**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free from verbal, sexual physical and mental abuse, corporal punishment, and involuntary seclusion for 1 of 5 residents (Resident #1) reviewed for abuse in that: The AP made Resident #1 clean up his own excrement from the floor and the toilet on 11/13/23. The AP threatened Resident #1 that if he did not clean up his excrement, he would not be able to go and smoke during the evening smoke break. LVN B failed to follow up and ensure that Resident #1 was free from abuse after the AP verbalize that she was going to make Resident #1 clean up his own excrement. The AP worked the remainder of her shift on 11/13/23-11/14/23 from 6:00 AM-6:00 PM after verbalizing that she verbalized that she would make Resident #1 clean his own excrement and after making Resident #1 clean his own excrement from the floor and the toilet. An IJ was identified on 11/21/23 at 4:50 PM. The IJ template was provided to the facility on [DATE] at 4:40 PM. While the IJ was removed on 11/22/23 at 02:58 PM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated because all staff had not been trained on 11/22/23. This failure could place residents at risk of physical harm, mental anguish, emotional distress, or death. Findings Included: Record review of Resident #1's face sheet, dated 11/21/23, revealed a [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (brain disorder), schizophrenia (mental illness), dementia (impaired memory), cognitive communication deficit (difficulty paying attention), history of falling, difficulty walking, unsteadiness on feet and lack of coordination. Record review of Resident #1's Quarterly Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. Section G Functional status I. Toilet use: provide supervision with one person to physically assist. J. Personal Hygiene: Limited assistance with one person to physically assist. Mobility Devices B. [NAME] Section H Bladder and Bowel Bowel Continence Frequently incontinent Section I Active Diagnoses Anxiety Disorder, depression, and Schizophrenia Record review of Resident #1 care plan dated 07/28/21 revealed the following: Focus Resident #1 was incontinent of: Bladder Record review of Resident #1 care plan dated 09/05/21 revealed the following: Focus Resident #1 was at Risk for Falls as evidenced By: History of Falls, Cognitive Impairment, Unsteady Gait, Medication use. Record review of Resident #1 care plan dated 07/29/21 revealed the following: Focus Resident #1 had impaired Visual Functioning and was at Risk for a decrease in ADLs and Injuries r/t Disease Process Record review of Resident #1 care plan dated 07/28/21 revealed the following: Focus Resident #1 had an ADL self-care performance deficit r/t disease processes. Intervention TOILET USE: Resident requires supervision set up assistance with one person assistance at times Record review of Resident #1 care plan dated 12/15/21 revealed the following: Focus Resident #1 had a diagnosis of Depression. Resident #1 was at risk for self-care deficit, ineffective coping, deficient diversional activity, and insomnia. During an interview on 11/21/23 at 9:54 AM, the ADM stated Resident #1 had a bowel movement and was given a laxative. She said Resident #1 had feces on the toilet and the floor. She said Housekeeper C came and told the AP that she would disinfect after she (the AP) had cleaned up the feces. She said the AP refused. She said the AP refused and then said Resident #1 would clean up his mess. She said this verbal interaction occurred in front of the charge nurse (LVN A and LVN B). She said after the charge nurse (LVN B) told her she could not make him, the AP still took Resident #1 down to his room with cleaner, and the resident cleaned up his floor and the bathroom. She said the AP told Resident #1 that he could not smoke until it was cleaned. She said the AP did complete her entire shift on this date. She said she did not learn about the incident until the following day (11/14/23) when LVN A reported it to her at 8:30 AM. She said at that time, she spoke with Resident #1, and he could recall the incident and that it did happen. She said Resident #1 was concerned about the AP being fired and did not want the AP fired because she had children to care for. She said that the AP was terminated because of the incident. The ADM stated that she was notified of the incident the next day 11/14/23 by LVN A. During an interview on 11/21/23 at 9:54 AM, the DON stated LVN A was leaving, and LVN B took over the shift when the incident occurred. She said both charge nurses (LVN A and LVN B) told the AP that she could not do this and that it was not okay. She said this incident occurred around 6 PM on 11/13/23. She said the AP was not referred because they wanted to wait to see what the state would do. During an interview on 11/21/23 at 10:30 AM, Resident #1 stated he did not know the date of the incident, but he remembered what happened. He said that he was supposed to get a shower. He said he was really sorry for using the restroom on the floor and the toilet. He said the staff told him he could not leave his room until he cleaned up his mess. He said he did not know her name. He said she was mad at him, he was nervous, and it made him feel bad. He said he cleaned it up the best he could. He said he did not have any more toilet paper, so he did his best with paper towels. He said no one came in to help him clean. He said that he was told that he could not smoke that day. He said he did not get to smoke that day. He said he was able to smoke the next day. He said no one came to talk to him or check on him. He said no one had done anything like that to him before. During an interview on 11/21/23 at 11:07 AM, LVN B stated that she was unsure of the exact date and time of the incident with the AP and Resident #1. She said Resident #1 had feces on the toilet. She said she told the AP that she would have to clean it. She said the AP told her that she would not clean it up. She said she had Resident #1 clean it up. She said she was aware of this the following day when the investigation was started. She said she was busy and remembered them (Resident #1 and the AP) going down the hall. She said she assumed that the AP would take Resident #1 down the hall to his room and check him to ensure he had no feces on him. She said she did not think anything of it. She said she did not report this to anyone. She said she assumed that she would not have him clean the feces. She said she was mad when she told her that she (the AP) would have to clean it. She said she could tell she was angry because of her facial expression. She said the AP thought cleaning the feces was the housekeeper's job. She said it was her understanding that no one followed up with Resident #1. She said she believed Resident #1 went