**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident has the right to be free from abuse for 1 (Resident #1) of 5 residents reviewed for abuse. -The facility failed to ensure Resident #1 was free from abuse when CNA A allowed her significant other to verbally abuse Resident #1, allowed the significant other entry into the facility, and took him to Resident #1's room. The Significant other then threatened Resident #1 by pointing a gun at him. On 03/05/24 an Immediate Jeopardy (IJ) was identified. While the IJ template was removed on 03/07/24, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed residents at risk of physical harm, mental anguish or emotional distress, pain and/or death. The findings included: Record review of Resident #1's admission Record, dated 03/05/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident's diagnoses included pressure ulcer of sacral region (the portion of your spine between your lower back and tailbone), paraplegia (condition that affects the lower half of the body, making it hard or impossible to walk, stand, or control the pelvic muscles), acute transverse myelitis demyelinating disease of central nervous system (neurological condition wherein the spinal cord is inflamed), and acquired absence (medical condition that indicates the loss or amputation) of right leg below knee. Record review of Resident #1's Quarterly MDS assessment, dated 02/05/24, revealed a BIMS score of 15, indicating intact cognitive skills. Further review revealed he required substantial/maximal assistance with toileting, bathing, and dressing. Record review of Resident #1's undated care plan revealed he required staff assistance for meeting emotional, intellectual, physical, and social needs related to physical limitations. The resident required extensive assistance with bed mobility and total assistance with transfers. Observation and interview on 03/04/24 at 12:15 p.m., revealed Resident #1 was lying in bed watching television. He said on 03/03/24 (he could not recall the time) Nurse B was in his room performing wound care on him while CNA A assisted. He said CNA A's phone kept going off and Nurse B told her not to answer. He said when they were done with his wound care, CNA A finally answered her phone, and it was her significant other. He said he could hear CNA A's significant other yelling at her and saying bitch, why didn't you answer this motherfucking phone. It does not take two hours to do wound care. He said he told Nurse B maybe CNA A's significant other needed to get his RN license or CNA so he could see that it took that long to do wound care. He said CNA A's significant other told her to tell him to shut the fuck up and CNA A told him. He said CNA A put her significant other on speaker phone and Resident #1 said he told him nah, you shut the fuck up. He said CNA A's significant other and him continued to curse at one another. He said CNA A left his room and came back approximately two minutes later and told him he needed to apologize to her significant other who was on speaker phone. He said her significant other also told him that he needed to apologize to him. He said he told them he was not going to apologize, and CNA A left his room again. He said it felt like CNA A was gone for approximately four to five minutes after she left his room the second time. He said Resident #2 was in his room when CNA A and her significant other entered his room. He said CNA A's significant other told her to get her bitch ass out and she left the room. He said he told Resident #2 to leave the room and he left. He said CNA A's significant other pulled out a gun and pointed it at him. He said soon after, Nurse B entered his room and pushed the significant other out. He said Nurse B told CNA A and her significant other that CNA A should have never let him in the building. He said he told police he did not want to press charges but did press charges against CNA A's significant other. He said he was not traumatized from having a gun pointed at him but was worried about the other residents. He said he was alright and felt safe at the facility. In an interview on 03/04/24 at 12:55 p.m., the Administrator said she had been working at the facility since August 2022. She said she received a call from the DON on Sunday, 03/03/24, between 2:30 p.m. and 2:50 p.m. She said she was told CNA A was doing wound care with Nurse B on Resident #1. She said she was told that while they were doing wound care, CNA A's significant other called her to go to lunch/go outside but she was saying to him she could not because she was in the middle of helping Nurse B. She said she guessed the significant other said some curse words to CNA A to relay to Resident #1 and from her understanding CNA A relayed what her significant other said to Resident #1. She said she was told Resident #1 said some curse words for CNA A to tell her significant other in return and then it sounded like it escalated to where her significant other wanted to come to the building so he could tell Resident #1 in person what he wanted to tell him. She said to her knowledge CNA A's significant other told her to go to the door and open it. She said CNA A opened the facility's door for her significant other and they went to Resident #1's room. She said she believed there was a yelling match and staff (unknown) called 911. She said the police came to the facility and escorted CNA A and her significant other off the property. She said she told the ADON to start in-servicing on violence in the workplace, abuse, neglect, and exploitation, to conduct safe surveys to check on the residents, gather witness statements, and told the DON to refer the resident to psych services to make sure he was okay and did not suffer any trauma. She said CNA A was suspended until further investigation was completed. She said the police were called and was told they would be patrolling the area a little more frequently for the next two weeks. She said all the keycode pads were recoded. She said they were planning on starting HIPPA staff in-service training violation because CNA A should not have been saying what care she was providing to Resident #1 and/or if the Resident #1's name was mentioned. She said staff were told that there were to be no more cell phones when providing care because it could have prevented the incident from occurring. She said the incident may have happened around 12:30ish p.m. In an interview on 03/04/24 at 1:47 p.m., the ADON said she had been working at the facility since 10/28/23. She said Nurse B called her on 03/03/24 and reported that CNA A and she were doing wound care on Resident #1. She said Nurse B told her CNA A was on the phone with her significant other who told CNA A that it was taking too long to do wound care. She said she was not sure if CNA A had her phone on speaker or at some point the significant other told CNA A to put the phone on speaker. She said Nurse B told her when CNA A had her phone on speaker, Resident #1 and the significant other started saying f-Us to each other and CNA A's significant other threatened to come to the facility with a handgun to handle Resident #1. She said she went to the facility and the cops were on the scene. She said she found out that CNA A entered the keycode in to the south hall's door, let her significant other inside the facility, and escorted him to Resident #1's room. She said she was present when Nurse B was talking to the cops and Nurse B told them the significant other had a handgun in his waistband. She said she walked away and went to speak with the resident. She said Resident #1 told her CNA A's significant other had a handgun, that it was visible, was in his hand, and went inside his room. She said she asked Resident #1 if the significant other pointed the handgun at him and he told her no. She said she asked him if he felt safe and he told her yes. She said Resident #1 told her he did not feel traumatized and did not need psych services. She said he told her the significant other said he would be back. In a telephone interview on 03/04/24 at 4:14 p.m., Nurse B said CNA A was helping her with Resident #1's wound care and had no clue that she was on the phone because she had her air pods/headphones in her ear. She said she was in the middle of taking off Resident #1's dressings and putting on new ones, and CNA was making and getting the bedding ready. She said CNA A said a few things (did not know what she said) and Resident #1 asked CNA A if she was talking to the air because they did not know she was on the phone. She said out of nowhere, CNA A blurted out it does take me two hours to do wound care. She said CNA A's significant other was upset because it was taking two hours. She said she asked CNA A what she was talking about, and CNA A told her she was talking to her significant other. She said she asked her what she meant, and she said CNA A told her that she answered her phone on her air pods/headphones. She said she asked CNA A to please not do that, especially at bedside. She said CNA A ignored her and continued talking on the phone. She said Resident #1 told CNA A to tell her significant other to go get his RN license and become a nurse and when he got his RN license and had to do wound care, he would see how extensive his wounds were and that it took two hours. She said after Resident #1 said that she carried on with what she was doing and thought CNA A got off the phone but then out of nowhere CNA A told Resident #1 that her significant other said, shut the fuck up. She said she was shocked that CNA A repeated those words, was still on her phone, and said that to the resident. She said she asked CNA A to exit the room, that it was very inappropriate, and why would she tell that to a resident. She said CNA A got an attitude and exited the room. She said CNA A went back to the hall and was walking around talking to her significant other. She said when she was done helping another resident, she went back down to Resident #1's room. She said Resident #1 told her CNA A had come in his room after she left, was on speaker phone with her significant other and cussed him out at bedside. She said that was when she found out CNA A was not down the hall. She said she was super busy because she was at the nurse's station charting, but from the corner of her eye she saw people walk past her but did not see who it was. She said she then heard really, really, really, loud screaming and was like what in the heck and triggered that oh my god it was probably CNA A's significant other going after Resident #1. She said she had a bad feeling about it because of the way they had talked and threatened each other over the phone. She said she jumped up, ran to the room, and heard the significant other tell Resident #1 I'm not a fucking boy, I'm a fucking man, and I am about to show you. She said when she got to the resident's room, CNA A's significant other looked at CNA A and told her to step out the room and shut the door behind her. She said she told CNA A's significant other, oh no, we are not doing this. She said he was at Resident #1's bedside hoovering over him. She said CNA A's significant other was wearing baggy pants and a real big baggy jacket, so she did not see the pistol at first. She said he had one arm around his waist, and had his other arm bunched up like he was nudging at Resident #1 trying to intimidate him while he was also screaming at him. She said she told CNA A's significant other we are not doing this; you need to get out of the room right now. She said Resident #1 told her that it was okay and to let him stay but she said no we are not doing this. She said she told Resident #1 they were not going to have him in there threatening him and that it was not happening. She said she was literally screaming at the top of her lungs. She said Resident #1 looked at her again and said that it was okay and to let him stay and she said she told the resident no. She said at that point she was confused and did not understand why the resident was telling her to let him stay. She said she had no clue what was going on and all she knew was CNA A let her significant other in the building and he was screaming at Resident #1 and had a pistol. She said at the time when she got in front of CNA A's significant other, she did not see the pistol. She said when he turned around, she was in between him and Resident #1, and told him to exit the room. She said he was trying to push up against her, nudging her, like a chest pump. She said she would not move so he did not get to Resident #1, but he was trying to stay there. She said she told him no, forced him backwards out of the room, and when he turned around to get in the hallway that was when she saw the pistol. She said when she noticed the pistol, she was like oh my god, just play it off, pretend you did not see it and she continued to escort CNA A and her significant other out of the building. She said she told them there was the exit and kept being forceful with them and said, exit the building, both of y'all. She said when she finally got CNA A and her significant other out the door area, she told both of them, do not come back on the premises, do not come back in this door. She said he did not care when he got out to the door. She said he was flaunting the pistol everywhere. She said he had it in his hand and was nonchalantly talking. She said she shut the door quickly and someone called 911. She said the cops went to the facility and after, she went back in the facility and talked to Resident #1. She said Resident #1 told her he told her to let CNA A's significant other to stay in his room because she did not see the pistol, and he did not want her to get hurt. She said Resident #1 told her it was going to be what it was. She said Resident #1 did not want her or Resident #2 to get hurt or shot if something went down. She said at the time it was not that scary, but when she thought back about it, it was pretty scary. She said she was just in full force mode trying to fix the situation and make it stop and did not think about how serious it was. In an interview on 03/04/24 at 5:33 p.m., CNA B said she had been working at the facility for 14 years and worked the 6:00 a.m. to 6:00 p.m. shift. She said she would tell the Administrator if there was someone in the building with a weapon but said she did not know what she would do if the administrator was not at the facility. She said she did not know what the facility's Emergency Procedure - Workplace Aggression/Violence procedure was. In an interview on 03/05/24 at 8:02 a.m., CNA C said she had been working at the facility for approximately 4 months. She said she received ANE, HIPPA, and cell phone use training yesterday, 03/04/24. She said the Administrator went over some other information during the in-service trainings, but she could not remember what it was about. She said she was not feeling well, and her brain was kind of foggy. In an interview on 03/05/24 at 10:08 a.m., CNA D said she had been working at the facility for approximately 2 ½ years. She said she did not receive Emergency Procedure - Aggression/Violence training. She said it was her signature on the in-service sign in sheet, but said she thought she was just signing off on getting the abuse policy. She said the sign-in sheet did not have the topics listed when she signed. In a follow-up interview on 03/05/24 at 10:32 a.m., CNA B said it was her signature on the in-service sign in sheet. She said they (could not recall who gave out the policies) gave out copy of the policies, reviewed the information, but said she just could not recall what was covered during the in-service trainings. In an interview on 03/05/24 at 12:35 p.m., Resident #2 said he was in Resident #1's room when a man came in and started arguing with Resident #1. He said he did not see a gun and did not know who the man was. He said Resident #1 told him to leave the room and he said he left right away. He said he did not remember what time it happened. In a telephone interview on 03/05/24 at 2:03 p.m., CNA A said she was in Resident #1's room doing care on him. She said her significant other called when she was doing wound care and she answered. She said when she answered the call, Resident #1 said something smart (could not recall what was said) to her significant other. She said Resident #1 then called her significant other a bitch, said he was a stay-at-home dad, and called him a MF word. She said Resident #1 was being vulgar and saying the B word and she told Resident #1 to respect her significant other and he said no. She said she told Resident #1 then to respect her by respecting her significant other. She said she was talking to her significant other on her headphones. She said her significant other did not say anything, but Resident #1 was still talking vulgarly. She said her significant other went to the facility to get her. She said she let her significant other in the building through the side door. She said she took her significant other to Resident #1's room, and he told Resident #1 to respect him as a man three times and then they left. She said her significant other did not have a gun. She said they were in Resident #1's room for about a minute. She said she was not on the phone when she was doing patient care but was on the phone while getting the bed linen up off the floor. In an interview on 03/07/24 at 8:22 a.m., the DON said the ADON notified her on 03/03/24 and she notified the Administrator. She said the ADON told her that CNA A may have to be sent home. She said the ADON told her that CNA A let her significant other in the building and in Resident #1's room. She said when the ADON made it to the building the police were already on the scene, and she said she told the ADON to go ahead and figure out what was going on and to call her back. She said she called the Administrator and told her what the ADON said happened. She said they got on the phone with regional support and the Regional Director of Operations, and the Administrator called in the report to the State. She said the ADON called her back, told her something about CNA A was on her phone, there was something about air pods, and that her significant other could hear conversations. She said she was told there was something about Resident #1 getting smart, phone being put on speaker, and an exchange of words between CNA A's significant other and Resident #1. She said she was told that CNA A's significant other went to the facility, and CNA A let him in Resident #1's room. She said the ADON said Nurse B and Resident #1 saw a pistol. Record review of the facility's policy titled Abuse Prohibition Policy, revised date 11/07/23, read in part .each resident has the right to be free from abuse .Policy: 1. The facility will prohibit neglect, mental or physical abuse .Definitions: Abuse means the willful infliction of injury .intimidation . Record review of the facility's policy titled Emergency Procedure - Workplace Aggression/Violence, dated 06/07/2023, read in part . The following procedure is utilized in the event of a Workplace Aggression/Violence incident in or near our facility. 1. If an incident or verbal aggression escalates or appears to be escalating to physical aggression, announce CODE GRAY: AGGRESSIVE (or any other code as adopted by the facility) with the location of the incident. 2. Call 911 if there is threat-based screaming, fighting, weapons involved, or any threat of danger. IF IN DOUBT, CALL 911. Provide the 911 dispatcher with as much relevant information as possible. 3. Instruct staff to move the residents and themselves immediately to safe, secure refuge and remain there until ALL CLEAR . This was determined to be an Immediate Jeopardy (IJ) and the Administrator was notified on 03/05/24 at 5:03 p.m. The IJ template was presented to the facility and the POR was requested at this time. The following Plan of Removal submitted by the facility was accepted on 03/06/24 at 12:08 p.m. and included: Plan of Removal Immediate Jeopardy On 03/03/2024, an abbreviated survey was initiated at [the facility]. On 03/05/2024 the surveyor provided an Immediate Jeopardy (IJ)Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: F689: Quality of Care, Accidents/Hazards the facility failed to provide a safe environment on 3/3/2024 when CNA allowed her significant other, who was armed with a pistol, to enter the facility through south hall's locked and coded door and access to Resident #1 Room. Administrator/Designee conducted life safety satisfaction assessment for all residents to ensure that no other resident affected completed by 3/5/2024. The facility also conducted In-Services on Workplace aggression/violence and ANE. Documents are in POR binder and uploaded to charts. The facility will follow policy and procedure regarding Workplace Aggression/Violence and ANE. Administrator/Designee will conduct in-services and they will be completed by 3/5/2024. Action on CNA A - suspended pending investigation on 3/3/2024. Psychosocial assessment completed on Resident #1 by social worker and resident no trauma/not affected by incident. Psychologists also saw Resident #1 and agreed to meet therapist on the next visit. Stated he was not affected by the incident. Nurse A was referred to our free services for Psych Services Action: Immediately, on March 5, 2024, Clinical Specialist in serviced DON and ADM to include Quality of care and treatment provided to facility residents. Training and competencies for DON, and ADM were completed on March 5, 2024: workplace violence, facility security, and ANE. On March 5, 2024, ADM/DON initiated in-services with all staff. In-services to include Workplace Aggression/violence and ANE, and life satisfaction surveys and any abnormalities will be given to family, physician, and ADM/DON. Completion date for staff in-services to be completed March 5, 2024. All Nursing staff will not be allowed to work until in servicing has been completed. Any contract staff or PRN staff will be in-service prior to working the floor. HIPAA and no use of cell phone while providing care in services was initiated on March 5, 2024, by ADM. Training will be documented and completed on March 5, 2024. Staff will not be allowed to work until in servicing has been completed. Any contract staff or PRN staff will be in-service prior to working the floor. The above training material (Workplace Aggression/violence and ANE) will be incorporated into the new hire orientation by ADM effective March 5, 2024, and ongoing. On March 5, 2024 an audit was conducted by ADM/Designee to identify other residents with potential trauma of from violence in the work place. Via direct observation, staff interviews, and record review, no other residents were identified as having an issue. In order to monitor current residents for potential risk, ADM/Designee will monitor residents with change in condition daily beginning March 5, 2024, for 30 days on all residents via Life Satisfaction/Trauma. The purpose of this log is to monitor residents with change in conditions. DON compliance will be monitored weekly by ADM/Designee for 90 days. Thereafter, QA will monitor quarterly up to a year for compliance of change of condition. If any issues are identified, the physician will be contacted (by ADM/Designee) immediately for further medical management and family/POA of the same. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns noted, will continue to monitor as per routine facility QA Committee. Start Date: 3/5/2024 Completion Date: 3/5/2024 Responsible: ADM and DON. Monitoring of the POR included: During interviews on 03/06/24 and 03/07/24, with staff from all shifts, revealed the following staff members were able to verbalize an understanding of the steps to take if an incident of workplace aggression/violence occurred: Administrator, DON, ADON, Rehab Director, Housekeeping/Laundry Manager, Nurses D, E and F, Medication Aide A, and CNAs A, B, E, and F. Record review of in-service sign in sheets for Workplace Aggression/Violence, ANE, HIPPA and cell phones revealed 44 staff signatures. Record review of Resident Life Satisfaction Round surveys, dated 03/05/24, revealed all 42 resident surveys were completed. Record review of CNA A's personnel file revealed the employee was suspended on 03/03/24 pending the facility's investigation. Record review of Resident #1's progress notes revealed the Social Worker completed a psychosocial assessment and resident reported no trauma from the incident. An Immediate Jeopardy was identified on 03/05/24 at 5:03 p.m. While the IJ was removed on 03/07/24, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems/plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards for 1 (Resident #1) of 5 residents reviewed for quality of care. -The facility failed to provide a safe environment when CNA A allowed her significant other, who was armed with a pistol, entry into the facility's locked building, and access to Resident #1. -The facility failed to provide the Emergency Procedure - Workplace Aggression/Violence training. On 03/05/24 an Immediate Jeopardy (IJ) was identified. While the IJ template was removed on 03/07/24, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed residents at risk of physical harm, mental anguish or emotional distress, pain and/or death. The findings included: Record review of Resident #1's admission Record, dated 03/05/24, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The resident's diagnoses included pressure ulcer of sacral region (the portion of your spine between your lower back and tailbone), paraplegia (condition that affects the lower half of the body, making it hard or impossible to walk, stand, or control the pelvic muscles), acute transverse myelitis demyelinating disease of central nervous system (neurological condition wherein the spinal cord is inflamed), and acquired absence (medical condition that indicates the loss or amputation) of right leg below knee. Record review of Resident #1's Quarterly MDS assessment, dated 02/05/24, revealed a BIMS score of 15, indicating intact cognitive skills. Further review revealed he required substantial/maximal assistance with toileting, bathing, and dressing. Record review of Resident #1's undated care plan revealed he required staff assistance for meeting emotional, intellectual, physical, and social needs related to physical limitations. The resident required extensive assistance with bed mobility and total assistance with transfers. Observation and interview on 03/04/24 at 12:15 p.m., revealed Resident #1 was lying in bed watching television. He said on 03/03/24 (he could not recall the time) Nurse B was in his room performing wound care on him while CNA A assisted. He said CNA A's phone kept going off and Nurse B told her not to answer. He said when they were done with his wound care, CNA A finally answered her phone, and it was her significant other. He said he could hear CNA A's significant other yelling at her and saying bitch, why didn't you answer this motherfucking phone. It does not take two hours