**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations involving abuse or neglect were reported to the facility Administrator immediately but no later than 2 hours for 1 of 6 residents (Resident #34) reviewed for abuse and neglect. The facility failed to immediately notify their Abuse Coordinator (the Former Administrator) when the Weekend Activities Assistant had yelled at Resident #34 at the nurse's station in front of other residents and staff on 07/14/24. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 07/14/24 and ended on 07/14/24. The facility had corrected the noncompliance before the investigation began. This failure placed residents at risk of continued abuse, trauma, and psychosocial harm. Findings included: Record review of the facility's Reporting Abuse to Facility Management policy, revised December 2009 reflected the following: It is the responsibility of our employees, facility consultants, Attending Physicians, family members, visitors etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management .3. All personnel, residents, family members, visitors, etc., are encouraged to report incidents of resident abuse or suspected incidents of abuse .9. When an incident of resident abuse is suspected or confirmed, the incident must be immediately reported to facility management regardless of the time lapse since the incident occurred. Reporting procedures should be followed as outlined in this policy. Record review of Resident #34's admission Record, dated 10/22/24, reflected the was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #34's Quarterly MDS Assessment, dated 09/13/24, reflected she had a BIMS score of 15, indicating no cognitive impairment. Her diagnoses included anxiety disorder (characterized by intense, excessive, and persistent worry and fear about everyday situations), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), and psychotic disorder (a group of serious mental illnesses that all have signs of psychosis, which is characterized by an impaired relationship with reality, often including confusion, hallucinations, and delusions). Record review of Resident #34's care plan, revised on 08/22/24, reflected the following: Focus: [Resident #34 is at risk for adverse psychosocial effects related to verbal allegation .Goal: Will have no indications of psychosocial well being problems by/through review date .Interventions: Consult with: Pastoral care, Social services, Psych services .When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Observation and interview on 10/23/24 at 9:47 AM revealed Resident #34 lying in her bed in her room. Resident #34 said she was doing okay now but was very upset about what happened between her and the Weekend Activities Assistant. Resident #34 said the Weekend Activities Assistant had yelled at her because she thought the resident said something to her friend by telling him to come to her room but she never told him to do that. Resident #34 said the Weekend Activities Assistant only wanted to believe the male resident, so she got mad at Resident #34 and hurt her feelings by yelling at her. Resident #34 said it also embarrassed her because the Weekend Activities Assistant yelled at her in front of people and put her hand on her thigh. Resident #34 said she told someone about what happened and got the Weekend Activities Assistant fired for yelling at her. Resident #34 said it made her feel really bad about herself because it was in front of people who then took the Weekend Activities Assistant's side of things. Resident #34 said the situation made her cry and not want to leave her room. Resident #34 said lots of residents loved the Weekend Activities Assistant, including herself, until she yelled at her and things changed. Telephone interview on 10/24/24 at 8:28 AM with Resident #34's family member revealed she was called one day and was told that the Weekend Activities Assistant was very rude to Resident #34 and touched her leg. Resident #34's family member said then the Weekend Activities Assistant came to Resident #34's room and told her it was all her fault, they let me go. Resident #34's family member said Resident #34 was very upset and crying over the situation. Resident #34's family member said the Weekend Activities Assistant was rude on many occasions to the residents at the facility. Record review of the facility's Provider Investigation Report, dated 07/22/24, reflected an incident date of 07/14/24 involving Resident #34 and The Weekend Activities Assistant. The Description of the Allegation section reflected: Resident alleged the activity director hit her leg and yelled at her at the nurses station for kissing another resident who is no longer her friend. The Provider Response section reflected: .Education continues for MANE . The Provider Action Taken Post-Investigation section reflected: We recommend termination of employee for violating our policy for abuse, neglect, and retaliation/fear of reprisal for any resident. We will Continue training and add the communications and inappropriate texts and messaging to the training [sic] . The facility investigation findings reflected the facility confirmed abuse had occurred. Record review of a witness statement from the Weekend Activities Assistant, dated 07/14/24 reflected: Upon arrival, I saw the grievance on the floor from [Resident #22], stating that [Resident #45] keeps coming into thier private living area uninvited, after being told to stay away- I went to [Resident #45], asked him why he can't follow our wishes to stay away from [Resident #34]. He again said 'ok, I wont go in there anymore, but tell her to quit telling me to come in.' After that, I went to [Resident #34] and asked her what happened- her story was that she doesn't want anything to do with him and he is the one that keeps pursuing her- I asked her if she knew how much this affected her Roommate- And that [Resident #22] was told by [Resident #34] that [Resident #45] had kissed her, but her story changed 3X, [Resident #34], says that I hit her leg- This is simply a bald-face lie- I did not put my hand on her, in anyway shape or form This statement is true- [signed by the Weekend Activities Assistant] [sic]. Telephone interview on 10/23/24 at 9:20 AM with the Weekend Activities Assistant revealed Resident #34 accused her of hitting and kicking her three times. The Weekend Activities Assistant said she never laid a hand on Resident #34. The Weekend Activities Assistant said she was terminated from the facility because she went to Resident #34's room and told the resident she should not have said those things. The Weekend Activities Assistant said she never retaliated against Resident #34. The Weekend Activities Assistant said when she talked to Resident #34 at the nurse's station, there were 3 nurses standing nearby and 5 other residents. The Weekend Activities Assistant said she never got loud while talking with Resident #34 but her voice was loud to begin with. The Weekend Activities Assistant said she told Resident #34 that the resident needed to decide who she wanted to be with and what she wanted to be. The Weekend Activities Assistant said she had this conversation with Resident #34 at the nurse's station with others nearby and they could hear the conversation. The Weekend Activities Assistant said she did not think the conversation would have been embarrassing to Resident #34. The Weekend Activities Assistant said she was originally suspended based on the allegation Resident #34 made. The Weekend Activities Assistant said she did not think talking to Resident #34 was abusive or went against her rights in any way. The Weekend Activities Assistant said she had called and still talked to residents at the facility but never discussed the situation regarding her being terminated. Interview on 10/23/24 at 2:05 PM with MA D revealed she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Interview on 10/24/24 at 8:15 AM with the WCN revealed she was standing at the nurse's station when the Weekend Activities Assistant came towards Resident #34. The WCN said apparently there was something that happened and she did not have the background information nor remembered the words that were said during the conversation between Resident #34 and the Weekend Activities Assistant. The WCN said the main thing she took away from it was that the Weekend Activities Assistant was yelling at Resident #34. The WCN said Resident #34 did not take it well trying and tried to tell the Weekend Activities Assistant that she did not do whatever she was accusing her of. The WCN said Resident #34 told the Weekend Activities Assistant you don't have to yell at me like that. The WCN said someone called the Former Administrator and the Weekend Activities Assistant was to be sent home. The WCN said after the told the Weekend Activities Assistant to go home, the Weekend Activities Assistant went to Resident #34's room and said, you got me fired. The WCN said Resident #34 told the Weekend Activities Assistant No, I didn't want to fire you. The WCN said the Weekend Activities Assistant should not have yelled at Resident #34, nor should she have had that conversation in public which made Resident #34 feel humiliated in front of people. The WCN said the situation happened at the nurse's station where other residents and staff were around. The WCN said when the Weekend Activities Assistant yelled at Resident #34, it was abuse even if that was