to his smoke break because she saw him coming down the hallway but did not physically see him smoke. She said smoking was Resident #1 favorite part of his day. She said LVN A was present for the verbal altercation. She said she was coming in for her shift, and LVN A was leaving for the day. She said she was unsure if the AP was having a bad day or moment. She said the AP does what she was typically told. She said she should have reported it as soon as she heard it, but the reason why she did not report it was because she was busy with her other nursing duties, and she did not think that she would make Resident #1 clean up his own excrement. During an interview on 11/21/23 at 11:28 AM, the Activity Director stated she was unsure when the AP made Resident #1 clean up his fecal matter off the floor and the toilet. Still, she remembered she stayed past her shift to help with the evening shift. She said she heard the AP tell Resident #1 directly that he was going to have to clean up his mess. Resident #1 said he could not clean it up, and the AP kept yelling yes, you can, yes, you can. She said she heard LVN B tell her no that she (the AP) could not do that. She said after LVN B told her no, she left to do medications for the other residents. She said she saw Resident #1 going to his room. She said she did not see the AP at that time. She said 20 minutes later, she went down the hall, and Resident #1 attempted to leave his room. She said she then saw the AP tell Resident #1 no that he could not come out and that she needed to check his room first to ensure it was done right. She said when the AP came out, she told Resident #1, Good job, and then he was allowed to go. She said that after she saw that, she went to LVN B and told her what she saw. She told LVN B, Did you know she made him (Resident #1 clean that up? She said LVN B responded, No, but the DON had been notified, and she had already called. She said she witnessed the AP yelling at one of the laundry ladies, stating that she was not paid to clean that up. She said that she supervised smoking that evening, and Resident #1 was allowed to smoke. She said that after the incident, she was told to report it to the ADM immediately. During an interview on 11/21/23 at 11:38 AM, the DON stated the incident occurred on the 12th of November. She said she was notified the morning that she came in on 11/13/23. She said she was notified by LVN A the night before. She said that she was told that the AP was griping about having to clean up the mess. She said she followed up with LVN B to see if the mess had been cleaned and handled. She said LVN B told her it had been handled and the mess had been cleaned. The DON said, I just left it there. She said she never followed up to see who cleaned up the feces. During an interview on 11/21/23 at 11:45 AM, LVN B stated that she could not remember who reported that Resident #1 had cleaned up the fecal matter. She said she had so much going on the night of the incident. She said she was trying to remember if it was the activity director or who it was because she was busy. She said she was busy with passing medications and was the only nurse in the evening. She said the AP worked her entire shift that evening. She said that the incident happened at shift change around 6:00 PM. She said she received a text from the DON asking if the mess had been cleaned up. She said she did not know how the DON knew about the incident. She said she assumed LVN A told her about it. She said the potential negative outcome was the comment about making Resident #1 clean his poop would make him feel bad. She said Resident #1 needs assistance. She said that was why he was at the facility. She said Resident #1 may have been confused and felt he had done something wrong. She said the AP would have been sent home if this had been reported. She said that the AP not being sent home would have placed Resident #1 and the other residents at risk for abuse. During an interview on 11/21/23 at 11:28 AM, Housekeeper C stated that on 11/13/23, she was on Hall 4 when she was told by the AP, Hey, look what Resident #1 did to you. She said the AP told her, You are the housekeeper, and you can clean it. She told the AP, No, you have to clean, then I come and disinfect. She said she told the AP she could not contaminate the housekeeping cart. She said the AP then was yelling where everyone could hear, saying that she would not clean it but that he (Resident # 1) would do it. She said the AP was screaming, upset and mad. She said the AP told her that she told Resident #1 that he better do it because she would not do it. She said the AP told her that she told Resident #1 that if he didn't clean the mess, then Resident #1 would not go out and smoke. She said the AP told Resident #1 that even if he went outside, he would not get a cigarette if he did not clean up the mess. She said even after Resident #1 cleaned the poop, there was still some on the toilet. She said she did not see Resident #1 cleaning but did see Resident #1 following the AP saying, I will clean it, I will clean it. She said the AP told her Resident #1 was cleaning the toilet. She said she did not see him personally cleaning the toilet She said the AP was mad and could tell because she was screaming at her. She said she was screaming so loud that everyone could hear. During an interview on 11/21/23 at 2:24 PM, the ADM stated once she was made aware of the incident, by LVN A she started educating staff on ANE. She said they educated staff on housekeeping and staff responsibilities regarding cleaning up body fluids. She said this incident was not covered in their QAPI meeting. She said this was not covered in their QAPI meeting because they had their meeting on 11/07 or 11/08 of November, and the incident occurred on the 13th. She said the QAPI meetings were on the 2nd Wednesday of the month. She said there was never a time that they deviated outside of the scheduled QAPI meetings. She said regarding the incident, she expected that the AP would have been removed from the facility immediately. She said it was abuse. She said it was a form of shaming and degrading Resident #1. She said when the AP threatened to withhold Resident #1's smoke break, this was a form of punishment. She said she was unaware that any of the nurses had reported the information to the DON. She said she was unaware that the DON was aware of the information until after LVN A wrote her statement. She said the AP worked the incident date from 6:00 AM to 6:00 PM. During an interview on 11/21/23 at 4:50 PM, the DON stated that she did not consider what the AP said verbal abuse because the AP did not tell the statement directly to Resident #1. She called and asked about the mess being cleaned but did not follow up with who cleaned it. During an interview