to do wound care. He said he told Nurse B maybe CNA A's significant other needed to get his RN license or CNA so he could see that it took that long to do wound care. He said CNA A's significant other told her to tell him to shut the fuck up and CNA A told him. He said CNA A put her significant other on speaker phone and Resident #1 said he told him nah, you shut the fuck up. He said CNA A's significant other and him continued to curse at one another. He said CNA A left his room and came back approximately two minutes later and told him he needed to apologize to her significant other who was on speaker phone. He said her significant other also told him that he needed to apologize to him. He said he told them he was not going to apologize, and CNA A left his room again. He said it felt like CNA A was gone for approximately four to five minutes after she left his room the second time. He said Resident #2 was in his room when CNA A and her significant other entered his room. He said CNA A's significant other told her to get her bitch ass out and she left the room. He said he told Resident #2 to leave the room and he left. He said CNA A's significant other pulled out a gun and pointed it at him. He said soon after, Nurse B entered his room and pushed the significant other out. He said Nurse B told CNA A and her significant other that CNA A should have never let him in the building. He said he told police he did not want to press charges but did press charges against CNA A's significant other. He said he was not traumatized from having a gun pointed at him but was worried about the other residents. He said he was alright and felt safe at the facility. In an interview on 03/04/24 at 12:55 p.m., the Administrator said she had been working at the facility since August 2022. She said she received a call from the DON on Sunday, 03/03/24, between 2:30 p.m. and 2:50 p.m. She said she was told CNA A was doing wound care with Nurse B on Resident #1. She said she was told that while they were doing wound care, CNA A's significant other called her to go to lunch/go outside but she was saying to him she could not because she was in the middle of helping Nurse B. She said she guessed the significant other said some curse words to CNA A to relay to Resident #1 and from her understanding CNA A relayed what her significant other said to Resident #1. She said she was told Resident #1 said some curse words for CNA A to tell her significant other in return and then it sounded like it escalated to where her significant other wanted to come to the building so he could tell Resident #1 in person what he wanted to tell him. She said to her knowledge CNA A's significant other told her to go to the door and open it. She said CNA A opened the facility's door for her significant other and they went to Resident #1's room. She said she believed there was a yelling match and staff (unknown) called 911. She said the police came to the facility and escorted CNA A and her significant other off the property. She said she told the ADON to start in-servicing on violence in the workplace, abuse, neglect, and exploitation, to conduct safe surveys to check on the residents, gather witness statements, and told the DON to refer the resident to psych services to make sure he was okay and did not suffer any trauma. She said CNA A was suspended until further investigation was completed. She said the police were called and was told they would be patrolling the area a little more frequently for the next two weeks. She said all the keycode pads were recoded. She said they were planning on starting HIPPA staff in-service training violation because CNA A should not have been saying what care she was providing to Resident #1 and/or if the Resident #1's name was mentioned. She said staff were told that there were to be no more cell phones when providing care because it could have prevented the incident from occurring. She said the incident may have happened around 12:30ish p.m. In an interview on 03/04/24 at 1:47 p.m., the ADON said she had been working at the facility since 10/28/23. She said Nurse B called her on 03/03/24 and reported that CNA A and she were doing wound care on Resident #1. She said Nurse B told her CNA A was on the phone with her significant other who told CNA A that it was taking too long to do wound care. She said she was not sure if CNA A had her phone on speaker or at some point the significant other told CNA A to put the phone on speaker. She said Nurse B told her when CNA A had her phone on speaker, Resident #1 and the significant other started saying f-Us to each other and CNA A's significant other threatened to come to the facility with a handgun to handle Resident #1. She said she went to the facility and the cops were on the scene. She said she found out that CNA A entered the keycode in to the south hall's door, let her significant other inside the facility, and escorted him to Resident #1's room. She said she was present when Nurse B was talking to the cops and Nurse B told them the significant other had a handgun in his waistband. She said she walked away and went to speak with the resident. She said Resident #1 told her CNA A's significant other had a handgun, that it was visible, was in his hand, and went inside his room. She said she asked Resident #1 if the significant other pointed the handgun at him and he told her no. She said she asked him if he felt safe and he told her yes. She said Resident #1 told her he did not feel traumatized and did not need psych services. She said he told her the significant other said he would be back. In a telephone interview on 03/04/24 at 4:14 p.m., Nurse B said CNA A was helping her with Resident #1's wound care and had no clue that she was on the phone because she had her air pods/headphones in her ear. She said she was in the middle of taking off Resident #1's dressings and putting on new ones, and CNA was making and getting the bedding ready. She said CNA A said a few things (did not know what she said) and Resident #1 asked CNA A if she was talking to the air because they did not know she was on the phone. She said out of nowhere, CNA A blurted out it does take me two hours to do wound care. She said CNA A's significant other was upset because it was taking two hours. She said she asked CNA A what she was talking about, and CNA A told her she was talking to her significant other. She said she asked her what she meant, and she said CNA A told her that she answered her phone on her air pods/headphones. She said she asked CNA A to please not do that, especially at bedside. She said CNA A ignored her and continued talking on the phone. She said Resident #1 told CNA A to tell her significant other to go get his RN license and become a nurse and when he got his RN license and had to do wound care, he would see how extensive his wounds were and that it took two hours. She said after Resident #1 said that she carried on with what she was doing and thought CNA A got off the phone but then out of nowhere CNA A told Resident #1 that her significant other said, shut the fuck up. She said she was shocked that CNA A repeated those words, was still on her phone, and said that to the resident. She said she asked CNA A to exit the room, that it was very inappropriate, and why would she tell that to a resident. She said CNA A got an attitude and exited the room. She said CNA A went back to the hall and was walking around talking to her significant other. She said when she was done helping another resident, she went back down to Resident #1's room. She said Resident #1 told her CNA A had come in his room after she left, was on speaker phone with her significant other and cussed him out at bedside. She said that was when she found out CNA A was not down the hall. She said she was super busy because she was at the nurse's station charting, but from the corner of her eye she saw people walk past her but did not see who it was. She said she then heard really, really, really, loud screaming and was like what in the heck and triggered that oh my god it was probably CNA A's significant other going after Resident #1. She said she had a bad feeling about it because of the way they had talked and threatened each other over the phone. She said she jumped up, ran to the room, and heard the significant other tell Resident #1 I'm not a fucking boy, I'm a fucking man, and I am about to show you. She said when she got to the resident's room, CNA A's significant other looked at CNA A and told her to step out the room and shut the door behind her. She said she told CNA A's significant other, oh no, we are not doing this. She said he was at Resident #1's bedside hoovering over him. She said CNA A's significant other was wearing baggy pants and a real big baggy jacket, so she did not see the pistol at first. She said he had one arm around his waist, and had his other arm bunched up like he was nudging at Resident #1 trying to intimidate him while he was also screaming at him. She said she told CNA A's significant other we are not doing this; you need to get out of the room right now. She said Resident #1 told her that it was okay and to let him stay but she said no we are not doing this. She said she told Resident #1 they were not going to have him in there threatening him and that it was not happening. She said she was literally screaming at the top of her lungs. She said Resident #1 looked at her again and said that it was okay and to let him stay and she said she told the resident no. She said at that point she was confused and did not understand why the resident was telling her to let him stay. She said she had no clue what was going on and all she knew was CNA A let her significant other in the building and he was screaming at Resident #1 and had a pistol. She said at the time when she got in front of CNA A's significant other, she did not see the pistol. She said when he turned around, she was in between him and Resident #1, and told him to exit the room. She said he was trying to push up against her, nudging her, like a chest pump. She said she would not move so he did not get to Resident #1, but he was trying to stay there. She said she told him no, forced him backwards out of the room, and when he turned around to get in the hallway that was when she saw the pistol. She said when she noticed the pistol, she was like oh my god, just play it off, pretend you did not see it and she continued to escort CNA A and her significant other out of the building. She said she told them there was the exit and kept being forceful with them and said, exit the building, both of y'all. She said when she finally got CNA A and her significant other out the door area, she told both of them, do not come back on the premises, do not come back in this door. She said he did not care when he got out to the door. She said he was flaunting the pistol everywhere. She said he had it in his hand and was nonchalantly talking. She said she shut the door quickly and someone called 911. She said the cops went to the facility and after, she went back in the facility and talked to Resident #1. She said Resident #1 told her he told her to let CNA A's significant other to stay in his room because she did not see the pistol, and he did not want her to get hurt. She said Resident #1 told her it was going to be what it was. She said Resident #1 did not want her or Resident #2 to get hurt or shot if something went down. She said at the time it was not that scary, but when she thought back about it, it was pretty scary. She said she was just in full force mode trying to fix the situation and make it stop and did not think about how serious it was. In an interview on 03/04/24 at 5:33 p.m., CNA B said she had been working at the facility for 14 years and worked the 6:00 a.m. to 6:00 p.m. shift. She said she would tell the Administrator if there was someone in the building with a weapon but said she did not know what she would do if the administrator was not at the facility. She said she did not know what the facility's Emergency Procedure - Workplace Aggression/Violence procedure was. In an interview on 03/05/24 at 8:02 a.m., CNA C said she had been working at the facility for approximately 4 months. She said she received ANE, HIPPA, and cell phone use training yesterday, 03/04/24. She said the Administrator went over some other information during the in-service trainings, but she could not remember what it was about. She said she was not feeling well, and her brain was kind of foggy. In an interview on 03/05/24 at 10:08 a.m., CNA D said she had been working at the facility for approximately 2 ½ years. She said she did not receive Emergency Procedure - Aggression/Violence training. She said it was her signature on the in-service sign in sheet, but said she thought she was just signing off on getting the abuse policy. She said the sign-in sheet did not have the topics listed when she signed. In a follow-up interview on 03/05/24 at 10:32 a.m., CNA B said it was her signature on the in-service sign in sheet. She said they (could not recall who gave out the policies) gave out copy of the policies, reviewed the information, but said she just could not recall what was covered during the in-service trainings. In an interview on 03/05/24 at 12:35 p.m., Resident #2 said he was in Resident #1's room when a man came in and started arguing with Resident #1. He said he did not see a gun and did not know who the man was. He said Resident #1 told him to leave the room and he said he left right away. He said he did not