how she talked that was not an excuse to treat a resident that way. The WCN said Resident #34 was crying a lot after the situation happened. The WCN said Resident #34 was at the nurse's station looking for her pain pill when she called her family member and told them that the Weekend Activities Assistant had humiliated and abused her. The WCN said staff should change the way they talk to a resident to remain respectful. The WCN said the Weekend Activities Assistant had yelled at Resident #34 twice at the nurse's station and then also went to her room on the way out of the building. The WCN said she did not consider the situation to be abuse at the time she witnessed it because she was new at the facility and other staff who witnessed it had said that was how the Weekend Activities Assistant normally talked but after the second time it happened that day, Resident #34 had called her family member to report it to them. The WCN said she did not like what was said to Resident #34 so she reported it to the Former Administrator. The WCN said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Interview on 10/24/24 at 8:37 AM with CNA V revealed Resident #34 came up to her and said the Weekend Activities Assistant had yelled at her. CNA V said she told the nurse and Resident #34 was going to write a grievance about it. CNA V said Resident #34 was very upset and was crying about the situation. CNA V said she was not sure what happened or why the Weekend Activities Assistant had yelled at Resident #34. CNA V said Resident #34 had made an allegation of abuse but she did not report it to the Former Administrator. CNA V said she had been told to report any allegation of abuse to the Former Administrator but did not think about it at the time. CNA V said she realized that she should have immediately reported the allegation of abuse to the Former Administrator and would immediately report an allegation to the current Administrator. CNA V said she was not sure who the nurse was that told Resident #34 to file a grievance about the Weekend Activities Assistant yelling at her. CNA V said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Telephone interview on 10/24/24 at 3:00 PM with the Former Administrator revealed staff called her and told her that Resident #34 made an allegation to them about the Weekend Activities Assistant, saying she cussed and yelled at her at the nurse's station. The Former Administrator told them what steps to make, including letting the Weekend Activities Assistant know she has to leave out of the building. Interview on 10/24/24 at 3:22 PM with the Administrator revealed he started at the facility on 10/03/24 and was not fully aware of the self-reports from July. The Administrator said he expected staff to treat residents with dignity and respect. The Administrator said staff were not allowed to yell at residents and that would be considered abuse. The Administrator said all staff were trained on the facility's abuse policy and were expected to follow it. The Administrator said all staff were responsible for ensuring residents were free from abuse. The Administrator said all staff knew to report abuse immediately to him, as the Abuse Coordinator. The Administrator said if a resident was abused it could destroy their emotional state, cause them to feel disrespected or belittled, or could cause them to become depressed. Record review of an in-service, dated 07/14/24, reflected staff were trained on the facility's policy regarding abuse and neglect, including when, what, and to whom abuse should be reported to; the WCN and CNA V had both signed the in-service. The Administrator was notified on 10/24/24 at 4:58 PM, that a past non-compliance IJ situation had been identified due to the above failures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 2 of 6 residents (Residents #34 and #3) reviewed for abuse. 1. The facility failed to ensure Resident #34 had the right to be free from abuse when she was verbally and mentally abused by the Weekend Activities Assistant on 07/14/24. 2. The facility failed to ensure Resident #3 had the right to be free from abuse when he was verbally and mentally abused by CNA U on 07/08/24. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 07/08/24 and ended on 07/14/24. The facility had corrected the noncompliance before the investigation began. These failures placed residents at risk of abuse, trauma, and psychosocial harm. Findings included: 1. Record review of Resident #34's admission Record, dated 10/22/24, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #34's Quarterly MDS Assessment, dated 09/13/24, reflected she had a BIMS score of 15, indicating no cognitive impairment. Her diagnoses included anxiety disorder (characterized by intense, excessive, and persistent worry and fear about everyday situations), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), and psychotic disorder (a group of serious mental illnesses that all have signs of psychosis, which is characterized by an impaired relationship with reality, often including confusion, hallucinations, and delusions). Record review of Resident #34's care plan, revised on 08/22/24, reflected the following: Focus: [Resident #34] is at risk for adverse psychosocial effects related to verbal allegation .Goal: Will have no indications of psychosocial well being problems by/through review date .Interventions: Consult with: Pastoral care, Social services, Psych services .When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Record review of Resident #34's Psychiatric Follow Up, dated 07/17/24, reflected: Staff reports: more tearful/withdrawn since an incident with staff member .Presents: in activity room with peers agreed to leave for interview .Subjective: 'not so good' said another resident came in her room and they kissed one night next day he changed details of the event to others, [the Weekend Activities Assistant] confronted her publicly about it. It made her uncomfortable, now feels others do not like her. Wants to isolate in her room to avoid perceived shame/judgement. [arrow up] dep/stress/anx denies- SI/HI, irritability, mania psychosis, insomnia, [arrow down] appetite no other concerns reported [sic]. Record review of Resident #34's Psychological Services Progress Note, dated 07/24/24, reflected: Patient's Response to Intervention: Pt is stressed and angry today - has had some conflicts with peers and is still upset and reactive to those - she is responsive to some de escalation and redirection to coping vs over focus on recent past incidents. Followed up with staff Record review of witness statement written by the Housekeeping Supervisor for Resident #34 dated 07/14/24 reflected: Today July 14, 2024, witnessed by the [WCN] and [MA D] & Nurse, The Weekend Activities Assistant said to resident 'You told [Resident #45] to come in the room, when he is not allowed in the room, and yall are going to be seperated to different facilitys.' Resident states she was yelling at her 'for kissing [Resident #45] and asking him to come in her room, and should have told him to leave the room.', Resident called her [family member] and told her about situation. Resident states she did not hit her but did not apreciate how she yelled at her, also that The Weekend Activities Assistant came to her room after word went to The Weekend Activities Assistant about situation and states- 'The Weekend Activities Assistant told me she was going to get fired because of her lying about it and you don't even feel bad about it.' Resident states- -[Resident #22] lied to [the Weekend Activities Assistant] and thats why she was trying to tell her to not allow him in her room but yelled at her. -Resident was Asked- Do you feel like you were abused?- -Residents Answer- 'No, just yelling and did not understand why [the Weekend Activities Assistant] came in here to tell her she is going to get her fired.' witness 1) X [signed by the WCN] 2) X __[blank]_______ X Resident [signed by Resident #34] X [signed by the Housekeeping Supervisor] [sic]. Observation and interview on 10/23/24 at 9:47 AM revealed Resident #34 lying in her bed in her room. Resident #34 said she was doing okay now but was very upset about what happened between her and the Weekend Activities Assistant. Resident #34 said the Weekend Activities Assistant had yelled at her because she thought something that was not true. Resident #34 said the Weekend Activities Assistant only wanted to believe the male resident, so she got mad at her and hurt her feelings by yelling at her. Resident #34 said it also embarrassed her because the Weekend Activities Assistant yelled at her in front of people and put her hand on her thigh. Resident #34 said she told someone about what happened and got the Weekend Activities Assistant fired for yelling at her. Resident #34 said it made her feel really bad about herself because it was in front of people who then took the Weekend Activities Assistant's side of things. Resident #34 said the situation made her cry and not want to leave her room. Resident #34 said lots of residents loved the Weekend Activities Assistant, including herself, until she yelled at her and things changed. Telephone interview on 10/24/24 at 8:28 AM with Resident #34's family member revealed the family member was called one day and was told the Weekend Activities Assistant was very rude to Resident #34 and touched her leg. Resident #34's family member said then the Weekend