on 11/22/23 at 12:00 PM, LVN A stated that on 11/13/23 she worked from 6 AM to 6 PM. She said Resident #1 had come to her and asked where his room was. She said she told Resident #1 where his room was. She said while giving LVN B a report that the AP found excrement on the toilet and the floor, she overheard the AP say she would make Resident #1 clean it. She told the AP she could not do that and would not make Resident #1 clean it. She said Resident #1 was seated at the nurse's station. She said she was not sure if he heard what was being said. She said he may not understand what was happening even if he did hear. She said Resident #1 was very forgetful and needed constant reminders. She said the incident occurred around 6:15 or 6:20 PM. After giving the report, she told LVN B she needed to leave because her shift was over. She said the AP had not made Resident #1 clean up the excrement before she left. She said after leaving work, she went to the DON's home and reported that the AP said she would make Resident #1 clean up her mess. She said the DON's initial response was, What? She repeated what she had told her. She said the DON stated, She cannot do that. She said that the DON told her she would call the facility. She said the DON had called to ask if the body fluids had been cleaned. She said she was unsure if LVN B knew who had cleaned it up at the time. The following day (11/14/23), LVN A said the Activity Director told her during a smoke break that Resident #1 had cleaned up the mess. LVN A said that she reported it to the DON again because anything could have happened. She said the DON at that time did not know that the AP had followed through with making Resident #1 clean up his mess. LVN A said she did not follow up the day before because she did not think she would do it. She said Resident #1 could have potentially consumed the chemical, the fumes could have made him sick, and he would not do well with cleaning because of his cognitive state. She said Resident #1 could have spilled the chemical on himself or even fallen. She said this could also be considered emotional abuse because being incontinent is embarrassing, and this entire incident could have embarrassed him and caused him to lose his dignity. She said even if a person was lower level cognitively, they should not be subject to abuse. She said she would not want this done to her loved one because it could hurt your feelings. She said the AP has a strong personality, and LVN B does not. She said this may have been why LVN B did nothing. During an interview on 11/22/23 at 01:13 PM, the AP stated that the excrement was left from the previous shift. She said the excrement was on the floor and the toilet. She said she had Resident #1 clean up the mess because she did not know she was not allowed to do so. She said she never received an in-service or training and could not have them cleaned. She said she thought it was okay because she was encouraging independence. She said she reported to housekeeping that they had to clean it up, and when housekeeping got upset, she went and retrieved a nurse. She said she (the AP) told Resident #1 that he would clean up his mess and was very capable of doing it. She said she helped him clean it up. She said she did not feel like what she did was abuse. She said no one ever told her that she could not do it. She said she was not told by LVN B, LVN A, or anyone that she could not do it. She said if she was doing wrong, she should have been told. She said she did tell him if he did not clean it up, then he could not smoke. She said she only told him this because he said no when she first told him he had to clean it up. She said she did not consider what she said a threat or a punishment at the time. She said this was okay because she had seen others tell other residents things like that. She said she had seen staff tell residents that if they did not get up, they would not get a food tray, so she thought this was okay. She said she had not done this with any other residents. Record review of the facility's video surveillance revealed the following occurred on 11/13/23 at 6:45 PM (The video surveillance did not have any sound): Observed Resident #1 walking by himself using a walker towards his room. The AP was walking quickly in front of him. She enters a room on the right, obtains a trash can and something unidentifiable in her left hand, and takes it in his room. She comes out. Resident #1 enters the room. The AP walked in and out of multiple rooms, talking with staff in the hallway. Resident #1 comes out of the room, the AP appears to say something, and Resident #1 returns to his room. After 2 minutes, Resident #1 came back out of the room. The AP exits another room and goes back into Resident #1 room, and Resident #1 goes back into the room. The AP returns to Resident #1's room and exits with the trash can. Resident #1 left his bedroom and walked down the hall. Record review of the AP employee file revealed the following: Termination Recommendation dated 11/14/23 based off of her having a resident clean his bathroom after soiling it. The termination recommendation revealed that she had a disciplinary on 04/15/23 for failure to complete assigned tasks and 04/25/23 for failure to report suspected abuse. All Staff Memo dated 04/18/23 stated that all calls to the DON and the ADM should be for emergency only. Community Orientation Checklist (undated) indicated the resident received the Resident abuse test. Abuse test dated 12/15/22 indicated that hitting a resident, refusing care and threatening a residents all constituted abuse. It also indicated that if a confused resident reports abuse that the staff has to report it. It indicated that any team member that is alleged to have abused was not allowed to work until the investigation is complete. The test stated allegations of abuse must be reported immediately. The test stated all allegations of abuse must be investigated. Record review of the facility policy, on Abuse (Revised 01/01/2023), revealed the following: The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, involuntary Seclusion/Confinement, and or Misappropriation of property. Abuse isa willful infliction of injury or negligent, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident. Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, caretakers, friends, or other individuals. This includes physical, verbal, sexual, physical/chemical restraint. Procedure The administrator in or designee are responsible for maintaining all facility policies that prohibit abuse, neglect, and misappropriation of funds personal belongings, involuntary seclusion, or corporal punishment. Identification of possible problems that need investigation investigating all allegations reporting incidents, investigations, and facility response to results of investigation within mandated time frames. Protecting residents during investigation Reporting/Investigation: The law requires the abuse coordinator or designee or employee of the facility who believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect or exploitation caused by another person to report the abuse, neglect or exploitation. Upon notification of an allegation of physical or mental abuse, neglect or involuntary seclusion, the facility will conduct interviews that include documented statements summaries from the alleged perpetrator, the alleged victim, family members, visitors who may have made observations, roommate, and any staff who worked prior to and during the time of the incident. Interviews may include employees of various departments and ships. A thorough physical assessment will be conducted on residents involved in the allegation of abuse neglect. Investigations will focus on determining if the abuse occurred, the extent of the abuse, and potential causes. Protection: it is utmost important that the residents suspected of being abused, and all other residents must be protected during the initial identification, an investigation process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm. Upon notification of the allegation, the abuse coordinator or designee will perform the following: identify the perpetrator that is identified by eyewitness or during the investigation and remove the perpetrator from further contact with the resident pending outcome of the investigation. Record review of the facility job description for Licensed Vocational Nurses (dated 11/02/2020) revealed the following: Position Summary To lead or direct licensed and non-professional staff in the delivery of direct Resident Care and Support functions. Essential Functions Identifies problems and guides personnel to their solution Pursue more specific investigation as needed. Consistently follows established standards, policies, and procedures in providing nursing care Accepts accountability for clinical care of assigned patients, including supervision of nonprofessional personnel. Responds appropriately in urgent and/ or emergency situations. Record review of the facility job description for Housekeeper Supervisor (dated 11/2020) revealed the following: Position Summary Perform scheduled housekeeping tasks that may be assigned by the housekeeper supervisor. Incumbents may mop, sweep, dusts, wash window, shampoo and vacuum carpets, arrange furniture and generally clean furniture, equipment, fixtures and hardware. Essential Functions: Clean and sanitize residences and contents, including, but not limited to, vacuuming, dusting, cleaning kitchen and bath fixtures, turning mattresses, moving light furniture, emptying trash receptacles Record review of the facility job description for Certified Nurse Aide (dated 11/2020) revealed the following: Position Summary Responsible for assisting residents with activities of daily living to promote resident independence and dignity. Essential Functions: To assure resident safety Keep residents clean and dry, toileting or providing incontinent care. Others duties as assigned Record review of the facility job description for Director of Nursing (dated 11/02/2020) revealed the following: Position Summary To lead or direct licensed and non-professional staff in the delivery of direct resident care and support functions. Essential Functions To assure resident safety Identifies problems and guides personnel to their solutions. Accepts accountability for clinical care of assigned patients, including supervision of nonprofessional personnel. Supports standards of nursing care through adherence to existence policies and procedures. Record review of the facility policy, Resident Rights (12/2016), revealed the following: Policy Statement Employees shall treat all residents with kindness, respect, and dignity Policy Interpretation and Implementation dignified existence Be treated with respect, kindness and dignity Be free from abuse, neglect, misappropriation of property, and exploitation; Be free from corporal punishment or involuntary seclusion, and physical or chemical restraints Perform services for the facility if he chooses or refuses to perform services for the facility Record review of the AP's time sheet revealed that on 11/13/23 she worked from 6:00 PM until 11/14/23 6:07 AM. The ADM and the DON were notified on 11/21/23 at 4:50 PM and IJ situation was identified due to the above failures and the ID template was provided. The following Plan of Removal submitted by the facility was accepted on 11/22/23 at 01:50 PM: F600 Plan of Removal Any allegation of abuse/neglect will be investigated immediately by EDO/designee, and residents will be protected immediately. EDO/designee will review daily all incidents and accidents and grievances for potential allegations of abuse/neglect in the standup meeting, and will investigate immediately, and residents will be immediately protected. All incontinent residents have the potential to be affected by this alleged deficient practice. No other residents were identified to have been affected by this alleged deficient practice. Abuse/Neglect inservices for all staff in the community completed 11/22/2023 and ongoing. Alleged Perpetrator terminated 11/14/2023 following the incident that occurred 11/13/2023. DON has been suspended pending further investigation effective 11/21/2023. Ad hoc QAPI conducted 11/21/2023 to discuss IJ with Medical Director. LVN B suspended pending further investigation effective 11/21/2023. Resident #1 had a Psychiatric evaluation by the NP on 11/20/2023. No new orders or changes in treatment after this evaluation. A follow-up telehealth psychiatric assessment was completed 11/22/2023. No new orders or changes to plan of care recommended. Nursing staff to continue to monitor psychosocial needs q shift. Trauma assessment completed 11/21/2023. 11/21/2023 Regional Nurse Consultant provided training to DCO and ADCO on policy on abuse/neglect, reporting of suspected abuse/neglect, types of abuse including, but not limited to involuntary seclusion/punishment, verbal threats to residents. Abuse and neglect in-servicing was initiated on 11/21/2023 by the ADCO for all staff regarding reporting any suspected abuse/neglect to Abuse Coordinator immediately, 24 hours/day. Review of types of abuse including, but not limited to involuntary seclusion/punishment of residents. Staff inserviced on taking measures to intervene immediately to protect residents from inappropriate/suspicious behavior, abuse or potential abuse toward a resident. This training will be provided to all staff prior to the start of their next shift until all staff have had the training. Completion date 11/22/2023. This training will also be part of new staff orientation. Administrator was in-serviced on 11/21/23 by the RVP on policy and procedure for abuse/neglect and reporting parameters for abuse/neglect allegations, including immediate removal of AP from the facility to protect all residents. Safe surveys conducted with all alert and oriented residents to assess for abuse/neglect. 