remember what time it happened. In a telephone interview on 03/05/24 at 2:03 p.m., CNA A said she was in Resident #1's room doing care on him. She said her significant other called when she was doing wound care and she answered. She said when she answered the call, Resident #1 said something smart (could not recall what was said) to her significant other. She said Resident #1 then called her significant other a bitch, said he was a stay-at-home dad, and called him a MF word. She said Resident #1 was being vulgar and saying the B word and she told Resident #1 to respect her significant other and he said no. She said she told Resident #1 then to respect her by respecting her significant other. She said she was talking to her significant other on her headphones. She said her significant other did not say anything, but Resident #1 was still talking vulgarly. She said her significant other went to the facility to get her. She said she let her significant other in the building through the side door. She said she took her significant other to Resident #1's room, and he told Resident #1 to respect him as a man three times and then they left. She said her significant other did not have a gun. She said they were in Resident #1's room for about a minute. She said she was not on the phone when she was doing patient care but was on the phone while getting the bed linen up off the floor. In an interview on 03/07/24 at 8:22 a.m., the DON said the ADON notified her on 03/03/24 and she notified the Administrator. She said the ADON told her that CNA A may have to be sent home. She said the ADON told her that CNA A let her significant other in the building and in Resident #1's room. She said when the ADON made it to the building the police were already on the scene, and she said she told the ADON to go ahead and figure out what was going on and to call her back. She said she called the Administrator and told her what the ADON said happened. She said they got on the phone with regional support and the Regional Director of Operations, and the Administrator called in the report to the State. She said the ADON called her back, told her something about CNA A was on her phone, there was something about air pods, and that her significant other could hear conversations. She said she was told there was something about Resident #1 getting smart, phone being put on speaker, and an exchange of words between CNA A's significant other and Resident #1. She said she was told that CNA A's significant other went to the facility, and CNA A let him in Resident #1's room. She said the ADON said Nurse B and Resident #1 saw a pistol. Record review of the facility's policy titled 'Emergency Procedure - Workplace Aggression/Violence, dated 06/07/2023, read in part . The following procedure is utilized in the event of a Workplace Aggression/Violence incident in or near our facility. 1. If an incident or verbal aggression escalates or appears to be escalating to physical aggression, announce CODE GRAY: AGGRESSIVE (or any other code as adopted by the facility) with the location of the incident. 2. Call 911 if there is threat-based screaming, fighting, weapons involved, or any threat of danger. IF IN DOUBT, CALL 911. Provide the 911 dispatcher with as much relevant information as possible. 3. Instruct staff to move the residents and themselves immediately to safe, secure refuge and remain there until ALL CLEAR . This was determined to be an Immediate Jeopardy (IJ) and the Administrator was notified on 03/05/24 at 5:03 p.m. The IJ template was presented to the facility and the POR was requested at this time . The following Plan of Removal submitted by the facility was accepted on 03/06/24 at 12:08 p.m. and included: Plan of Removal Immediate Jeopardy On 03/03/2024, an abbreviated survey was initiated at [the facility]. On 03/05/2024 the surveyor provided an Immediate Jeopardy (IJ)Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: F689: Quality of Care, Accidents/Hazards the facility failed to provide a safe environment on 3/3/2024 when CNA allowed her significant other, who was armed with a pistol, to enter the facility through south hall's locked and coded door and access to Resident #1 Room. Administrator/Designee conducted life safety satisfaction assessment for all residents to ensure that no other resident affected completed by 3/5/2024. The facility also conducted In-Services on Workplace aggression/violence and ANE. Documents are in POR binder and uploaded to charts. The facility will follow policy and procedure regarding Workplace Aggression/Violence and ANE. Administrator/Designee will conduct in-services and they will be completed by 3/5/2024. Action on CNA A - suspended pending investigation on 3/3/2024. Psychosocial assessment completed on Resident #1 by social worker and resident no trauma/not affected by incident. Psychologists also saw Resident #1 and agreed to meet therapist on the next visit. Stated he was not affected by the incident. Nurse A was referred to our free services for Psych Services Action: Immediately, on March 5, 2024, Clinical Specialist in serviced DON and ADM to include Quality of care and treatment provided to facility residents. Training and competencies for DON, and ADM were completed on March 5, 2024: workplace violence, facility security, and ANE. On March 5, 2024, ADM/DON initiated in-services with all staff. In-services to include Workplace Aggression/violence and ANE, and life satisfaction surveys and any abnormalities will be given to family, physician, and ADM/DON. Completion date for staff in-services to be completed March 5, 2024. All Nursing staff will not be allowed to work until in servicing has been completed. Any contract staff or PRN staff will be in-service prior to working the floor. HIPAA and no use of cell phone while providing care in services was initiated on March 5, 2024, by ADM. Training will be documented and completed on March 5, 2024. Staff will not be allowed to work until in servicing has been completed. Any contract staff or PRN staff will be in-service prior to working the floor. The above training material (Workplace Aggression/violence and ANE) will be incorporated into the new hire orientation by ADM effective March 5, 2024, and ongoing. On March 5, 2024 an audit was conducted by ADM/Designee to identify other residents with potential trauma of from violence in the work place. Via direct observation, staff interviews, and record review, no other residents were identified as having an issue. In order to monitor current residents for potential risk, ADM/Designee will monitor residents with change in condition daily beginning March 5, 2024, for 30 days on all residents via Life Satisfaction/Trauma. The purpose of this log is to monitor residents with change in conditions. DON compliance will be monitored weekly by ADM/Designee for 90 days. Thereafter, QA will monitor quarterly up to a year for compliance of change of condition. If any issues are identified, the physician will be contacted (by ADM/Designee) immediately for further medical management and family/POA of the same. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns noted, will continue to monitor as per routine facility QA Committee. Start Date: 3/5/2024 Completion Date: 3/5/2024 Responsible: ADM and DON. Monitoring of the POR included: During interviews on 03/06/24 and 03/07/24, with staff from all shifts, revealed the following staff members were able to verbalize an understanding of the steps to take if an incident of workplace aggression/violence occurred: Administrator, DON, ADON, Rehab Director, Housekeeping/Laundry Manager, Nurses D, E and F, Medication Aide A, and CNAs A, B, E, and F. Record review of in-service sign in sheets for Workplace Aggression/Violence, ANE, HIPPA and cell phones revealed 44 staff signatures. Record review of Resident Life Satisfaction Round surveys, dated 03/05/24, revealed all 42 resident surveys were completed. Record review of CNA A's personnel file revealed the employee was suspended on 03/03/24 pending the facility's investigation. Record review of Resident #1's progress notes, revealed the Social Worker completed a psychosocial assessment and resident reported no trauma from the incident. An Immediate Jeopardy was identified on 03/05/24 at 5:03 p.m. While the IJ was removed on 03/07/24, the facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems/plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews the facility failed to ensure residents were free from abuse and neglect for 4 (Resident #7, #8, #23, and #38,) of 21 residents on the North Hall and 2 (Resident #30 and #35) of 17 residents on the South Hall. The Administrator and DON failed to provide necessary protection from staff member (TA K) who verbally and mentally Intimidated residents by yelling at them in angry tones, slammed resident doors to create fear, threatened residents with physical abuse, used retaliatory behavior in not providing timely care and invaded resident privacy by entering residents rooms without knocking or asking permission when female residents were undressing affecting residents' psycho social well-being causing fear and psycho social harm. On 09/23/22 at 5:10 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/25/22 at 12:30 pm, the facility remained out of compliance at a severity level of more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received the IJ template on 09/25/22 at 12:30 PM. These failures could place the residents at an unsafe environment exposing them to verbal, mental and physical abuse, neglect and mental anguish. Findings Included: Resident #38 Record review of Resident #38's undated face sheet revealed she was a [AGE] year-old-female admitted on [DATE] with the diagnoses of necrotizing fasciitis (flesh eating bacteria), cellulitis of the lower limb, hypokalemia, abscess of the mouth, nausea vomiting, chronic diarrhea and pain in right toe. Record review of Resident #38's MDS re-admission dated 05/26/2022 revealed she had a BIMS (brief interview for memory status) of 15 indicating she was cognitively intact and able to make her needs known. Section G (functional status) revealed she required supervision for personal hygiene. Record review of Resident #38's Care Plan dated 05/22/2022 revealed she was at risk for falls, weight loss due to chronic diarrhea, and use of anti-depressant medication. Record review of Resident #38's physician orders dated 05/28/2022 initial orders revealed the following medications: Cymbalta 60 milligram (anti-depressant) 1 tablet a daily for depression. During initial tour of the facility on 09/20/22 at 9:35 AM, interview with Resident #38 asked the surveyor what she should do if a staff member threatened her for being a tattle tale. She said she would explain in further detail, but she was on her way to an outing with the activity director and fellow residents and would explain later. During an interview on 09/21/2022 at 8:00 AM, Resident #38 said TA K worked last night and told her that the state was in the building and that if she told on him (regarding the verbal abuse) it was going to be bad for her (threaten retribution) . She said it was an ongoing issue because of the problems he initially had with the smokers and the complaints against him regarding not giving showers and the allegation of being sexually inappropriate with Resident #35. She said she was afraid of him because of his behaviors, he yells at residents and slams doors and enter rooms without knocking. She said he worked last night (09/20/2022 6:00 PM to 09/21/2022 to 6:00 AM) and told her these things. She said she was told to sign the questionnaire when the thing with Resident #35 came up (sexual abuse allegation) but did not feel comfortable with it. During an interview 09/21/2022 at 8:10 AM with Resident #38's roommate ( Resident #9) who participates in the smoking area was alert and oriented times three (aware of person place and time). said she witnessed TA K making threatening remarks when he came into their room during his shift ( 09/20/2022 6:00 PM to 09/21/2022 to 6:00 AM)(but in the morning-unsure of the exact time) and accused Resident #9 of telling on him (regarding to the showers, and verbal abuse) and when Resident #9 said she did not tell on him, he then accused Resident #38 and said he would get her. Resident #38 understood TA K threatened to physically assault her. During an interview on 09/22/2022 at 2:00 PM with Resident #38, while she was on the telephone with her mother, her mother told the surveyor she was aware of the threats Resident #38 was receiving from TA K and hoped the surveyor will help resolve the threats she was receiving him (from TA K). Resident #35 Record review of Resident #35's undated face sheet revealed she was a [AGE] year-old-female admitted to the facility on [DATE] with the diagnoses of: hypertension, heart failure, thrombosis of other thoracic veins (blood clot in thoracic vein), Weakness, Other muscle spasm, and need for assistance with personal care. Review of Resident #35's annual MDS dated [DATE] revealed Resident #35 had a BIMS of 15 indicating she was cognitively intact and able to make her needs known. Section G (Functional Status) revealed she required extensive assistance with dressing, bathing, toilet use and hygiene with one person assistance. Review of Resident #35's Care Plan dated 08/21/2022 revealed resident had communication difficulty, at risk for pressure ulcers, utilize wheelchair for mobility, risk for falls and morbidly obese. Review of the facility's