Activities Assistant came to Resident #34's room and told her it was all her fault, they let me go. Resident #34's family member said Resident #34 was very upset and crying over the situation. Resident #34's family member said the Weekend Activities Assistant was rude on many occasions to the residents at the facility. Telephone interview on 10/23/24 at 9:20 AM with the Weekend Activities Assistant revealed Resident #34 accused her of hitting and kicking her three times. The Weekend Activities Assistant said she never laid a hand on Resident #34. The Weekend Activities Assistant said she was terminated from the facility because she went to Resident #34's room and told the resident she should not have said those things. The Weekend Activities Assistant said she never retaliated against Resident #34. The Weekend Activities Assistant said when she talked to Resident #34 at the nurse's station, there were 3 nurses standing nearby and 5 other residents. The Weekend Activities Assistant said she never got loud while talking with Resident #34 but her voice was loud to begin with. The Weekend Activities Assistant said she told Resident #34 that the resident needed to decide who she wanted to be with and what she wanted to be. The Weekend Activities Assistant said she had this conversation with Resident #34 at the nurse's station with others nearby and they could hear the conversation. The Weekend Activities Assistant said she did not think the conversation would have been embarrassing to Resident #34. The Weekend Activities Assistant said she was originally suspended based on the allegation Resident #34 made. The Weekend Activities Assistant said she did not think talking to Resident #34 was abusive or went against her rights in any way. The Weekend Activities Assistant said she had called and still talked to residents at the facility but never discussed the situation regarding her being terminated. Record review of a witness statement written by the Housekeeping Supervisor dated 07/14/24 reflected: To whom it may concern, I [Housekeeping Supervisor], I was on the west hall when I overheard Resident #34 call her [family member] to tell her the activities person [the Weekend Activities Assistant] was cussing and yelling and kicking her legs. I informed the [WCN and the Administrator] of the situation after witnessing [CNA V] tell [the Weekend Activities Assistant] that [Resident #34] is claiming abuse by her and I saw [the Weekend Activities Assistant] storm off- from investigation- it was told to me by [Resident #34] & [the Weekend Activities Assistant] 'that [the Weekend Activities Assistant] went into room to confront resident about situation because you know I did not abuse you, you will get me fired'- the [WCN] and I [the Housekeeping Supervisor] conducted investigation and sent [the Weekend Activities Assistant] home for the day per request of Admin, until investigation is completed. [sic]. Interview on 10/23/24 at 10:16 AM with the Housekeeping Supervisor revealed she did not witness anything that happened between Resident #34 and the Weekend Activities Assistant on 07/14/24. The Housekeeping Supervisor said she was cleaning and coming down the hallway when Resident #34 was on the phone at the nurse's station with her family member and said that the Weekend Activities Assistant had yelled at her, was being very rude to her, and came into her room and touched her leg. The Housekeeping Supervisor said Resident #34 told her family member that she was being neglected and abused. The Housekeeping Supervisor said she went to tell the WCN who had given Resident #34 the telephone to begin with. The Housekeeping Supervisor said she called the Previous Administrator to tell her about the allegation that Resident #34 made. The Housekeeping Supervisor said she was told to go and talk to Resident #34 to get her story which was that the Weekend Activities Assistant had yelled at her at the nurse's station and in her room. The Housekeeping Supervisor said she went to talk to the Weekend Activities Assistant who said she had gone back to Resident #34's room to confront her. The Housekeeping Supervisor said she was told to send the Weekend Activities Assistant home that day on 07/14/24. The Housekeeping Supervisor said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Interview on 10/23/24 at 10:43 AM with the Social Worker revealed Resident #34 and another resident in the facility were in a relationship until the male resident ended it. The Social Worker said Resident #34 was severely affected by it emotionally until the male resident tried to start up the relationship again. She said Resident #34 was not sure what to do and asked others to help her make the decision. She said the intention the Weekend Activities Assistant had in talking with Resident #34 about the situation was that either she wanted to be with the male resident or she did not, but the Weekend Activities Assistant did not want Resident #34 presenting one way to them and then another way to the male resident regarding their relationship. The Social Worker said on the day of the incident (07/14/24), the male resident went to Resident #34's room and there was some confusion as to whether Resident #34 invited him to see her or he went in on his own. She stated Resident #34 was already in an emotional state and misconstrued what the Weekend Activities Assistant said which was probably a training issue. The Social Worker said the problem with what the Weekend Activities Assistant did was when she went back to confront Resident #34 when she said to her look what you did, you got me fired. She stated this was not true, the Weekend Activities Assistant was only suspended pending the investigation at the time. The Social Worker said the real issue was that the Weekend Activities Assistant had talked to Resident #34 about the situation in front of everyone which made the resident feel embarrassed. The Social Worker said the Weekend Activities Assistant continued to be inappropriate when she was campaigning for herself to the other residents because the lines were blurred between employee and residents. The Social Workre said while the Weekend Activities Assistant was suspended pending the investigation, she had called residents on their personal cell phones which was viewed as retaliatory. The Social Worker said she spoke with Resident #34 who blamed herself for getting the Weekend Activities Assistant fired, so she explained to the resident that the Weekend Activities Assistant was terminated based upon her own actions. The Social Worker stated she followed-up with Resident #34 to ensure she was okay. She said she knew to report any abuse or allegation immediately to the Administrator and would do so now and that yelling at a resident was considered abuse. Record review of a witness statement written by MA D, dated 07/14/24, reflected: I [MA D], on the above date, 07/14/24, and approximate time of 0900 [9:00 AM], I did witness [the Weekend Activities Assistant], Activity Director approch down the hallway towards [Resident #34], she had mentioned to me [Resident #22] had left a grievance on her desk regarding [Resident #45] and [Resident #34]. She continued down the hallway to [Resident #34] at the nursing station, she was a little loud and showing concern towards [Resident #34]. I did witness what seemed to be [the Weekend Activities Assistant] a bit angry at the situation. I did not witness additional conversation as I was busy. End of report. [sic]. Interview on 10/23/24 at 2:05 PM with MA D revealed the Weekend Activities Assistant had verbally abused Resident #34 very loudly in the hallway where everyone could hear it and she wrote a witness statement about it. MA D said the Weekend Activities Assistant was very angry with Resident #34 because there was a grievance written about her. MA D said she saw the Weekend Activities Assistant in the hallway upset and in passing said she was so mad about the grievance. MA D said the Weekend Activities Assistant was upset because it was like a soap opera in the facility and said the Weekend Activities Assistant said she was sick of [Resident #34] crying for days about her male friend in the facility. MA D said the Weekend Activities Assistant was saying she was sick of [Resident #34] going back and forth with her male friend because he upset Resident #34 so much. MA D said she was down the hallway passing medications when she saw Resident #34 at the nurse's station in front of everyone and the charge nurse intervened to take Resident #34 to her room away from the Weekend Activities Assistant who had just yelled at her. MA D said Resident #34 was bawling, crying, and extremely visibly upset at what had just happened. MA D said Resident #34 was very emotional about the situation for a long time because the other residents were giving her a hard time because they loved the Weekend Activities Assistant. MA D said Resident #34 for a while and would not come out of her room after the situation had occurred. MA D said now Resident #34 has reintegrated again and people have stopped talking about what happened, but Resident #34 was blamed for the Weekend Activities Assistant being terminated by other residents. MA D said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Record review of a witness statement written by the WCN and dated 07/14/24 reflected: In the morning at the nursing station west while [Resident #34] is at