5 alert and interviewable residents will be interviewed weekly to assess for abuse/neglect x 4weeks, then weekly in Standards of Care Meeting. Administrator will review findings. Will evaluate findings in the monthly QAPI meeting until resolved. On 11/22/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 11/22/23 from 02:15 PM to 2:41 PM with (LVN D, E, Hospitality Aide F, and CNA G & H) revealed that they could identify all five types of abuse (mental, physical, emotional/mental, sexual, and financial). They all explained that they had been trained and understood that depriving a resident of things was unacceptable to get them to complete a task. They all could define their roles and responsibilities if they witness or suspect abuse. They could state that they would report any allegations, whether they believed it occurred or would occur to the Administrator Immediately. They all explained that it was important to protect the residents, including ensuring that the residents were not around any perpetrators and that the perpetrator was not putting other residents at risk. LVN D & E explained their role in ensuring they follow up with any abuse allegations, including reporting immediately to the ADM and removing any alleged perpetrators from the facility. Record review of 17 completed abuse and resident rights quizzes completed by multiple staff on various shifts between 11/21/23 &11/22/23 revealed the Resident rights quiz covered the Resident rights quiz covered the residents right to refuse treatments, care and or services. The abuse quiz discussed types of abuse to include threatening a resident and refusing care. It covered alleged perpetrators not being allowed to work with residents and that abuse needed to be reported immediately. Record review of the facility QAPI meeting signature sheet indicated that an ad hoc meeting occurred on 11/21/23. Record review of the facility Inservice dated 11/21/23 revealed the ADM being the facility's abuse coordinator and her contact number. The inservice explained that she can be reached at anytime and that abuse and neglect must be reported immediately. The inservices specified that if staff see or hear anything they must report what they have seen or heard immediately. The inservice specified that staff must report all allegation of abuse even if they feel it will not happen. The inservice specified that staff may not punish or threaten residents by isolating[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 1 of 5 (Resident #1) reviewed for abuse and neglect. The DON failed to respond to LVN A's report of the AP verbalizing that she would make Resident #1 clean up his own excrement from the toilet and the floor as a result no investigation was initiated. LVN B failed to report allegations of ANE after the AP verbalized that she would make Resident #1 clean up his own excrement from the toilet and the floor and that he would not be allowed to go smoke if this was not completed and as a result an investigation was not initiated. An IJ was identified on 11/21/23 at 4:50 PM. The IJ template was provided to the facility on [DATE] at 4:40 PM. While the IJ was removed on 11/22/23 at 02:58 PM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated because all staff had not been trained on 11/22/23. This failure could place residents at risk of allegations not thoroughly being investigated and residents being at risk for emotional and physical abuse and exposure to alleged perpetrators. Findings Included: Record review of Resident #1's face sheet, dated 11/21/23, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnosis to include Alzheimer's disease (brain disorder), schizophrenia (mental illness), dementia (impaired memory), cognitive communication deficit (difficulty paying attention), history of falling, difficulty walking, unsteadiness on feet and lack of coordination. Record review of Resident #1's Quarterly Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. Section G Functional status I. Toilet use: provide supervision with one person to physically assist. J. Personal Hygiene: Limited assistance with one person to physically assist. Mobility Devices B. [NAME] Section H Bladder and Bowel Bowel Continence Frequently incontinent Section I Active Diagnoses Anxiety Disorder, depression, and Schizophrenia Record review of Resident #1 care plan dated 07/28/21 revealed the following: Focus Resident #1 was incontinent of: Bladder Record review of Resident #1 care plan dated 09/05/21 revealed the following: Focus Resident #1 was at Risk for Falls as evidenced By: History of Falls, Cognitive Impairment, Unsteady Gait, Medication use. Record review of Resident #1 care plan dated 07/29/21 revealed the following: Focus Resident #1 had impaired Visual Functioning and was at Risk for a decrease in ADLs and Injuries r/t Disease Process Record review of Resident #1 care plan dated 07/28/21 revealed the following: Focus Resident #1 had an ADL self-care performance deficit r/t disease processes. Intervention TOILET USE: Resident requires supervision set up assistance with one person assistance at times Record review of Resident #1 care plan dated 12/15/21 revealed the following: Focus Resident #1 had a diagnosis of Depression. Resident #1 was at risk for self-care deficit, ineffective coping, deficient diversional activity, and insomnia. During an interview on 11/21/23 at 9:54 AM, the ADM stated Resident #1 had a bowel movement and was given a laxative. She said Resident #1 had feces on the toilet and the floor. She said Housekeeper C came and told the AP that she would disinfect after she (the AP) had cleaned up the feces. She said the AP refused. She said the AP refused and then said Resident #1 would clean up his mess. She said this verbal interaction occurred in front of the charge nurse (LVN A and LVN B). She said after the charge nurse (LVN B) told her she could not make him, the AP still took Resident #1 down to his room with cleaner, and the resident cleaned up his floor and the bathroom. She said the AP told Resident #1 that he could not smoke until it was cleaned. She said the AP did complete her entire shift on this date. She said she did not learn about the incident until the following day (11/14/23) when LVN A reported it to her at 8:30 AM. She said at that time, she spoke with Resident #1, and he could recall the incident and that it did happen. She said Resident #1 was concerned about the AP being fired and did not want the AP fired because she