #14 - verbally abused with attitude - CNA E Record Review revealed Medical Records completed the three above Safe Surveys again on 10/20/22, not timed, and all three residents' answers to Do you feel you have been intentionally injured by a team member? were changed to, No. In an interview on 10/27/22 at 10:02 AM, the Clinical Resource RN and DON said the facility began in-services with all staff on the types of abuse, with a written quiz. The DON was made the Abuse Prevention Coordinator. The facility began interview with staff to see if any abuse allegations had been reported to the Administrator that were not acted upon. The facility began a root cause analysis. She said the Safe Surveys conducted on 10/20/22 with Residents #12, #13, and #14 revealed verbal abuse by CNA E. The DON said CNA E worked on 10/21/22, after the allegations of verbal abuse were reported to the Administrator on 10/20/22. She said CNA E did not work after 10/21/22. She said CNA E was terminated on 10/24/22 for not reporting the allegation of abuse made by Resident #3's responsible party, but not related to the allegations of verbal abuse. Record Review of CNA E's time sheet dated 10/27/22 indicated she worked on 10/21/22 from 2:24 PM - 9:48 PM, 7.4 hours. Attempts were made to interview CNA E on 10/28/22 at 5:23 PM, 7:24 PM, and 10/29/22 at 12:19 PM, there was no answer to the phone call and messages, a text was also sent on 10/29/22 at 12:20 PM requesting an interview, no return call was received prior to the exit on 10/29/22 at 1:00 PM. In a telephone interview on 10/27/22 at 5:26 PM, Medical Records said she told the Administrator immediately about each of the allegations of verbal abuse on 10/20/22. She said she told him after each allegation was made. She said the DON was also present, during the discussion with the Administrator. She said the administrator told her to shred Resident #12, #13, #14's Safe Surveys that revealed verbal abuse. She said he told her State was not looking at verbal abuse as being intentionally injured. She said the Administrator, then gave her new forms to complete with the same residents again. She said on 10/26/22, after the investigator asked about the Safe Surveys, she got the three original Safe Surveys for Resident #12, #13, and #14 out of the shred bin to give to the Administrator. She said the Administrator understood on 10/20/22 Residents #12, #13, and #14 had alleged they were verbally abused by CNA E. In an interview on 10/27/22 at 5:41 PM, the DON said she was not involved in the conversation regarding the abuse, as stated above, on 10/20/22. She said she was not aware of abuse being reported on the three residents (Residents #12, #13, and #14) in question. In a telephone interview on 10/27/22 at 5:45 PM, the Administrator said DON was not in the room when Medical Records discussed the verbal abuse allegations. He said Medical Records did notify him on 10/20/22 of the verbal abuse allegations. He said with everything going on the verbal abuse allegations did not cross his mind again. He said yesterday (10/26/22) Medical Records did get the Safe Surveys out of the shred bin, but he did not tell her to shred them. He told her to set them aside in his office. He said he did ask her to conduct new Safe Surveys on Resident #12, #13, and #14 because he did not believe verbal abuse was applicable to the question, Do you feel that you have been intentionally injured by a team member?. He said he was aware of the facility abuse policy and reporting requirements. In an interview on 10/27/22 at 6:35 PM, Resident #14 said she was having increased anxiety related to the verbal abuse from CNA E and just a combination of things. She said she might need an increase in her anti-anxiety medication. Record Review of the facility's Abuse: Prevention of and Prohibition Against dated October 2022 indicated verbal abuse included the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representative, or within their hearing distance, regardless of their [NAME], ability to comprehend, or disability. Prevention included - all staff, residents and visitors are encouraged to report incidents and grievances without the fear of retribution. Supervising staff to identify and correct any inappropriate or unprofessional behaviors. Identifying, correcting, and intervening in situations in which abuse is more likely to occur. Investigation included - all identified events are reported to the Administrator immediately. After receiving the allegation, during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm. Protection included - immediately removing the employee from the care of any resident when an allegation