the nursing station awaiting for nurse to give pain pill, [Resident #45] passed by her and where talking and I saw [the Weekend Activities Assistant] start separating them because they kissed on Thursday and she was telling them not to be in the room together, and resident was refusing, I did not let him in my room, [the Weekend Activities Assistant] replies yes he said that you called him to come. [The Weekend Activities Assistant] voice tone was really loud, and ended having resident cry- stating that she should not yell at her in the presence of many people. No touching or hitting observed. After patient talking to [family member] state she's been abused by [the Weekend Activities Assistant], who yelled at her in public and Administrator was notified. [sic]. Interview on 10/24/24 at 8:15 AM with the WCN revealed she was standing at the nurse's station when the Weekend Activities Assistant came towards Resident #34. The WCN said apparently there was something that happened and she did not have the background information nor remembered the words that were said during the conversation between Resident #34 and the Weekend Activities Assistant. The WCN said the main thing she took away from it was that the Weekend Activities Assistant was yelling at Resident #34. The WCN said Resident #34 did not take it well trying and tried to tell the Weekend Activities Assistant that she did not do whatever she was accusing her of. The WCN said Resident #34 told the Weekend Activities Assistant you don't have to yell at me like that. The WCN said someone called the Previous Administrator and the Weekend Activities Assistant was to be sent home. The WCN said after the Weekend Activities Assistant was told to go home, the Weekend Activities Assistant went to Resident #34's room and said you got me fired. The WCN said Resident #34 told the Weekend Activities Assistant No, I didn't want to fire you. The WCN said the Weekend Activities Assistant should not have yelled at Resident #34, nor should she have had that conversation in public which made Resident #34 feel humiliated in front of people. The WCN said the situation happened at the nurse's station where other residents and staff were around. The WCN said when the Weekend Activities Assistant yelled at Resident #34, it was abuse even if that was how she talked that was not an excuse to treat a resident that way. The WCN said Resident #34 was crying a lot after the situation happened. The WCN said Resident #34 was at the nurse's station looking for her pain pill when she called her family member and told them that the Weekend Activities Assistant had humiliated and abused her. The WCN said staff should change the way they talk to a resident to remain respectful. The WCN said the Weekend Activities Assistant had yelled at Resident #34 twice at the nurse's station and then also went to her room on the way out of the building. The WCN said she did not consider the situation to be abuse at the time she witnessed it because she was new at the facility and other staff who witnessed it had said that was how the Weekend Activities Assistant normally talked but after the second time it happened that day, Resident #34 had called her family member to report it to them. The WCN said she did not like what was said to Resident #34 so she reported it to the Previous Administrator. The WCN said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Record review of an undated witness statement written by CNA V reflected: In the morning on [blank space] [Resident #34] was @ the Desk crying I asked her what was going on she told me [the Weekend Activities Assistant] yelled @ her. And it wasn't right and who to talk to. I told the Nurse on duty that she wanted to report [the Weekend Activities Assistant] for yelling @ her. [sic]. Interview on 10/24/24 at 8:37 AM with CNA V revealed Resident #34 came up to her and said the Weekend Activities Assistant had yelled at her. CNA V said she told the nurse and Resident #34 was going to write a grievance about it. CNA V said Resident #34 was very upset and was crying about the situation. CNA V said she was not sure what happened or why the Weekend Activities Assistant had yelled at Resident #34. CNA V said Resident #34 had made an allegation of abuse. CNA V said she was not sure who the nurse was that told Resident #34 to file a grievance about the Weekend Activities Assistant yelling at her. CNA V said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Interview on 10/24/24 at 9:00 AM with Resident #34's Psychiatric NP revealed he had cared for Resident #34 before and after the incident of abuse from 07/14/24. He stated Resident #34 was very sensitive and staff had to be aware of how they said things to her and where they said them. He stated the situation made Resident #34 feel very uncomfortable at the facility. He stated the situation with the Weekend Activities Assistant easily upset Resident #34 and made her self-isolate for a few weeks but that was just his guess on the timeline. The Psychiatric NP said Resident #34 was a very anxious resident who marinated/ruminated on things easily. He stated Resident #34 self-isolated because she felt as if others did not like her due to the Weekend Activities Assistant being fired. The Psychiatric NP said Resident #34 seemed back to normal now and was out of her room enjoying activities with others. During a confidential interview with a resident, the resident revealed she talked to the Weekend Activities Assistant often on the phone. The resident stated she was not supposed to say anything but was willing to tell the surveyor what they talked about sometimes. The resident said the Weekend Activities Assistant had yelled at her before, but she never reported it to anyone. The resident said she was cleaning up the activity room one day when the Weekend Activities Assistant walked up to her face and said, Why did you do that? Now I'm not going to be able to find anything in here! The resident said she wheeled out of the room away from the Weekend Activities Assistant. The resident said she and everyone else knew that the Weekend Activities Assistant had a temper, but that did not mean she could talk to people any kind of way. The resident said it made her feel bad that the Weekend Activities Assistant yelled at her, but she figured it was related to something with the Weekend Activities Assistant's home life because she knew things were not good. The resident said she knew the Weekend Activities Assistant had yelled at a few people, but no one ever reported her. She stated she was not sure why the Weekend Activities Assistant was always yelling. The resident said she was not afraid of the Weekend Activities Assistant but did not like that she yelled at people. The resident said she overheard the Weekend Activities Assistant yelling at Resident #34 because the Weekend Activities Assistant believed the male resident over Resident #34. The resident said the Weekend Activities Assistant got upset with Resident #34 and went to talk to her at the nurses' station. The resident said she was not sure why the Weekend Activities Assistant yelled at Resident #34 in front of everyone, but it made Resident #34 very upset, made her cry, and made her not want to leave her room for a while. The resident said the Weekend Activities Assistant should not have embarrassed Resident #34 that way by yelling at her in front of everyone or yelling at her in general but the Weekend Activities Assistant let her temper get the best of her. The resident said after the Weekend Activities Assistant had to leave the facility, she said it was because she broke a rule but the Resident was not allowed to tell anyone that was what the Weekend Activities Assistant had told her. Telephone interview on 10/24/24 at 3:00 PM with the Former Administrator revealed staff called her and told her Resident #34 made an allegation to them about the Weekend Activities Assistant, saying she cussed and yelled at her at the nurse's station. The Former Administrator told them what steps to take, including letting the Weekend Activities Assistant know she had to leave the building. The Former Administrator said the Weekend Activities Assistant did talk loud, so someone could perceive things as yelling or screaming. She stated as the Weekend Activities Assistant was leaving the facilitiy she was retaliatory towards Resident #34. She stated the Weekend Activities Assistant put her hands on her hips and told Resident #34, Why did you say all those lies about me? You got me fired., as she was leaving the building. The Former Administrator said Resident #34 had psychological issues that could be perpetuated by the Weekend Activities Assistant's behavior towards her. She stated she had to ask the Weekend Activities Assistant not to call the residents anymore because it was putting fuel on the fire regarding her behavior because she made the residents worried about her after she got fired. She stated the Weekend Activities Assistant could not separate the residents as customers of hers and honor them with respect instead of treating them like they were her family members. The Former Administrator said a resident had reported to her that the Weekend Activities Assistant had talked loud and hateful to some people especially if they gossiped, and the residents talked about her like she was another resident and not like an employee. She stated a resident had reported that