had children to care for. She said that the AP was terminated because of the incident. The ADM stated that she was notified of the incident the next day 11/14/23 by LVN A. During an interview on 11/21/23 at 9:54 AM, the DON stated LVN A was leaving, and LVN B took over the shift when the incident occurred. She said both charge nurses (LVN A and LVN B) told the AP that she could not do this and that it was not okay. She said this incident occurred around 6 PM on 11/13/23. She said the AP was not referred because they wanted to wait to see what the state would do. During an interview on 11/21/23 at 10:30 AM, Resident #1 stated he did not know the date of the incident, but he remembered what happened. He said that he was supposed to get a shower. He said he was really sorry for using the restroom on the floor and the toilet. He said the staff told him he could not leave his room until he cleaned up his mess. He said he did not know her name. He said she was mad at him, he was nervous, and it made him feel bad. He said he cleaned it up the best he could. He said he did not have any more toilet paper, so he did his best with paper towels. He said no one came in to help him clean. He said that he was told that he could not smoke that day. He said he did not get to smoke that day. He said he was able to smoke the next day. He said no one came to talk to him or check on him. He said no one had done anything like that to him before. During an interview on 11/21/23 at 11:07 AM, LVN B stated that she was unsure of the exact date and time of the incident with the AP and Resident #1. She said Resident #1 had feces on the toilet. She said she told the AP that she would have to clean it. She said the AP told her that she would not clean it up. She said she had Resident #1 clean it up. She said she was aware of this the following day when the investigation was started. She said she was busy and remembered them (Resident #1 and the AP) going down the hall. She said she assumed that the AP would take Resident #1 down the hall to his room and check him to ensure he had no feces on him. She said she did not think anything of it. She said she did not report this to anyone. She said she assumed that she would not have him clean the feces. She said she was mad when she told her that she (the AP) would have to clean it. She said she could tell she was angry because of her facial expression. She said the AP thought cleaning the feces was the housekeeper's job. She said it was her understanding that no one followed up with Resident #1. She said she believed Resident #1 went to his smoke break because she saw him coming down the hallway but did not physically see him smoke. She said smoking was Resident #1 favorite part of his day. She said LVN A was present for the verbal altercation. She said she was coming in for her shift, and LVN A was leaving for the day. She said she was unsure if the AP was having a bad day or moment. She said the AP does what she was typically told. She said she should have reported it as soon as she heard it, but the reason why she did not report it was because she was busy with her other nursing duties, and she did not think that she would do it During an interview on 11/21/23 at 11:28 AM, the Activity Director stated she was unsure when the AP made Resident #1 clean up his fecal matter off the floor and the toilet. Still, she remembered she stayed past her shift to help with the evening shift. She said she heard the AP tell Resident #1 directly that he was going to have to clean up his mess. Resident #1 said he could not clean it up, and the AP kept yelling yes, you can, yes, you can. She said she heard LVN B tell her no that she (the AP) could not do that. She said after LVN B told her no, she left to do medications for the other residents. She said she saw Resident #1 going to his room. She said she did not see the AP at that time. She said 20 minutes later, she went down the hall, and Resident #1 attempted to leave his room. She said she then saw the AP tell Resident #1 no that he could not come out and that she needed to check his room first to ensure it was done right. She said when the AP came out, she told Resident #1, Good job, and then he was allowed to go. She said that after she saw that, she went to LVN B and told her what she saw. She told LVN B, Did you know she made him (Resident #1 clean that up? She said LVN B responded, No, but the DON had been notified, and she had already called. She said she witnessed the AP yelling at one of the laundry ladies, stating that she was not paid to clean that up. She said that she supervised smoking that evening, and Resident #1 was allowed to smoke. She said that after the incident, she was told to report it to the ADM immediately. During an interview on 11/21/23 at 11:38 AM, the DON stated the incident occurred on the 12th. She said she was notified the morning that she came in on 11/13/23. She said she was notified by LVN A the night before. She said she was told that the AP was griping about having to clean up the mess. She said she followed up with LVN B to see if the mess had been cleaned and handled. She said LVN B told her it had been handled and the mess had been cleaned. The DON said, I just left it there. She said she never followed up to see who cleaned up the feces. During an interview on 11/21/23 at 11:45 AM, LVN B stated that she could not remember who reported that Resident #1 had cleaned up the fecal matter. She said she had so much going on the night of the incident. She said she was trying to remember if it was the activity director or who it was because she was busy. She said she was busy with passing medications and was the only nurse in the evening. She said the AP worked her entire shift that evening. She said that the incident happened at shift change around 6:00 PM. She said she received a text from the DON asking if the mess had been cleaned up. She said she did not know how the DON knew about the incident. She said she assumed LVN A told her about it. She said the potential negative outcome was the comment about making Resident #1 clean his poop would make him feel bad. She said Resident #1 needs assistance. She said this is why he is at the facility. She said Resident #1 may have been confused and felt he had done something wrong. She said the AP would have been sent home if this had been reported. She said that the AP not being sent home would have placed Resident #1 and the other residents at risk for abuse. During an interview on 11/21/23 at 2:24 PM, the ADM stated once she was made aware of the incident, she started educating staff on ANE. She said they educated staff on housekeeping and staff responsibilities regarding cleaning up body fluids. She said this incident was not covered in their QAPI meeting. She said this was not covered