Incident Report dated 08/31/2022 revealed the following: Sexual assault allegation reported by resident (Resident #35) Resident stated male CNA (TA K) hugged her and made a humping movement rubbed his penis against her arms. Resident said she told male CNA (TA K) to stop. Male CNA (TA K) suspended until further notice pending investigation of allegation of sexual assault allegations . Authorities notified . Review of Police Report (undated report case #22-02928) revealed Insufficient evidence to substantiate the assault and the State Agency investigator did not find sufficient evidence to substantiate the allegation. Resident #35 disputed their findings and feared TA K. During Resident Council meeting on 09/21/2022 at 10:15 AM, 14 residents attended, Resident #35 was the president of the council (preceding over the meeting). Residents 6 of (14) expressed grievances regarding TA K because he said he would only give out two cigarettes due to the residents complaining about him about showers. The said he told the residents on the smoke break he can do whatever he wanted to and when he gives out the cigarettes for the breaks even though three cigarettes were giving on other breaks. Several (4 on the north hall) residents said TA K would go up and down the hall and slam doors, yell at residents and just walk into rooms without knocking and especially when the ladies were dressing. Surveyor asked residents attending the Resident Council Meeting how many people were afraid of TA, 9 residents held up their hands including Resident #7, #,8, #23, #35 and #38 (4 others did not wish to be identified). Resident #8 Review of Resident #8's undated face sheet revealed she was a [AGE] year-old-female re-admitted on [DATE] with the diagnoses of: bipolar disorder, gout (excessive uric acid collected in joints), pain in ankle and foot, insomnia (difficulty sleeping). Review of Resident #8's last assessed MDS dated [DATE] revealed she had a BIMS score of 12 indicating she was moderately cognitively impaired but able to make her needs known. Section G (Function Status) revealed she needed set up and supervision with personal hygiene. Review of Resident #8's Care Plan dated 10/11/2018 revealed to participate in activities, risk for falls due to safety awareness, and chronic illness due to lupus (autoimmune syndrome). During interview on 09/22/2022 at 10:50 AM Resident #8 said, TA K would yell at the residents and would bump into them inappropriately hugging them. She said she was afraid of TA K; he had a habit of coming into women's room not knocking when he knew they were dressing. She said she was afraid of him because he was always threatening the residents in one way or another (unspecific regarding threats). She said she was told to sign the questionnaire (about Resident #35's sexual assault allegation and if they felt safe) and was uncomfortable about being identified. During an interview on 09/22/2022 at 2:20 PM with Resident #8's family member, (son) said she mentioned the inappropriate behavior TA K displayed (inappropriate hugging, yelling at residents, slamming doors making threatening comments) and he was in the process of getting her moved out. Resident #23 Review of Resident #23's undated face sheet revealed she was a [AGE] year-old-female re-admitted on [DATE] with the diagnoses of: Displaced fracture of base of neck of left femur, Overactive bladder, Pneumonia, abnormalities of gait and mobility. Review of Resident #23's Initial MDS dated [DATE] revealed she had a BIMS score of 14 indicating she was cognitively intact and able to make her needs known. Section G (Function Status) revealed she required extensive assistance with personal hygiene. Review of Resident #23's Care Plan dated 08/10/2022 revealed she was at risk for pressure ulcers and at risk for anemia. During an interview with Resident #23 on 09/22/2022 at 11:05 AM, she said TA K came one night to change her and told her we need to make love. She said she told him that was a very inappropriate statement. She said, he said she misunderstood him and changed her brief. She said he made her very uncomfortable, and she was lucky she only needed to be changed one time. She said her family member, Resident #32 (lives in same room) said he did not hear the conversation, but TA K goes down the hall and yells and was very loud. Resident #30 Review of Resident #30's undated face sheet revealed he was a [AGE] year-old-male admitted on [DATE] with the diagnoses of: Malignant neoplasm of bronchus or lung (Admission), anxiety disorder, Pain, and displaced fracture of surgical neck of left humerus. Review of Resident #30's MDS dated [DATE] revealed a BIMS of 3 indicating he was severely cognitively impaired. Section G (Function Status) revealed he required extensive assistance for personal hygiene. During one-on-one interview with Resident #30 on 09/23/2022 3:00 PM, he stated he was familiar with TA K, and he worked the night shift. He stated he was uncomfortable around him and felt intimidated. He stated he would rather stay wet than ask him for help because he could tell it (changing his briefs from an incontinent episode) made TA K mad. He stated no one else made him feel that way. He stated TA K acted mad and smarted off to us when he took the smokers out to smoke. He stated he could not remember what he said but he knew TA K made him feel bad He could not remember a specific date or time. Resident #7 Review of Resident #7's undated face sheet revealed he was a [AGE] year-old-male admitted to the facility on [DATE] with the diagnoses of: Chronic pain due to trauma, Anorexia nervosa, binge eating/purging type, schizoaffective disorder, bipolar type, Tachycardia, Gastro-esophageal reflux disease with esophagitis, Heart failure, disorder of thyroid, Vascular dementia with behavior disturbances. Review of Resident #7's Quarterly MDS dated [DATE] revealed he had a BIMS score of 15 indicating he was cognitively intact and able to make his needs known. Section G (Functional Section) revealed he required extensive assistance for personal hygiene. During an interview with Resident #7 on 09/22/2022 at 2:45 PM, he said he was always arguing with TA K because he always made a fuss about changing him. He said he called him a bitch and not being a man because Resident #7 needed someone to change him. (Resident #7 said no use to complaining because no one does anything about it. He said they (residents) complain about TA K, but nothing is done (Resident Council grievances) During an interview with the Administrator and DON on 09/22/2022 at 11:40 AM, they said they must find out what was going on. The Administrator said she found out TA K left one night and went home around 11:00 PM (disciplinary documentation stated date of incident 08/31/2022) and was missing for 5 hours. The Administrator said human resources (corporate) told Administrator and DON they had the options of terminating him or counsel him and allow him to return to work. She said we were given that options. The DON said the Aide who worked with him said he left for 5 hours and fell asleep at home. The Administrator said HR (human resources) told them it was clear cut reason to terminate him, but we were given the option of counseling him. The Administrator and DON stated they chose to allow him to return to work. Interview with the Activity Director on 09/22/2022 at 12:15 PM, said she was aware of the problems the residents who participates in the smoke breaks during the smoke breaks (#7, #8, #9 #35, and #38 and four more not willing to be identified) was having with TA (transition assistant) and has given the Resident Council minutes to the ADON (resident council minutes and grievances were reviewed by surveyor prior to the Resident Council meeting on 09/21/2022 at 10:15 AM) and they discuss the problem in the stand-up meetings (morning meeting of facility department heads). She said they counseled him and let him come back. She said she has no influence on who to hire or fire. She said, all I can do is make the Administrator know. During an interview with Resident #38 on 09/22/2022 at 12:35 PM, said the call lights will turn on and a light will come on outside the room, but the alarm will not come on. Resident #38 resides on the hall where TA K works. Resident #38 said because the call lights would not sound, he TA K could be verbally and mentally abusive. Resident #38 said because of the sexual abuse allegation TA K had to work on the North Hall the call lights would not sound he TA K could be threatening, yell at the resident slam doors and threaten them. Observation of Resident #38's Call light being turned on 09/22/2022 at 12:35 PM revealed the light outside of her room coming on but not audible sound coming on. Observation on 09/23/2022 at 9:30 AM alarm system was checked on the North Hall, in the center of the hall a switch could be turn off and on. When the switch was in the Off position, the audio alarm did not activate when the resident activated the call light system in their room. When the switch was in the on position, the audio alarm sounded when the call light was activated by the resident. Resident #38 said because the call lights would not sound, he TA K could be verbally and mentally abusive. During an interview with ADON on 09/22/2022 at 4:35 PM, she said she has never been given any of the grievances or Resident Council minutes by the Activities Director and has not been aware of residents being threatened. During an interview with the Administrator on 09/23/2022 at 10:40 AM, surveyor asked if she was aware of the complaints from the residents, that they were being threatened by TA K. She said this was the first time she heard about the complaints and never received any of the Resident Council Minutes or grievances. Administrator was told by the survey team. During interview with CNA I on 09/23/2022 at 3:00 PM, she said she was working the South Hall and noticed the call light panel going off for residents on the North Hall. She said TA K was only allowed to work the North Hall because of the allegations of sexual abuse alleged by Resident #35. She said she went to the North Hall and noticed several call lights on and took care of the residents. She said she then texted TA K and asked where he was, she said he wrote back and said he went home and fell asleep. She said he said he will be back. She said he did not come back untill 5 AM in the morning. She said he threatened her if she told anyone. CNA I was unspecific about the threat but noticed someone was trying to vandalize her car the next night She called the Administrator who said not to take any more calls from him. Record review revealed inappropriate behavior dated 09/21/2022 at 6:00 AM ADON confronted TA K regarding his charting .he did not give a fuck about charting the point of care in the computer, and they would not be done. She said she asked him to discuss the matter with her and he said, he did not have to talk to her . The Administrator told ADON to write down this encounter for disciplinary action. Attempts to interview TA K was made on 09/23/2022 at 2:00 PM, Regional Operations Manager also attempted to call TA K at an undisclosed time on 09/23/2022 for an interview he said TA K hung up the telephone and would not speak to the Regional Operations Manager as told to surveyors. Attempts to interview Charge nurse on 09/23/2022 regarding TA K leaving the facility for 5 hours was made without success in returning telephone calls. During an interview with the Administrator 09/25/2022 at 2:30 PM, she said Resident #35 came to her and said TA K was telling us on smoke break we were all a bunch of liars, and he would preach about he was tight with God, and we were going to hell and Resident #35 was making up the sexual assault allegation. She said regarding the interview of CNA L, Administrator said because of the sexual abuse allegation there were not to be any discussions about what happened that was why she told her not to take any more calls from TA K. When asked by the surveyors what the Administrator thought about TA K calling the residents liars and preaching, she said she told TA K not to preach to the residents anymore. Administrator added TA K has been terminated. Review of Email provided by Administrator to Human Resources dated 09/23/2022 at 8:10 AM confirmed termination of TA K. Review of the Grievances dated 08/28/2022 On 6:30 PM recorded by the Resident Council secretary revealed: during smoke break TA K informed everyone that we were only getting two cigarettes instead of three that we usually get for the last smoke break of the day. When asked why he said we complained about the showers not being given then we were to have our break cut short. Then asked if it was the nurses or the management, he said it was his decision and if we did not like it that we could go in and not go bother to come out for the next smoke break that he would be taking us out on. He told a group since he got in trouble that we were only getting two cigarettes instead of the three. He continues to push the issue about showers so that Resident #7 was the blame for only getting two cigarettes since he complained about the showers . TA K said he was taking us out of the kindness of his heart. TA K continued to argue with Resident #35 and said he was in charge and that what he says is final and if we don't like it, there is the door. It was brought to my attention as Resident Council Secretary by Resident Council President that Resident #35 said when TA K was giving her hugs, he was making a motion as if humping her. Review of the Grievances dated 09/06/2022 revealed the following: (Activities Director and Social Worker in attendance and emergency Resident Council meeting was called) Social Worker - 1. Recognizing and reviewing malicious grievances. Just because you don't like someone is not a reason for a grievance. But if they are threatening you or bullying you or touching you in appropriately or when told not to. This is malicious grievance and should be told to an employee and written up. Harassing is not tolerated in this facility. 