the Weekend Activities Assistant did get mad and raised her voice but she still loved the residents. She said she had to tell the resident that she still had a duty to fulfill as the Administrator to keep the residents safe. Record review of a witness statement from the Weekend Activities Assistant, dated 07/14/24 reflected: Upon arrival, I saw the grievance on the floor from [Resident #22], stating that [Resident #45] keeps coming into thier private living area uninvited, after being told to stay away- I went to [Resident #45], asked him why he can't follow our wishes to stay away from [Resident #34]. He again said 'ok, I wont go in there anymore, but tell her to quit telling me to come in.' After that, I went to [Resident #34] and asked her what happened- her story was that she doesn't want anything to do with him and he is the one that keeps pursuing her- I asked her if she knew how much this affected her Roommate- And that [Resident #22] was told by [Resident #34] that [Resident #45] had kissed her, but her story changed 3X, [Resident #34], says that I hit her leg- This is simply a bald-face lie- I did not put my hand on her, in anyway shape or form This statement is true- [signed by the Weekend Activities Assistant] [sic]. Record review of an undated and unsigned witness statement that was included in the facility's provider investigation report evidence reflected: .Even tho, [the Weekend Activities Assistant] has a temper. She was upset with us before, but we know, she loves us .If [the Weekend Activities Assistant] needs to control that more have her talk with someone .[sic]. Record review of the facility's Provider Investigation Report, dated 07/22/24, reflected an incident date of 07/14/24 involving Resident #34 and the Weekend Activities Assistant. For the Description of the Allegation section was: Resident alleged the activity director hit her leg and yelled at her at the nurses station for kissing another resident who is no longer her friend. The Provider Response section reflected: Activity director was sent home on suspension as a precaution on Sunday following the communication. She then alleged it was abuse on Monday and no longer inappropriate comments. Resident did say that [the Weekend Activities Assistant] never hit her. She tapped her on the leg bending down to speak to her while she was sitting in her wc at the ns. Interviews with staff and other residents was completed to determine any other witnesses possible or other information related to the investigation. Education continues for MANE. Additional training added regarding separation of employees and residents and a healthy, professional boundary. Psych services were called. MD called. Medical director informed. Planned call with [Resident #34's family member] on 7/23/2024 to review final findings of the investigation [sic]. The Investigation Summary reflected: [The Weekend Activities Assistant's] communication was witnessed at the station to be loud and with her usual deep, loud voice .The problem is that the employee was informed later about the resident's comments by another CNA. She became upset and went back to resident in her room with hands on hip saying, 'Why did you lie about me.' 'You got me fired. You don't even care.' The activity director then started calling around to other residents on their personal cell phones to discuss her being upset she got fired perpetuating the theatrics of the matter further placing [Resident #34] at risk for feeling the act director has retaliated against her for reporting the matter. The resident says she frequently pits one resident against another with comments or actions .She had been counseled on multiple occasions about toning down her voice, and remaining focused on her personal feelings or beliefs with regard to residents and their needs. We feel she struggles to separate her being the residents 'friends' and being their paid employee and understanding her responses are required to be above reproach. We found through interviews, she is still calling the residents as of this evening of this report. She told another resident via text that '[Resident #34] ruined her life.' .It is unclear why she intentionally went down to the residents' room to 'confront her'. Regardless, it was inappropriate and with disregard for or lack of true understanding of the consequences of her actions. [sic]. The Provider Action Taken Post-Investigation section reflected: We recommend termination of employee for violating our policy for abuse, neglect, and retaliation/fear of reprisal for any resident. We will Continue training and add the communications and inappropriate texts and messaging to the training. Separation is required for employees. We treat our residents like family but there is a professional line. Ongoing monitoring for resident continues to ensure there are no lasting adverse outcomes related to this incident. Counseling as necessary for support services for resident. SW and Administrator will continue checking ins. [sic]. The facility investigation findings confirmed abuse had occurred. Record review of the grievances binder and log for the last three months revealed there was no grievance on file regarding the Weekend Activities Assistant yelling at Resident #34. Record review of an undated and untitled paper provided by the facility reflected personnel information for the Weekend Activities Assistant including a position start date of 11/18/20, a termination date of 07/30/24 with a termination reason of Gross Misconduct; a last work date of 07/14/24 and comments of Discourtesy to residents .please refer to separation notice. Record review of an in-service, dated 07/14/24, reflected staff were trained on the facility's policy regarding abuse and neglect, including when, what, and to whom abuse should be reported to; the WCN and CNA V had both signed the in-service. 2. Record review of Resident #3's admission Record, dated 10/22/24, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #3's Annual MDS Assessment, dated 10/04/24, reflected he had a BIMS score of 13, indicating no cognitive impairment. Further review revealed he had a diagnosis of cerebral palsy (a group of conditions that affect movement and posture. It's caused by damage that occurs to the developing brain, most often before birth). Observation and interview on 10/23/24 at 9:30 AM of Resident #3 revealed he was in his wheelchair in the dining room alone. Resident #3 was able to remember when the CNA yelled at him. Resident #3 said the CNA was very mean to him and he felt it was abusive. Resident #3 said it made him feel bad when it happened. Resident #3 said the CNA

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect of residents for 2 of 6 residents (Residents #34 and #3) reviewed for abuse. 1. The facility failed to protect Resident #34 from retaliation after the Weekend Activities Assistant was suspended based on an allegation of abuse on 07/14/24. 2. The facility failed to protect Resident #3 from verbal and mental abuse by CNA U on 07/08/24. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 07/08/24 and ended on 07/14/24. The facility had corrected the noncompliance before the investigation began. These failures placed residents at risk of ongoing abuse, trauma, and psychosocial harm. Findings included: 1. Record review of the facility's policy, revised December 2016, and titled Abuse Investigation and Reporting reflected: .5. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. [sic]. Record review of Resident #34's admission Record, dated 10/22/24, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #34's Quarterly MDS Assessment, dated 09/13/24, reflected she had a BIMS score of 15, indicating no cognitive impairment. Her diagnoses included anxiety disorder (characterized by intense, excessive, and persistent worry and fear about everyday situations), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), and psychotic disorder (a group of serious mental illnesses that all have signs of psychosis, which is characterized by an impaired relationship with reality, often including confusion, hallucinations, and delusions). Record review of Resident #34's care plan, revised on 08/22/24, reflected the following: Focus: [Resident #34] is at risk for adverse psychosocial effects related to verbal allegation .Goal: Will have no indications of psychosocial well being problems by/through review date .Interventions: Consult with: Pastoral care, Social services, Psych services .When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Record review of Resident #34's Psychiatric Follow Up, dated 07/17/24, reflected: Staff reports: more tearful/withdrawn since an incident with staff member .Presents: in activity room with peers agreed to leave for interview .Subjective: 'not so good' said another resident came in her room and they kissed one night next day he changed details of the event to others, [the Weekend Activities Assistant] confronted her publicly about it. It made her uncomfortable, now feels others do not like her. Wants to isolate in her room to avoid perceived shame/judgement. [arrow up] dep/stress/anx denies- SI/HI, irritability, mania psychosis, insomnia, [arrow down] appetite no other concerns reported [sic]. Record review of Resident #34's Psychological Services Progress Note, dated 07/24/24, reflected: Patient's Response to Intervention: Pt is stressed and angry today - has had some conflicts with peers and is still upset and reactive to those - she is responsive to some de escalation and redirection to coping vs over focus on recent past incidents. Followed up with staff Record review of witness statement written by the Housekeeping Supervisor for Resident #34 dated 07/14/24 reflected: Today July 14, 2024, witnessed by the [WCN] and [MA D] & Nurse, The Weekend Activities Assistant said to resident 'You told [Resident #45] to come in the room, when he is not allowed in the room, and yall are going to be seperated to different facilitys.' Resident states she was yelling at her 'for kissing [Resident #45] and asking him to come in her room, and should have told him to leave the room.', Resident called her [family member] and told her about situation. Resident states she did not hit her but did not apreciate how she yelled at her, also that The Weekend Activities Assistant came to her room after word went to The Weekend Activities Assistant about situation and states- 'The Weekend Activities Assistant told me she was going to get fired because of her lying about it and you don't even feel bad about it.' Resident states- -[Resident #22] lied to [the Weekend Activities Assistant] and thats why she was trying to tell her to not allow him in her room but yelled at her. -Resident was Asked- Do you feel like you were abused?