in their QAPI meeting because they had their meeting on 11/07 or 11/08 of November, and the incident occurred on the 13th. She said the QAPI meetings are on the 2nd Wednesday of the month. She said there was never a time that they deviated outside of the scheduled QAPI meetings. She said regarding the incident, she expected that the AP would have been removed from the facility immediately. She said it was abuse. She said it was a form of shaming and degrading Resident #1. She said when the AP threatened to withhold Resident #1's smoke break, this was a form of punishment. She said she was unaware that any of the nurses had reported the information to the DON. She said she was unaware that the DON was aware of the information until after LVN A wrote her statement. She said the AP worked the incident date from 6:00 AM to 6:00 PM. During an interview on 11/21/23 at 4:50 PM, the DON stated that she did not consider what the AP said verbal abuse because the AP did not tell the statement directly to Resident #1. She called and asked about the mess being cleaned but did not follow up with who cleaned it. During an interview on 11/22/23 at 12:00 PM LVN, A stated that 11/13/23 she worked from 6 AM to 6 PM. She said Resident #1 had come to her and asked where his room was. She said she told Resident #1 where his room was. She said while giving LVN B a report that the AP found excrement on the toilet and the floor. She said she overheard the AP say she would make Resident #1 clean it. She told the AP she could not do that and would not make Resident #1 clean it. She said Resident #1 was seated at the nurse's station. She said she was not sure if he heard what was being said. She said he may not understand what was happening even if he did hear. She said Resident #1 was very forgetful and needed constant reminders. She said the incident occurred around 6:15 or 6:20 PM. After giving the report, she told LVN B she needed to leave because her shift was over. She said the AP had not made Resident #1 clean up the excrement before she left. She said after leaving work, she went to the DON's home and reported that the AP said she would make Resident #1 clean up her mess. She said the DON's initial response was, What? She repeated what she had told her. She said the DON stated, She cannot do that. She said that the DON told her she would call the facility. She said the DON had called to ask if the body fluids had been cleaned. She said she was unsure if LVN B knew who had cleaned it up at the time. The following day (11/14/23), LVN A said the Activity Director told her during a smoke break that Resident #1 had cleaned up the mess. LVN A said that she reported it to the DON again because anything could have happened. She said the DON at that time did not know that the AP had followed through with making Resident #1 clean up his mess. LVN A said she did not follow up the day before because she did not think she would do it. She said Resident #1 could have potentially consumed the chemical, the fumes could have made him sick, and he would not do well with cleaning because of his cognitive state. She said Resident #1 could have spilled the chemical on himself or even fallen. She said this could also be considered emotional abuse because being incontinent is embarrassing, and this entire incident could have embarrassed him and caused him to lose his dignity. She said even if a person is lower level cognitively, they should not be subject to abuse. She said she would not want this done to her loved one because it could hurt your feelings. She said the AP has a strong personality, and LVN B does not. She said this may have been why LVN B did nothing. Record review of the video surveillance revealed the following occurred on 11/13/23 (The video surveillance did not have any sound): Observed Resident #1 walking by himself using a walker towards his room. The AP was walking quickly in front of him. She enters a room on the right, obtains a trash can and something unidentifiable in her left hand, and takes it in his room. She comes out. Resident #1 enters the room. The AP walked in and out of multiple rooms, talking with staff in the hallway. Resident #1 comes out of the room, the AP appears to say something, and Resident #1 returns. After 2 minutes, Resident #1 came back out of the room. The AP exits another room and goes back into Resident #1 room, and Resident #1 goes back into the room. The AP returns to the room and exits with the trash can. Resident #1 left his bedroom and walked down the hall. Record review of the facility policy, Abuse (Revised 01/01/2023), revealed the following: The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, involuntary Seclusion/Confinement, and or Misappropriation of property. Abuse is a willful infliction of injury or negligent, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident. Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, caretakers, friends, or other individuals. This includes physical, verbal Reporting/Investigation: The law requires the abuse coordinator or designee or employee of the facility who believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect or exploitation caused by another person to report the abuse, neglect or exploitation. Upon notification of an allegation of physical or mental abuse, neglect or involuntary seclusion, the facility will conduct interviews that include documented statements summaries from the alleged perpetrator, the alleged victim, family members, visitors who may have made observations, roommate, and any staff who worked prior to and during the time of the incident. Interviews may include employees of various departments and ships. A thorough physical assessment will be conducted on residents involved in the allegation of abuse neglect. Investigations will focus on determining if the abuse occurred, the extent of the abuse, and potential causes. Protection: It is utmost important that the residents suspected of being abused, and all other residents must be protected during the initial identification, an investigation process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm. Upon notification of the allegation, the abuse coordinator or designee will perform the following: identify the perpetrator that is identified by eyewitness or during the investigation and remove the perpetrator from further contact with the resident pending outcome of the investigation. Record review of the facility job description for Licensed Vocational Nurses (dated 11/02/2020) revealed the following: Position Summary To lead or direct licensed and non-professional staff in the delivery of direct Resident Care and Support functions. Essential Functions Identifies problems and guides personnel to their solution Pursue more specific investigation as needed. Consistently