2. Only the employees are to call and talk to resident family. No one is to have the phone number It has been brought to the attention that a resident has been calling other resident family unless it's the resident themselves or have the business to call other than the facility or the resident in question. It has been brought to the attention that a resident has been calling other resident family or guardian . Review of the Grievances dated 09/15/2022 recorded by the Resident Council secretary revealed the following: During the 6:30 PM smoke break. One of the aides said something about the one in purple (Resident #35) thinking it was her (related to sexual assault allegation) Things got heated Then TA K said that at this facility the residents have many real Big Liars Then he started in on a soap box sermon about him and God are like that! And that those liars were going to Hell. The residents here will be struck down. I (resident #38 Resident Council Secretary). Told the charge nurse and she said that the incident was reported to her. I did not know that all the situation was not reported. Review of the Grievances dated 09/21/2022 recorded by the R revealed the following: TA K split up the smokers into 2 groups sending out one group. TA K kept stating that the Administrator told him he had to take us out into groups instead of all at once. No one was told of this until we were on our way to the patio. TA K told Resident #8 he could not come outside because he did not have cigarettes. Resident #38 was awakened at 11:30 PM by a loud noise in her room TA K told me If you have any complaints about me (beating his chest) then keep your mouth shut. He then turned to my roommate and asked her if she called the Administrator and report me. She said No. Then he said your neighbor is doing that. On the same day Resident #35 asked to keep her door open, and TA K yelled and slammed the door shut time was 10:15 PM During an interview with Administrator on 09/23/2022 at 4:40 PM she said TA K's only had abuse and neglect training completed with no other modules completed at the time of hire. Review of TA K's hire date provided by the facility was 08/16/2022. Record review of TA K's disciplinary action dated 08/31/2022 revealed the following: Final Warning- Time clock abuse - Not clocking out (5 hours left the building) contacting employees while investigation is ongoing - contacting and engaging with residents during investigation. Immediate termination if this problem occurs (Need) to follow command when leaving the building - clocking out when leaving the building - not reaching out to employees or residents when investigation is ongoing. Review of facility policy and procedure dated June 2021 titled, Abuse Prevention Program revealed the following [in part]: .2 Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The includes but is not limited to freedom from corporate punishment involuntary seclusion verbal mental sexual or physical abuses . 5. Our Center will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor and to the Abuse Prevention Coordinator immediately. 6. Our Center will protect residents from harm, reprisal, discriminating or coercion during investigations of abuse allegations. 7. All reports of resident abuse, neglect, exploitation, misappropriation of resident property mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by the Center management. Findings of abuse investigation will also be reported. 8. Our Center will provide protection for the health, welfare and the rights of each resident residing in the Center to ensure the reporting of crimes. Immediate Jeopardy (IJ) situation was identified on 09/23/2022 at 5:10 PM and the Administrator was informed. The IJ Template was provided at this time. The POR (Plan of Removal) was accepted on 9/24/2022 at 12:40 PM The POR revealed in part: Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or may be discussed in this response and plan of removal. The facility failed to ensure residents were free from verbal, mental, or sexual abuse. Action Item: 1. Administrator and the DON were suspended on 9/24/22 pending investigation of incident 2. Review of all resident grievances to identify allegations of abuse; all allegations will be reported timely. All residents will be interviewed for active grievances and allegations of abuse 3. Review of all resident grievances occurs daily Monday through Friday in the morning meeting. Any allegations of abuse/neglect will be reported timely. 4. Resident grievance forms are posted on the walls in wall hangers throughout the center. The resident/representative can leave the form in the file folder outside the administrator's office, with or without signing the form. Resident counsel occurred on 9/24/22, the minutes include the grievance process, how to file an anonymous grievance, who the abuse coordinator is, how to report abuse, zero retaliation policy. 5. Staff interviews to be completed to identify allegations of abuse/neglect. If interviews identify allegations of abuse; all allegations will be reported timely. 6. Staff education on the grievance process to be presented written and verbally. Staff to complete posttest to demonstrate comprehension of material. 7. QA committee will review the POR is effective 8. Safe surveys will be completed with all residents that are interview able; responsible parties will be phone interviewed for all residents that are un-interview able and those residents will be assessed for signs of physical or psychosocial distress. 9. TA K has been terminated as of 9/22/22 and Activity Director will be suspended pending investigation on 9/23/22. 10. Physical and emotional assessments to be completed on all residents. Change of condition events to be completed as identified. The event includes physician and family/responsible parties. Notifications. The Medical Director and resident physicians were notified of the immediate jeopardy on 9/24/22. 11. Employee TA K has notified that he not allowed on property by the Regional Director of Operations on 9/24/22. Staff education completed on terminated employee TA not being allowed on property and to notify Regional Director of Operations and police if former staff member attempts to enter center to be presented written and verbally. Staff to complete posttest to demonstrate comprehension of material. Staff interviews to be completed to identify allegations of abuse/neglect. If interviews identify allegations of abuse; all allegations will be reported timely. Regional Director of Operations on 9/24/22 at 2:30 pm initiated education of employees. All will be completed by end of today except for one staff member who is out of state, another is on a second job. Will not be allowed to return to work until training is completed. Observation and interview with Regional Operations Manager 0n 09/25/2022 at 2:40 pm revealed signs related to Resident Council Minuets were posted in the lobby, 2 hallways and behind the glass board. Grievance forms were in the lobby area in a hanging file with signage. Grievance forms were placed in the box outside the Administrators door or can hand it to any department heads. Observation on 09/24/22 at 4:00 pm revealed Regional Operations Director conducting a Resident Council Meeting. He went over the grievance process, how to file a grievance and who the Grievance officer was. Interviewed the following residents on 9/24/2022 at 5:00 pm Resident #20, #31, #11, and #5, (all went to the Resident Council meeting), discussion included how to file a grievance, name of the grievance officer, and retaliation. One resident who did not attend the Resident Council meeting due to being on Transmission Based Precautions said staff came in and educated him on abuse and how to file a grievance. Interview with LVN C on 09/24/22 at 3:00 pm (day shift)stated she had an In-service this morning before she started work. She said she had another one at approx. 10:00 am and another one at 12:30 pm. In services were with ROM and MDS Nurse and BOM. She said in-services were about abuse and reporting abuse and she completed a written test. Interview with Housekeeping Supervisor on 09/24/22 at 3:10 pm (day shift)stated she had was in-service at 8:00 am and at 9:30 am by ROM and MDS Nurse. Housekeeping Supervisor Stated she in-services her employees this morning. Interview Housekeeper and Laundry Aide on 09/24/22 at 3:20 pm (day shift) said they were educated this morning by Housekeeping Supervisor on how to report abuse. Observation on 09/24/22 at 3:30 pm revealed, Business office Manager (BOM) in-servicing, LVN B and Home care 1 on (day shift) concerning Regional [NAME] President was acting Abuse Coordinator and how to report abuse, etc. Interview, with CNA F on 09/24/22 at 3:35 pm (day shift)stated she received education concerning how to recognize abuse and how to report it earlier this morning after the residents had breakfast. All staff educated by ROM took a written test scoring 80% or greater. Observation at 3:37pm revealed ROM educate CNA F concerning the Regional Operations Manager (ROM) is the abuse coordinator and how to report abuse. Interview with LVN B on 09/24/22 at 3:40 pm (day shift)stated she received training this morning shortly after she came to work his morning. The training was conducted by ROM. The training consisted of abuse, how to identify abuse and report it and took a written test. Interview with LVN D on 09/24/22 at 8:44 pm (night shift) said she was trained before shift by the BOM. The training consisted of abuse, how to identify and report abuse, who the abuse coordinator was and took a written test. Interview with CNA I on 09/24/22 at 8:56 pm said she was trained before shift by the BOM. The training consisted of abuse, how to identify and report abuse, who the abuse coordinator was and took a written test. Interview with LVN A on 09/24/22 at 9:00 pm said she was trained before shift by the BOM. The Training consisted of abuse, how to identify and report abuse, who the abuse coordinator was and took a written test. Staff Social Worker, CMA and PT (who are out of town and/or out of the country) will be interview regarding abuse and neglect prior to their shift. The Regional Operations Director, Administrator, DON, ADON, and Corporate Nurse were informed the Immediate Jeopardy was removed on 09/25/22 at 12:40 p.m. The facility remained out of compliance at a severity level of 2 with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to fully investigate, prevent, and correct an alleged violations of abuse and neglect for 4 (Resident #7, #8, #23, and #38,) of 21 on the North Hall and 2 (Resident #30 and #35) of 17 on the South Hall. The facility did not thoroughly investigate and correct an allegations of abuse that resulted in Resident #7, #8, #9, #23, 30, #35, and #38 causing psycho social harm and fearby TA K, while allowing him to continue working with residents in the facility. The Administrator and DON failed to provide residents necessary protection from staff member (TA K) who was threatening physical and verbal abuse in retaliation against residents who alleged incidents of his abusive behavior On 09/23/22 at 5:10 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/25/22 at 12:30 pm, the facility remained out of compliance at a severity level of more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received the IJ template on 09/25/22 at 12:30 PM. This failure could place residents at risk of verbal, mental and physical abuse, neglect and mental anguish. Findings include: Resident #38 Record review of Resident #38's undated face sheet revealed she was a [AGE] year-old-female admitted on [DATE] with the diagnoses of necrotizing fasciitis (flesh eating bacteria), cellulitis of the lower limb, hypokalemia, abscess of the mouth, nausea vomiting, chronic diarrhea and pain in right toe. Record review of Resident #38's MDS re-admission dated 05/26/2022 revealed she had a BIMS (brief interview for memory status) of 15 indicating she was cognitively intact and able to make her needs known. Section G (functional status) revealed she required supervision for personal hygiene. Record review of Resident #38's Care Plan dated 05/22/2022 revealed she was at risk for falls, weight loss due to chronic diarrhea, and use of anti-depressant medication. Record review of Resident #38's physician orders dated 05/28/2022 initial orders revealed the following medications: Cymbalta 60 milligram (anti-depressant) 1 tablet a daily for depression. During initial tour of the facility on 09/20/22 at 9:35 AM, interview with Resident #38 asked the surveyor what she should do if a staff member threatened her for being a tattle tale. She said she would explain in further detail, but she was on her way to an outing with the activity director and fellow residents and would explain later. During an interview on 09/21/2022 at 8:00 AM, Resident #38 said TA K worked last night and told her that the state was in the building and that if she told