- -Residents Answer- 'No, just yelling and did not understand why [the Weekend Activities Assistant] came in here to tell her she is going to get her fired.' witness 1) X [signed by the WCN] 2) X __[blank]_______ X Resident [signed by Resident #34] X [signed by the Housekeeping Supervisor] [sic]. Observation and interview on 10/23/24 at 9:47 AM revealed Resident #34 lying in her bed in her room. Resident #34 said she was doing okay now but was very upset about what happened between her and the Weekend Activities Assistant. Resident #34 said the Weekend Activities Assistant had yelled at her because she thought something that was not true. Resident #34 said the Weekend Activities Assistant only wanted to believe the male resident, so she got mad at her and hurt her feelings by yelling at her. Resident #34 said it also embarrassed her because the Weekend Activities Assistant yelled at her in front of people and put her hand on her thigh. Resident #34 said she told someone about what happened and got the Weekend Activities Assistant fired for yelling at her. Resident #34 said it made her feel really bad about herself because it was in front of people who then took the Weekend Activities Assistant's side of things. Resident #34 said the situation made her cry and not want to leave her room. Resident #34 said lots of residents loved the Weekend Activities Assistant, including herself, until she yelled at her and things changed. Telephone nterview on 10/24/24 at 8:28 AM with Resident #34's family member revealed she was called one day and was told that the Weekend Activities Assistant was very rude to Resident #34 and touched her leg. Resident #34's family member said then the Weekend Activities Assistant came to Resident #34's room and told her it was all her fault, they let me go. Resident #34's family member said Resident #34 was very upset and crying over the situation. Resident #34's family member said the Weekend Activities Assistant was rude on many occasions to the residents at the facility. Telephone interview on 10/23/24 at 9:20 AM with the Weekend Activities Assistant revealed Resident #34 accused her of hitting and kicking her three times. She stated she never laid a hand on Resident #34. She said she was terminated from the facility because she went to Resident #34's room and told the resident she should not have said those things. The Weekend Activities Assistant said she never retaliated against Resident #34. She said when she talked to Resident #34 at the nurses' station, there were 3 nurses standing nearby and 5 other residents. The Weekend Activities Assistant said she never got loud while talking with Resident #34, but her voice was loud to begin with. She said she told Resident #34 that the resident needed to decide who she wanted to be with and what she wanted to be. She said she had this conversation with Resident #34 at the nurse's station with others nearby and they could hear the conversation. The Weekend Activities Assistant said she did not think the conversation would have been embarrassing to Resident #34. She said she was originally suspended based on the allegation Resident #34 made. She said she did not think talking to Resident #34 was abusive or went against her rights in any way. The Weekend Activities Assistant said she had called and still talked to residents at the facility but never discussed the situation regarding her being terminated. Record review of a witness statement written by the Housekeeping Supervisor dated 07/14/24 reflected: To whom it may concern, I [Housekeeping Supervisor], I was on the west hall when I overheard Resident #34 call her [family member] to tell her the activities person [the Weekend Activities Assistant] was cussing and yelling and kicking her legs. I informed the [WCN and the Administrator] of the situation after witnessing [CNA V] tell [the Weekend Activities Assistant] that [Resident #34] is claiming abuse by her and I saw [the Weekend Activities Assistant] storm off- from investigation- it was told to me by [Resident #34] & [the Weekend Activities Assistant] 'that [the Weekend Activities Assistant] went into room to confront resident about situation because you know I did not abuse you, you will get me fired'- the [WCN] and I [the Housekeeping Supervisor] conducted investigation and sent [the Weekend Activities Assistant] home for the day per request of Admin, until investigation is completed [sic]. Interview on 10/23/24 at 10:16 AM with the Housekeeping Supervisor revealed she did not witness anything that happened between Resident #34 and the Weekend Activities Assistant on 07/14/24. She said she was cleaning and coming down the hallway when Resident #34 was on the phone at the nurse's station with her family member and said that the Weekend Activities Assistant had yelled at her, was being very rude to her, and came into her room and touched her leg. She said Resident #34 told her family member that she was being neglected and abused. The Housekeeping Supervisor said she went to tell the WCN who had given Resident #34 the telephone to begin with. She said she called the Former Administrator to tell her about the allegation that Resident #34 made. The Housekeeping Supervisor said she was told to go and talk to Resident #34 to get her story which was that the Weekend Activities Assistant had yelled at her at the nurse's station and in her room. She said she went to talk to the Weekend Activities Assistant who said she had gone back to Resident #34's room to confront her. She said she was told to send the Weekend Activities Assistant home that day on 07/14/24. The Housekeeping Supervisor said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Interview on 10/23/24 at 10:43 AM with the Social Worker revealed Resident #34 and another resident in the facility were in a relationship until the male resident ended it. She said Resident #34 was severely affected by it emotionally until the male resident tried to start up the relationship again. The Social Worker said Resident #34 was not sure what to do and asked others to help her make the decision. She said the intention the Weekend Activities Assistant had in talking with Resident #34 about the situation was that either she wanted to be with the male resident or she did not, but the Weekend Activities Assistant did not want Resident #34 presenting one way to them and then another way to the male resident regarding their relationship. She said on the day of the incident (07/14/24), the male resident went to Resident #34's room and there was some confusion as to whether Resident #34 invited him to see her or he went in on his own. The Social Worker said Resident #34 was already in an emotional state and misconstrued what the Weekend Activities Assistant said which was probably a training issue. She stated the problem with what the Weekend Activities Assistant did was when she went back to confront Resident #34 and she said to her, look what you did, you got me fired. The Social Worker said this was not true, the Weekend Activities Assistant was only suspended pending the investigation at the time. She said the real issue was that the Weekend Activities Assistant had talked Resident #34 about the situation in front of everyone which made the resident feel embarrassed. She said the Weekend Activities Assistant continued to be inappropriate when she was campaigning for herself to the other residents because the lines were blurred between employee and residents. The Social Worker said while the Weekend Activities Assistant was suspended pending the investigation, she had called residents on their personal cell phones which was viewed as retaliatory. She said she spoke with Resident #34 who blamed herself for getting the Weekend Activities Assistant fired, so she explained that she was terminated based on her own actions. The Social Worker said she followed up with Resident #34 to ensure she was okay. She said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Record review of a witness statement written by MA D, dated 07/14/24, reflected: I [MA D], on the above date, 07/14/24, and