follows established standards, policies, and procedures in providing nursing care Accepts accountability for clinical care of assigned patients, including supervision of nonprofessional personnel. Responds appropriately in urgent and/ or emergency situations. Record review of the facility job description for Director of Nursing (dated 11/02/2020) revealed the following: Position Summary To lead or direct licensed and non-professional staff in the delivery of direct resident care and support functions. Essential Functions To assure resident safety Identifies problems and guides personnel to their solutions. Accepts accountability for clinical care of assigned patients, including supervision of nonprofessional personnel. Supports standards of nursing care through adherence to existence policies and procedures. Record review of the facility policy, Resident Rights (12/2016), revealed the following: Policy Statement Employees shall treat all residents with kindness, respect, and dignity Policy Interpretation and Implementation dignified existence Be treated with respect, kindness and dignity Be free from abuse, neglect, misappropriation of property, and exploitation; Be free from corporal punishment or involuntary seclusion, and physical or chemical restraints Perform services for the facility if he chooses or refuses to perform services for the facility The Adm and the DON were notified on 11/21/23 at 4:50 PM and IJ situation was identified due to the above failures and the ID template was provided. The following Plan of Removal submitted by the facility was accepted on 11/22/23 at 01:50 PM: F609 Plan of Removal Any allegation of abuse/neglect will be investigated immediately by EDO/designee, and residents will be protected immediately. EDO/designee will review daily all incidents and accidents and grievances for potential allegations of abuse/neglect in the standup meeting, and will investigate immediately, and residents will be immediately protected. All incontinent residents have the potential to be affected by this alleged deficient practice. No other residents were identified to have been affected by this alleged deficient practice. Abuse/Neglect inservices for all staff in the community completed 11/22/2023 and ongoing. Alleged Perpetrator terminated 11/14/2023 following the incident that occurred 11/13/2023. DON has been suspended pending further investigation effective 11/21/2023. Ad hoc QAPI conducted 11/21/2023 to discuss IJ with Medical Director. LVN B suspended pending further investigation effective 11/21/2023. Resident #1 had a Psychiatric evaluation by the NP on 11/20/2023. No new orders or changes in treatment after this evaluation. A follow-up telehealth psychiatric assessment was completed 11/22/2023. No new orders or changes to plan of care recommended. Nursing staff to continue to monitor psychosocial needs q shift. Trauma assessment completed 11/21/2023. 11/21/2023 Regional Nurse Consultant provided training to DCO and ADCO on policy on abuse/neglect, reporting of suspected abuse/neglect, types of abuse including, but not limited to involuntary seclusion/punishment, verbal threats to residents. Abuse and neglect in-servicing was initiated on 11/21/2023 by the ADCO for all staff regarding reporting any suspected abuse/neglect to Abuse Coordinator immediately, 24 hours/day. Review of types of abuse including, but not limited to involuntary seclusion/punishment of residents. Staff inserviced on taking measures to intervene immediately to protect residents from inappropriate/suspicious behavior, abuse or potential abuse toward a resident. This training will be provided to all staff prior to the start of their next shift until all staff have had the training. Completion date 11/22/2023. This training will also be part of new staff orientation. Administrator was in-serviced on 11/21/23 by the RVP on policy and procedure for abuse/neglect and reporting parameters for abuse/neglect allegations, including immediate removal of AP from the facility to protect all residents. Safe surveys conducted with all alert and oriented residents to assess for abuse/neglect. 5 alert and interviewable residents will be interviewed weekly to assess for abuse/neglect x 4weeks, then weekly in Standards of Care Meeting. Administrator will review findings. Will evaluate findings in the monthly QAPI meeting until resolved. On 11/22/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 11/22/23 from 02:15 PM to 2:41 PM with (LVN D, E, Hospitality Aide F, and CNA G & H)) revealed that they could identify all five types of abuse (mental, physical, emotional/mental, sexual, and financial). They all explained that they had been trained and understood that depriving a resident of things was unacceptable to get them to complete a task. They all could define their roles and responsibilities if they witness or suspect abuse. They could state that they would report any allegations, whether they believed it occurred or would occur, to the Administrator Immediately. They all explained that it was important to protect the residents, including ensuring that the residents were not around any perpetrators and that the perpetrator was not putting other residents at risk. LVN D & E explained their role in ensuring they follow up with any abuse allegations, including reporting immediately to the ADM and removing any alleged perpetrators from the facility. Record review of 17 completed abuse and resident rights quizzes completed by multiple staff on various shifts between 11/21/23 &11/22/23 revealed the Resident rights quiz covered the residents right to refuse treatments, care and or services. The abuse quiz discussed types of abuse to include threatening a resident and refusing care. It covered alleged perpetrators not being allowed to work with residents and that abuse needed to be reported immediately. Record review of the facility QAPI meeting signature sheet indicating that an ad hoc meeting occurred on 11/21/23. Record review of the facility Inservice dated 11/21/23 revealed the ADM being the facility's abuse coordinator and her contact number. The inservice explained that she can be reached at anytime and that abuse and neglect must be reported immediately. The inservices specified that if staff see or hear anything they must report what they have seen or heard immediately. The inservice specified that staff must report all allegation of abuse even if they feel it will not happen. The inservice specified that staff may not punish or threaten residents by isolating them or withholding their rights or their privileges. The abuse policy revised 01/01/23 was also attached. 22 staff member signatures were reviewed. The ADM was informed the Immediate Jeopardy was removed on 11/22/23 at 2:48 PM the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.