on him (regarding the verbal abuse) it was going to be bad for her (threaten retribution) . She said it was an ongoing issue because of the problems he initially had with the smokers and the complaints against him regarding not giving showers and the allegation of being sexually inappropriate with Resident #35. She said she was afraid of him because of his behaviors, he yells at residents and slams doors and enter rooms without knocking. She said he worked last night (09/20/2022 6:00 PM to 09/21/2022 to 6:00 AM) and told her these things. She said she was told to sign the questionnaire when the thing with Resident #35 came up (sexual abuse allegation) but did not feel comfortable with it. During an interview 09/21/2022 at 8:10 AM with Resident #38's roommate ( Resident #9) who participates in the smoking area was alert and oriented times three (aware of person place and time). said she witnessed TA K making threatening remarks when he came into their room during his shift ( 09/20/2022 6:00 PM to 09/21/2022 to 6:00 AM)(but in the morning-unsure of the exact time) and accused Resident #9 of telling on him (regarding to the showers, and verbal abuse) and when Resident #9 said she did not tell on him, he then accused Resident #38 and said he would get her. Resident #38 understood TA K threatened to physically assault her. During an interview on 09/22/2022 at 2:00 PM with Resident #38, while she was on the telephone with her mother, her mother told the surveyor she was aware of the threats Resident #38 was receiving from TA K and hoped the surveyor will help resolve the threats she was receiving him (from TA K). Resident #35 Record review of Resident #35's undated face sheet revealed she was a [AGE] year-old-female admitted to the facility on [DATE] with the diagnoses of: hypertension, heart failure, thrombosis of other thoracic veins (blood clot in thoracic vein), Weakness, Other muscle spasm, and need for assistance with personal care. Review of Resident #35's annual MDS dated [DATE] revealed Resident #35 had a BIMS of 15 indicating she was cognitively intact and able to make her needs known. Section G (Functional Status) revealed she required extensive assistance with dressing, bathing, toilet use and hygiene with one person assistance. Review of Resident #35's Care Plan dated 08/21/2022 revealed resident had communication difficulty, at risk for pressure ulcers, utilize wheelchair for mobility, risk for falls and morbidly obese. Review of the facility's Incident Report dated 08/31/2022 revealed the following: Sexual assault allegation reported by resident (Resident #35) Resident stated male CNA (TA K) hugged her and made a humping movement rubbed his penis against her arms. Resident said she told male CNA (TA K) to stop. Male CNA (TA K) suspended until further notice pending investigation of allegation of sexual assault allegations . Authorities notified . Review of Police Report (undated report case #22-02928) revealed Insufficient evidence to substantiate the assault and the State Agency investigator did not find sufficient evidence to substantiate the allegation. Resident #35 disputed their findings and feared TA K. During Resident Council meeting on 09/21/2022 at 10:15 AM, 14 residents attended, Resident #35 was the president of the council (preceding over the meeting). Residents 6 of (14) expressed grievances regarding TA K because he said he would only give out two cigarettes due to the residents complaining about him about showers. The said he told the residents on the smoke break he can do whatever he wanted to and when he gives out the cigarettes for the breaks even though three cigarettes were giving on other breaks. Several (4 on the north hall) residents said TA K would go up and down the hall and slam doors, yell at residents and just walk into rooms without knocking and especially when the ladies were dressing. Surveyor asked residents attending the Resident Council Meeting how many people were afraid of TA, 9 residents held up their hands including Resident #7, #,8, #23, #35 and #38 (4 others did not wish to be identified). Resident #8 Review of Resident #8's undated face sheet revealed she was a [AGE] year-old-female re-admitted on [DATE] with the diagnoses of: bipolar disorder, gout (excessive uric acid collected in joints), pain in ankle and foot, insomnia (difficulty sleeping). Review of Resident #8's last assessed MDS dated [DATE] revealed she had a BIMS score of 12 indicating she was moderately cognitively impaired but able to make her needs known. Section G (Function Status) revealed she needed set up and supervision with personal hygiene. Review of Resident #8's Care Plan dated 10/11/2018 revealed to participate in activities, risk for falls due to safety awareness, and chronic illness due to lupus (autoimmune syndrome). During interview on 09/22/2022 at 10:50 AM Resident #8 said, TA K would yell at the residents and would bump into them inappropriately hugging them. She said she was afraid of TA K; he had a habit of coming into women's room not knocking when he knew they were dressing. She said she was afraid of him because he was always threatening the residents in one way or another (unspecific regarding threats). She said she was told to sign the questionnaire (about Resident #35's sexual assault allegation and if they felt safe) and was uncomfortable about being identified. During an interview on 09/22/2022 at 2:20 PM with Resident #8's family member, (son) said she mentioned the inappropriate behavior TA K displayed (inappropriate hugging, yelling at residents, slamming doors making threatening comments) and he was in the process of getting her moved out. Resident #23 Review of Resident #23's undated face sheet revealed she was a [AGE] year-old-female re-admitted on [DATE] with the diagnoses of: Displaced fracture of base of neck of left femur, Overactive bladder, Pneumonia, abnormalities of gait and mobility. Review of Resident #23's Initial MDS dated [DATE] revealed she had a BIMS score of 14 indicating she was cognitively intact and able to make her needs known. Section G (Function Status) revealed she required extensive assistance with personal hygiene. Review of Resident #23's Care Plan dated 08/10/2022 revealed she was at risk for pressure ulcers and at risk for anemia. During an interview with Resident #23 on 09/22/2022 at 11:05 AM, she said TA K came one night to change her and told her we need to make love. She said she told him that was a very inappropriate statement. She said, he said she misunderstood him and changed her brief. She said he made her very uncomfortable, and she was lucky she only needed to be changed one time. She said her family member, Resident #32 (lives in same room) said he did not hear the conversation, but TA K goes down the hall and yells and was very loud. Resident #30 Review of Resident #30's undated face sheet revealed he was a [AGE] year-old-male admitted on [DATE] with the diagnoses of: Malignant neoplasm of bronchus or lung (Admission), anxiety disorder, Pain, and displaced fracture of surgical neck of left humerus. Review of Resident #30's MDS dated [DATE] revealed a BIMS of 3 indicating he was severely cognitively impaired. Section G (Function Status) revealed he required extensive assistance for personal hygiene. During one-on-one interview with Resident #30 on 09/23/2022 3:00 PM, he stated he was familiar with TA K, and he worked the night shift. He stated he was uncomfortable around him and felt intimidated. He stated he would rather stay wet than ask him for help because he could tell it (changing his briefs from an incontinent episode) made TA K mad. He stated no one else made him feel that way. He stated TA K acted mad and smarted off to us when he took the smokers out to smoke. He stated he could not remember what he said but he knew TA K made him feel bad He could not remember a specific date or time. Resident #7 Review of Resident #7's undated face sheet revealed he was a [AGE] year-old-male admitted to the facility on [DATE] with the diagnoses of: Chronic pain due to trauma, Anorexia nervosa, binge eating/purging type, schizoaffective disorder, bipolar type, Tachycardia, Gastro-esophageal reflux disease with esophagitis, Heart failure, disorder of thyroid, Vascular dementia with behavior disturbances. Review of Resident #7's Quarterly MDS dated [DATE] revealed he had a BIMS score of 15 indicating he was cognitively intact and able to make his needs known. Section G (Functional Section) revealed he required extensive assistance for personal hygiene. During an interview with Resident #7 on 09/22/2022 at 2:45 PM, he said he was always arguing with TA K because he always made a fuss about changing him. He said he called him a bitch and not being a man because Resident #7 needed someone to change him. (Resident #7 said no use to complaining because no one does anything about it. He said they (residents) complain about TA K, but nothing is done (Resident Council grievances) During an interview with the Administrator and DON on 09/22/2022 at 11:40 AM, they said they must find out what was going on. The Administrator said she found out TA K left one night and went home around 11:00 PM (disciplinary documentation stated date of incident 08/31/2022) and was missing for 5 hours. The Administrator said human resources (corporate) told Administrator and DON they had the options of terminating him or counsel him and allow him to return to work. She said we were given that options. The DON said the Aide who worked with him said he left for 5 hours and fell asleep at home. The Administrator said HR (human resources) told them it was clear cut reason to terminate him, but we were given the option of counseling him. The Administrator and DON stated they chose to allow him to return to work. Interview with the Activity Director on 09/22/2022 at 12:15 PM, said she was aware of the problems the residents who participates in the smoke breaks during the smoke breaks (#7, #8, #9 #35, and #38 and four more not willing to be identified) was having with TA (transition assistant) and has given the Resident Council minutes to the ADON (resident council minutes and grievances were reviewed by surveyor prior to the Resident Council meeting on 09/21/2022 at 10:15 AM) and they discuss the problem in the stand-up meetings (morning meeting of facility department heads). She said they counseled him and let him come back. She said she has no influence on who to hire or fire. She said, all I can do is make the Administrator know. During an interview with Resident #38 on 09/22/2022 at 12:35 PM, said the call lights will turn on and a light will come on outside the room, but the alarm will not come on. Resident #38 resides on the hall where TA K works. Resident #38 said because the call lights would not sound, he TA K could be verbally and mentally abusive. Resident #38 said because of the sexual abuse allegation TA K had to work on the North Hall the call lights would not sound he TA K could be threatening, yell at the resident slam doors and threaten them. Observation of Resident #38's Call light being turned on 09/22/2022 at 12:35 PM revealed the light outside of her room coming on but not audible sound coming on. Observation on 09/23/2022 at 9:30 AM alarm system was checked on the North Hall, in the center of the hall a switch could be turn off and on. When the switch was in the Off position, the audio alarm did not activate when the resident activated the call light system in their room. When the switch was in the on position, the audio alarm sounded when the call light was activated by the resident. Resident #38 said because the call lights would not sound, he TA K could be verbally and mentally abusive. During an interview with ADON on 09/22/2022 at 4:35 PM, she said she has never been given any of the grievances or Resident Council minutes by the Activities Director and has not been aware of residents being threatened. During an interview with the Administrator on 09/23/2022 at 10:40 AM, surveyor asked if she was aware of the complaints from the residents, that they were being threatened by TA K. She said this was the first time she heard about the complaints and never received any of the Resident Council Minutes or grievances. Administrator was told by the survey team. During interview with CNA I on 09/23/2022 at 3:00 PM, she said she was working the South Hall and noticed the call light panel going off for residents on the North Hall. She said TA K was only allowed to work the North Hall because of the allegations of sexual abuse alleged by Resident #35. She said she went to the North Hall and noticed several call lights on and took care of the residents. She said she then texted TA K and asked where he was, she said he wrote back and said he went home and fell asleep. She said he said he will be back. She said he did not come back untill 5 AM in the morning. She said he threatened her if she told anyone. CNA I was unspecific about the threat but noticed someone was trying to vandalize her car the next night She called the Administrator who said not to take any more calls from him. Record review revealed inappropriate behavior dated 09/21/2022 at 6:00 AM ADON confronted TA K regarding his charting .he did not give a fuck about charting the point of care in the computer, and they would not be done. She said she asked him to discuss the matter with her and he said, he did not have to talk to her . The Administrator told ADON to write down this encounter for disciplinary action. Attempts to interview TA