approximate time of 0900 [9:00 AM], I did witness [the Weekend Activities Assistant], Activity Director approch down the hallway towards [Resident #34], she had mentioned to me [Resident #22] had left a grievance on her desk regarding [Resident #45] and [Resident #34]. She continued down the hallway to [Resident #34] at the nursing station, she was a little loud and showing concern towards [Resident #34]. I did witness what seemed to be [the Weekend Activities Assistant] a bit angry at the situation. I did not witness additional conversation as I was busy. End of report. [sic]. Interview on 10/23/24 at 2:05 PM with MA D revealed the Weekend Activities Assistant had verbally abused Resident #34 very loudly in the hallway where everyone could hear it and she wrote a witness statement about it. MA D said the Weekend Activities Assistant was very angry with Resident #34 because there was a grievance written about her. MA D said she saw the Weekend Activities Assistant in the hallway upset and in passing said she was so mad about the grievance. MA D said the Weekend Activities Assistant was upset because it was like a soap opera in the facility and said the Weekend Activities Assistant said she was sick of [Resident #34] crying for days about her male friend in the facility. MA D said the Weekend Activities Assistant was saying she was sick of [Resident #34] going back and forth with her male friend because he upset Resident #34 so much. MA D said she was down the hallway passing medications when she saw Resident #34 at the nurse's station in front of everyone and the charge nurse intervened to take Resident #34 to her room away from the Weekend Activities Assistant who had just yelled at her. MA D said Resident #34 was bawling, crying, and extremely visibly upset at what had just happened. MA D said Resident #34 was very emotional about the situation for a long time because the other residents were giving her a hard time because they loved the Weekend Activities Assistant. MA D said Resident #34 for a while and would not come out of her room after the situation had occurred. MA D said now Resident #34 has reintegrated again and people have stopped talking about what happened, but Resident #34 was blamed for the Weekend Activities Assistant being terminated by other residents. MA D said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Record review of a witness statement written by the WCN and dated 07/14/24 reflected: In the morning at the nursing station west while [Resident #34] is at the nursing station awaiting for nurse to give pain pill, [Resident #45] passed by her and where talking and I saw [the Weekend Activities Assistant] start separating them because they kissed on Thursday and she was telling them not to be in the room together, and resident was refusing, I did not let him in my room, [the Weekend Activities Assistant] replies yes he said that you called him to come. [The Weekend Activities Assistant] voice tone was really loud, and ended having resident cry- stating that she should not yell at her in the presence of many people. No touching or hitting observed. After patient talking to [family member] state she's been abused by [the Weekend Activities Assistant], who yelled at her in public and Administrator was notified. [sic]. Interview on 10/24/24 at 8:15 AM with the WCN revealed she was standing at the nurse's station when the Weekend Activities Assistant came towards Resident #34. The WCN said apparently there was something that happened and she did not have the background information nor remembered the words that were said during the conversation between Resident #34 and the Weekend Activities Assistant. The WCN said the main thing she took away from it was that the Weekend Activities Assistant was yelling at Resident #34. The WCN said Resident #34 did not take it well trying and tried to tell the Weekend Activities Assistant that she did not do whatever she was accusing her of. The WCN said Resident #34 told the Weekend Activities Assistant you don't have to yell at me like that. The WCN said someone called the Former Administrator and the Weekend Activities Assistant was to be sent home. The WCN said after the Weekend Activities Assistant was told to go home, the Weekend Activities Assistant went to Resident #34's room and said you got me fired. The WCN said Resident #34 told the Weekend Activities Assistant No, I didn't want to fire you. The WCN said the Weekend Activities Assistant should not have yelled at Resident #34, nor should she have had that conversation in public which made Resident #34 feel humiliated in front of people. The WCN said the situation happened at the nurse's station where other residents and staff were around. The WCN said when the Weekend Activities Assistant yelled at Resident #34, it was abuse even if that was how she talked that was not an excuse to treat a resident that way. The WCN said Resident #34 was crying a lot after the situation happened. The WCN said Resident #34 was at the nurse's station looking for her pain pill when she called her family member and told them that the Weekend Activities Assistant had humiliated and abused her. The WCN said staff should change the way they talk to a resident to remain respectful. The WCN said the Weekend Activities Assistant had yelled at Resident #34 twice at the nurse's station and then also went to her room on the way out of the building. The WCN said she did not consider the situation to be abuse at the time she witnessed it because she was new at the facility and other staff who witnessed it had said that was how the Weekend Activities Assistant normally talked but after the second time it happened that day, Resident #34 had called her family member to report it to them. The WCN said she did not like what was said to Resident #34 so she reported it to the Former Administrator. The WCN said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Record review of an undated witness statement written by CNA V reflected: In the morning on [blank space] [Resident #34] was [at] the Desk crying I asked her what was going on she told me [the Weekend Activities Assistant] yelled [at] her. And it wasn't right and who to talk to. I told the Nurse on duty that she wanted to report [the Weekend Activities Assistant] for yelling [at] her [sic]. Interview on 10/24/24 at 8:37 AM with CNA V revealed Resident #34 came up to her and said the Weekend Activities Assistant had yelled at her. CNA V said she told the nurse and Resident #34 was going to write a grievance about it. CNA V said Resident #34 was very upset and was crying about the situation. CNA V said she was not sure what happened or why the Weekend Activities Assistant had yelled at Resident #34. CNA V said Resident #34 had made an allegation of abuse. CNA V said she was not sure who the nurse was that told Resident #34 to file a grievance about the Weekend Activities Assistant yelling at her. CNA V said she knew to report any abuse or allegation immediately to the Administrator and would do so now, and that yelling at a resident was considered abuse. Interview on 10/24/24 at 9:00 AM with Resident #34's Psychiatric NP revealed he had cared for Resident #34 before and after the incident of abuse from 07/14/24. He stated Resident #34 was very sensitive and staff had to be aware of how they said things to her and where they said it. He stated the situation made Resident #34 feel very uncomfortable at the facility. He said the situation with the Weekend Activities Assistant easily upset Resident #34 and made her self-isolate for a few weeks but that was just his guess on the timeline. Resident #34's Psychiatric NP said Resident #34 was a very anxious resident who marinated/ruminated on things easily. He said Resident #34 self-isolated because she felt as if others did not like her due to the Weekend Activities Assistant being fired. He stated Resident #34 seemed back to normal now and was out of her room enjoying activities with others. During a confidential interview with a resident, the resident revealed she talked to the Weekend Activities Assistant often on the phone and she was not supposed to say anything but was willing to tell the surveyor what they talked about sometimes. The resident said the Weekend Activities Assistant had yelled at her before, but she never reported it to anyone. The resident said she was cleaning up the activity room one day when the Weekend Activities Assistant walked up to her face and said, Why did you do that? Now I'm not going to be able to find anything in here! The resident said she wheeled out of the room away from the Weekend Activities Assistant. The resident said she and everyone else knew that the Weekend Activities Assistant had a temper but that did not mean she could talk to people any kind of way. The resident said it made her feel bad that the Weekend Activities Assistant yelled at her but she figured it was related to something with the Weekend Activities Assistant's home life because she knew things were not good. The resident said that she knew the Weekend Activities Assistant had yelled at a few people but no one ever reported her and she was not sure why the Weekend Activities Assistant was always yelling. The resident said she was not afraid of the Weekend Activities Assistant but did not like that she yelled at people. The resident said she overheard the Weekend Activities Assistant yelling at Resident #34 because the Weekend Activities Assistant believed the male resident over Resident #34. The resident said the Weekend Activities Assistant got upset with Resident #34 and went to talk to her at the nurse's station. The resident said she was not sure why the Weekend Activities Assistant yelled at Resident #34 in front of everyone but it made Resident #34 very upset, made her cry, and made her not want to leave her room for a while. The resident said the Weekend Activities Assistant should not have embarrassed Resident #34 that way by yelling at her in front of everyone or yelling at her in general but the Weekend Activities Assistant let her temper get the best of her. The resident said after the Weekend Activities Assistant had to leave the facility, she said it was because she broke a rule but the Resident was not allowed to tell anyone that was what the Weekend Activities Assistant had told her. Telephone interview on 10/24/24 at 3:00 PM with the Former Administrator revealed staff called her and told her that Resident #34 made an allegation to them about the Weekend Activities Assistant, saying she cussed and yelled at her at the nurse's station. She stated she told them what steps to take, including letting the Weekend Activities Assistant know she has to leave out of the building. She said the Weekend Activities Assistant did talk loud and so someone could perceive things as yelling or screaming. The Former Administrator said on the Weekend Activities Assistant's way out of the facility she was retaliatory towards Resident #34 when she put her hands on her hips and told Resident #34 Why did you say all those lies about me? You got me fired. while she was leaving the building. She stated Resident #34 had psychological issues that could be perpetuated by the Weekend Activities Assistant's behavior towards her. The Former Administrator said she had to ask the Weekend Activities Assistant not to call the residents anymore because it was putting fuel on the fire regarding her behavior because she made the residents worried about her after she got fired. She said the Weekend Activities Assistant could not separate the residents as customers of hers and honor them with respect instead of treating them like they were her family members. The Former Administrator said a resident had reported to her that the Weekend Activities Assistant had talked loud and hateful to some people especially if they gossiped and the residents talked about her like she was another resident and not like an employee. She said a resident had reported that the Weekend Activities Assistant did get mad and raised her voice but she still loved the residents. The Former Administrator said she had to tell the resident that she still had a duty to fulfill as the Administrator to keep the residents safe. Record review of a witness statement from the Weekend Activities Assistant, dated 07/14/24 reflected: Upon arrival, I saw the grievance on the floor from [Resident #22], stating that [Resident #45] keeps coming into thier private living area uninvited, after being told to stay away- I went to [Resident #45], asked him why he can't follow our wishes to stay away from [Resident #34]. He again said 'ok, I wont go in there anymore, but tell her to quit telling me to come in.' After that, I went to [Resident #34] and asked her what happened- her story was that she doesn't want anything to do with him and he is the one that keeps pursuing her- I asked her if she knew how much this affected her Roommate- And that [Resident #22] was told by [Resident #34] that [Resident #45] had kissed her, but her story changed 3X, [Resident #34], says that I hit her leg- This is simply a bald-face lie- I did not put my hand on her, in anyway shape or form This statement is true- [signed by the Weekend Activities Assistant] [sic]. Record review of an undated and unsigned witness statement that was included in the facility's provider investigation report evidence reflected: .Even tho, [the Weekend Activities Assistant] has a temper. She was upset with us before, but we know, she loves us .If [the Weekend Activities Assistant] needs to control that more have her talk with someone [sic] Record review of the facility's Provider Investigation Report, dated 07/22/24, reflected an incident date of 07/14/24 involving Resident #34 and the Weekend Activities Assistant. The Description of the Allegation section reflected: Resident alleged the activity director hit her leg and yelled at her at the nurses station for kissing another resident who is no longer her friend. The Provider Response section reflected: Activity director was sent home on suspension as a precaution on Sunday following the communication. She then alleged it was abuse on Monday and no longer inappropriate comments. Resident did say that [the Weekend Activities Assistant] never hit her. She tapped her on the leg bending down to speak to her while she was sitting in her wc at the ns. Interviews with staff and other residents was completed to determine any other witnesses possible or other information related to the investigation. Education continues for MANE. Additional training added regarding separation of employees and residents and a healthy, professional boundary. Psych services were called. MD called. Medical director informed. Planned call with [Resident #34's family member] on 7/23/2024 to review final findings of the investigation [sic]. The Investigation Summary reflected: [The Weekend Activities Assistant's] communication was witnessed at the station to be loud and with her usual deep, loud voice .The problem is that the employee was informed later about the resident's comments by another Cna. She became upset and went back to resident in her room with hands on hip saying, 'Why did you lie about me.' 'You got me fired. You don't even care.' The activity director then started calling around to other residents on their personal cell phones to discuss her being upset she got fired perpetuating the theatrics of the matter further placing [Resident #34] at risk for feeling the act director has retaliated against her for reporting the matter. The resident says she frequently pits one resident against another with comments or actions .She had been counseled on multiple occasions about toning down her voice, and remaining focused on her personal feelings or beliefs with regard to residents and their needs. We feel she struggles to separate her being the residents 'friends' and being their paid employee and understanding her responses are required to be above reproach. We found through interviews, she is still calling the residents as of this evening of this report. She told another resident via text that '[Resident #34] ruined her life.' .It is unclear why she intentionally went down to the residents' room to 'confront her'. Regardless, it was inappropriate and with disregard for or lack of true understanding of the consequences of her actions. [sic]. The Provider Action Taken Post-Investigation section reflected: We recommend termination of employee for violating our policy for abuse, neglect, and retaliation/fear of reprisal for any resident. We will Continue training and add the communications and inappropriate texts and messaging to the training. Separation is required for employees. We treat our residents like family but there is a professional line. Ongoing monitoring for resident continues to ensure there are no lasting adverse outcomes related to this incident. Counseling as necessary for support services for resident. SW and Administrator will continue checking ins. [sic]. The Facility Investigation Findings confirmed abuse had occurred. Record review of the grievances binder and log for the last 3 months revealed there was no grievance on file regarding the Weekend Activities Assistant yelling at Resident #34. Record review of an undated and untitled paper provided by the facility reflected personnel information for the Weekend Activities Assistant including a position start date of 11/18/20, a termination date of 07/30/24 with a termination reason of Gross Misconduct; a last work date of 07/14/24 and comments of Discourtesy to residents .please refer to separation notice. Record review of an in-service, dated 07/14/24, reflected staff were trained on the facility's policy regarding abuse and neglect, including when, what, and to whom abuse should be reported to; the WCN and CNA V had both signed the in-service. 2. Record review of Resident #3's admission Record, dated 10/22/24, reflected the resident was a [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #3's Annual MDS Assessment, dated 10/04/24, reflected he had a BIMS score of 13, indicating no cognitive impairment. Further review revealed he had a diagnosis of cerebral palsy (a group of conditions that affect movement and posture. It's caused by damage that occurs to the developing brain, most often before birth). Observation and interview on 10/23/24 at 9:30 AM revealed Resident #3 in his wheelchair in the dining room alone. Resident #3 was able to remember when the CNA yelled at him. Resident #3 said the CNA was very mean to him, and he felt it was abusive. Resident #3 said it made him feel bad when it happened. Resident #3 said the CNA got fired and now staff treat him very well. Record review of the facility's Provider Investigation Report dated 07/15/24 reflected the facility reported an incident involved Resident #3 on 07/08/24. The de[TRUNCATED]