K was made on 09/23/2022 at 2:00 PM, Regional Operations Manager also attempted to call TA K at an undisclosed time on 09/23/2022 for an interview he said TA K hung up the telephone and would not speak to the Regional Operations Manager as told to surveyors. Attempts to interview Charge nurse on 09/23/2022 regarding TA K leaving the facility for 5 hours was made without success in returning telephone calls. During an interview with the Administrator 09/25/2022 at 2:30 PM, she said Resident #35 came to her and said TA K was telling us on smoke break we were all a bunch of liars, and he would preach about he was tight with God, and we were going to hell and Resident #35 was making up the sexual assault allegation. She said regarding the interview of CNA L, Administrator said because of the sexual abuse allegation there were not to be any discussions about what happened that was why she told her not to take any more calls from TA K. When asked by the surveyors what the Administrator thought about TA K calling the residents liars and preaching, she said she told TA K not to preach to the residents anymore. Administrator added TA K has been terminated. Review of Email provided by Administrator to Human Resources dated 09/23/2022 at 8:10 AM confirmed termination of TA K. Review of the Grievances dated 08/28/2022 On 6:30 PM recorded by the Resident Council secretary revealed: during smoke break TA K informed everyone that we were only getting two cigarettes instead of three that we usually get for the last smoke break of the day. When asked why he said we complained about the showers not being given then we were to have our break cut short. Then asked if it was the nurses or the management, he said it was his decision and if we did not like it that we could go in and not go bother to come out for the next smoke break that he would be taking us out on. He told a group since he got in trouble that we were only getting two cigarettes instead of the three. He continues to push the issue about showers so that Resident #7 was the blame for only getting two cigarettes since he complained about the showers . TA K said he was taking us out of the kindness of his heart. TA K continued to argue with Resident #35 and said he was in charge and that what he says is final and if we don't like it, there is the door. It was brought to my attention as Resident Council Secretary by Resident Council President that Resident #35 said when TA K was giving her hugs, he was making a motion as if humping her. Review of the Grievances dated 09/06/2022 revealed the following: (Activities Director and Social Worker in attendance and emergency Resident Council meeting was called) Social Worker - 1. Recognizing and reviewing malicious grievances. Just because you don't like someone is not a reason for a grievance. But if they are threatening you or bullying you or touching you in appropriately or when told not to. This is malicious grievance and should be told to an employee and written up. Harassing is not tolerated in this facility. 2. Only the employees are to call and talk to resident family. No one is to have the phone number It has been brought to the attention that a resident has been calling other resident family unless it's the resident themselves or have the business to call other than the facility or the resident in question. It has been brought to the attention that a resident has been calling other resident family or guardian . Review of the Grievances dated 09/15/2022 recorded by the Resident Council secretary revealed the following: During the 6:30 PM smoke break. One of the aides said something about the one in purple (Resident #35) thinking it was her (related to sexual assault allegation) Things got heated Then TA K said that at this facility the residents have many real Big Liars Then he started in on a soap box sermon about him and God are like that! And that those liars were going to Hell. The residents here will be struck down. I (resident #38 Resident Council Secretary). Told the charge nurse and she said that the incident was reported to her. I did not know that all the situation was not reported. Review of the Grievances dated 09/21/2022 recorded by the R revealed the following: TA K split up the smokers into 2 groups sending out one group. TA K kept stating that the Administrator told him he had to take us out into groups instead of all at once. No one was told of this until we were on our way to the patio. TA K told Resident #8 he could not come outside because he did not have cigarettes. Resident #38 was awakened at 11:30 PM by a loud noise in her room TA K told me If you have any complaints about me (beating his chest) then keep your mouth shut. He then turned to my roommate and asked her if she called the Administrator and report me. She said No. Then he said your neighbor is doing that. On the same day Resident #35 asked to keep her door open, and TA K yelled and slammed the door shut time was 10:15 PM During an interview with Administrator on 09/23/2022 at 4:40 PM she said TA K's only had abuse and neglect training completed with no other modules completed at the time of hire. Review of TA K's hire date provided by the facility was 08/16/2022. Record review of TA K's disciplinary action dated 08/31/2022 revealed the following: Final Warning- Time clock abuse - Not clocking out (5 hours left the building) contacting employees while investigation is ongoing - contacting and engaging with residents during investigation. Immediate termination if this problem occurs (Need) to follow command when leaving the building - clocking out when leaving the building - not reaching out to employees or residents when investigation is ongoing. Review of facility policy and procedure dated June 2021 titled, Abuse Prevention Program revealed the following [in part]: .2 Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The includes but is not limited to freedom from corporate punishment involuntary seclusion verbal mental sexual or physical abuses . 5. Our Center will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor and to the Abuse Prevention Coordinator immediately. 6. Our Center will protect residents from harm, reprisal, discriminating or coercion during investigations of abuse allegations. 7. All reports of resident abuse, neglect, exploitation, misappropriation of resident property mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by the Center management. Findings of abuse investigation will also be reported. 8. Our Center will provide protection for the health, welfare and the rights of each resident residing in the Center to ensure the reporting of crimes. Immediate Jeopardy (IJ) situation was identified on 09/23/2022 at 5:10 PM and the administrator was informed. The IJ template was provided at this time. The POR (Plan of Removal) was accepted on 9/24/2022 at 12:40 PM The POR revealed in part: Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents, or other individuals who draft or may be discussed in this response and plan of removal. The facility failed to ensure residents were free from verbal, mental, or sexual abuse. Action Item: 1. Administrator and the DON were suspended on 9/24/22 pending investigation of incident 2. Review of all resident grievances to identify allegations of abuse; all allegations will be reported timely. All residents will be interviewed for active grievances and allegations of abuse 3. Review of all resident grievances occurs daily Monday through Friday in the morning meeting. Any allegations of abuse/neglect will be reported timely. 4. Resident grievance forms are posted on the walls in wall hangers throughout the center. The resident/representative can leave the form in the file folder outside the administrator's office, with or without signing the form. Resident counsel occurred on 9/24/22, the minutes include the grievance process, how to file an anonymous grievance, who the abuse coordinator is, how to report abuse, zero retaliation policy. 5. Staff interviews to be completed to identify allegations of abuse/neglect. If interviews identify allegations of abuse; all allegations will be reported timely. 6. Staff education on the grievance process to be presented written and verbally. Staff to complete posttest to demonstrate comprehension of material. 7. QA committee will review the POR is effective 8. Safe surveys will be completed with all residents that are interview able; responsible parties will be phone interviewed for all residents that are un-interview able and those residents will be assessed for signs of physical or psychosocial distress. 9. TA K has been terminated as of 9/22/22 and Activity Director will be suspended pending investigation on 9/23/22. 10. Physical and emotional assessments to be completed on all residents. Change of condition events to be completed as identified. The event includes physician and family/responsible parties. Notifications. The Medical Director and resident physicians were notified of the immediate jeopardy on 9/24/22. 11. Employee TA K has notified that he not allowed on property by the Regional Director of Operations on 9/24/22. Staff education completed on terminated employee TA not being allowed on property and to notify Regional Director of Operations and police if former staff member attempts to enter center to be presented written and verbally. Staff to complete posttest to demonstrate comprehension of material. Staff interviews to be completed to identify allegations of abuse/neglect. If interviews identify allegations of abuse; all allegations will be reported timely. Regional Director of Operations on 9/24/22 at 2:30 pm initiated education of employees. All will be completed by end of today except for one staff member who is out of state, another is on a second job. Will not be allowed to return to work until training is completed. Observation and interview with Regional Operations Manager 0n 09/25/2022 at 2:40 pm revealed signs related to Resident Council Minuets were posted in the lobby, 2 hallways and behind the glass board. Grievance forms were in the lobby area in a hanging file with signage. Grievance forms were placed in the box outside the Administrators door or can hand it to any department heads. Observation on 09/24/22 at 4:00 pm revealed Regional Operations Director conducting a Resident Council Meeting. He went over the grievance process, how to file a grievance and who the Grievance officer was. Interviewed the following residents on 9/24/2022 at 5:00 pm Resident #20, #31, #11, and #5, (all went to the Resident Council meeting), discussion included how to file a grievance, name of the grievance officer, and retaliation. One resident who did not attend the Resident Council meeting due to being on Transmission Based Precautions said staff came in and educated him on abuse and how to file a grievance. Interview with LVN C on 09/24/22 at 3:00 pm (day shift)stated she had an In-service this morning before she started work. She said she had another one at approx. 10:00 am and another one at 12:30 pm. In services were with ROM and MDS Nurse and BOM. She said in-services were about abuse and reporting abuse and she completed a written test. Interview with Housekeeping Supervisor on 09/24/22 at 3:10 pm (day shift)stated she had was in-service at 8:00 am and at 9:30 am by ROM and MDS Nurse. Housekeeping Supervisor Stated she in-services her employees this morning. Interview Housekeeper and Laundry Aide on 09/24/22 at 3:20 pm (day shift) said they were educated this morning by Housekeeping Supervisor on how to report abuse. Observation on 09/24/22 at 3:30 pm revealed, Business office Manager (BOM) in-servicing, LVN B and Home care 1 on (day shift) concerning Regional [NAME] President was acting Abuse Coordinator and how to report abuse, etc. Interview, with CNA F on 09/24/22 at 3:35 pm (day shift)stated she received education concerning how to recognize abuse and how to report it earlier this morning after the residents had breakfast. All staff educated by ROM took a written test scoring 80% or greater. Observation at 3:37pm revealed ROM educate CNA F concerning the Regional Operations Manager (ROM) is the abuse coordinator and how to report abuse. Interview with LVN B on 09/24/22 at 3:40 pm (day shift)stated she received training this morning shortly after she came to work his morning. The training was conducted by ROM. The training consisted of abuse, how to identify abuse and report it and took a written test. Interview with LVN D on 09/24/22 at 8:44 pm (night shift) said she was trained before shift by the BOM. The training consisted of abuse, how to identify and report abuse, who the abuse coordinator was and took a written test. Interview with CNA I on 09/24/22 at 8:56 pm said she was trained before shift by the BOM. The training consisted of abuse, how to identify and report abuse, who the abuse coordinator was and took a written test. Interview with LVN A on 09/24/22 at 9:00 pm said she was trained before shift by the BOM. The Training consisted of abuse, how to identify and report abuse, who the abuse coordinator was and took a written test. Staff Social Worker, CMA and PT (who are out of town and/or out of the country) will be interview regarding abuse and neglect prior to their shift. The Regional Operations Director, Administrator, DON, ADON, and Corporate Nurse were informed the Immediate Jeopardy was removed on 09/25/22 at 12:40 p.m. The facility remained out of compliance at a severity level of 2 with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.