**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 4 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when CNA A allegedly physically and verbally assaulted her on 07/28/2025. An IJ (Immediate Jeopardy) was identified on 08/02/2025. The IJ began on 08/02/2025 and was removed on 08/03/2025. The facility took action to remove the IJ before the abbreviated survey began; however, all staff had not been trained on staff-to-resident abuse prevention. The IJ template was provided to the facility on [DATE] at 04:53 p.m. and signed by the ED. While the IJ was removed on 08/03/2025, the facility remained out of compliance at a scope of isolated and severity level 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. This failure could place residents at risk for emotional and physical abuse. The findings included: Record review of Resident #1's admission Record, dated 07/30/2025, reflected Resident #1 was admitted on [DATE] and discharged on 07/29/2025. Resident #1 was noted to be [AGE] years old. Record review of Resident #1's EMR Medical Diagnosis tab, undated and accessed 07/30/2025, reflected Resident #1 was diagnosed with rhabdomyolysis (a condition that causes skeletal muscle to break down rapidly which can result in muscle pain and kidney injury), dorsalgia (back pain), and morbid (severe) obesity (overweight or excess body fat). Record review of Resident #1's EMR MDS tab, undated and accessed 07/30/2025, reflected Resident #1's Entry MDS was the only MDS complete. Record review of Resident #1's .Brief Interview For Mental Status (BIMS) Evaluation, dated effective 07/28/2025, reflected a BIMS score of 15.0, indicating she was cognitively intact. During an interview on 07/30/2025 at 09:08 a.m., Resident #1's family member stated Resident #1 called him on 07/28/2025 around 04:00 p.m. regarding a CNA (CNA A) making threatening statements and throwing a wheelchair at her (Resident #1). He stated he was not present to witness the incident, but Resident #1's roommate, Resident #2 and Resident #2's family were present in the room. He stated he stayed in Resident #1 and Resident #2's room overnight (07/28/2025 to 07/29/2025) following the incident and until both residents were discharged to another facility, due to feeling unsafe. He stated ADON G did not seem to care and only offered to change the CNA assigned to Resident #1 and Resident #2. He stated the facility staff did not immediately the police following the report of CNA A making threatening statements or throwing the wheelchair at Resident #1 until after he told ADON G he reported the incident to the police. During an observation and interview with Resident #1, at NF C, on 07/30/2025 at 02:00 p.m., revealed Resident #1 discharged from NF B and admitted to a different nursing facility, NF C on 07/29/2025. Resident #1 stated an incident occurred on 07/28/2025 at 02:51 p.m. Resident #1 observed to verify the time of the incident by reviewing her text messages to a family member. Resident #1 stated the incident occurred after she had turned on her call light due to needing assistance to go to the restroom. She stated CNA A came into her room, took the wheelchair that was in the room and removed it from the room. She stated the facility staff seemed to be trying to locate a missing wheelchair for another resident and that was why CNA A took the wheelchair out of the room. She stated she told CNA A that she needed to go to the restroom and CNA A replied by pushing a walker at her. Resident #1 stated the only reason the walker didn't hit her was because she lifted her leg out of the way. Resident #1 was observed to indicate her leg with no visible injury. Resident #1 stated after CNA A returned and assisted her to the restroom on the day of incident, 07/28/2025, she overheard CNA A say under her breath, I'm getting ready to shoot people and later stated I'm fixing to start busting people. Resident #1 stated she would have normally taken CNA A's statements as expressions of annoyance or frustration but because CNA A had been visibly getting more and more heated prior to those statements, she took the statements as threats and didn't know what people CNA A was referring to, the other staff or the residents. Resident #1 stated after the incident her family could not leave due to her and her roommate's concerns for safety. Resident #1 stated she and her roommate transferred to a different nursing facility due to concerns for quality of care and safety. Record review of Resident #2's admission Record, dated 07/30/2025, reflected Resident #2 was admitted on [DATE] and discharged on 07/29/2025. Resident #2 was noted to be [AGE] years old. Record review of Resident #2's EMR Medical Diagnosis tab, undated and accessed 07/30/2025, reflected Resident #2 was diagnosed with cerebral infarction (a disruption in the brain's blood flow), fracture (break) of right patella (kneecap), and type 2 diabetes mellitus (DM2; a condition that develops with the way the body regulates and uses sugar as fuel). Record review of Resident #2's EMR MDS tab, undated and accessed 07/30/2025, reflected Resident #2's Entry MDS was the only MDS complete. Record review of Resident #2's .Brief Interview For Mental Status (BIMS) Evaluation, dated effective 07/23/2025, reflected a BIMS score of 15.0, indicating she was cognitively intact. During an observation and interview with Resident #2, at NF C, on 07/30/2025 at 04:40 p.m., revealed Resident #2 discharged from NF B and admitted to a different nursing facility, NF C on 07/29/2025. Resident #2 was observed to be Resident #1's roommate at NF C. Resident #2 stated she was Resident #1's roommate at NF B and transferred with Resident #1 following the incident that occurred on 07/28/2025. Resident #2 stated she had several quality-of-care concerns with staff prior to the incident. Resident #2 stated she had not had previous concerns regarding CNA A; however, after the incident on 07/28/2025 CNA A was mad at her. Resident #2 stated she was unable to hear or witness the alleged statements or the walker having been thrown due to the positioning and location of her bed in NF B. Resident #2 stated CNA A had told her prior to the incident on 07/28/2025 that she (CNA A) had a bad temper. During an interview on 07/31/2025 at 11:01 a.m., Resident #2's family member stated she was present in Resident #1 and Resident #2's room at the time of the incident on 07/28/2025. She stated she was unable to hear CNA A's alleged threatening statements during the incident. She stated she did observe CNA A storm out of Resident #1 and Resident #2's room while facility staff were trying to locate a missing wheelchair and then later re-entered the room and threw a walker toward Resident #1. She stated Resident #1 would have been hit if Resident #1 wasn't paying attention and was able to lean back and out of the way. During an interview on 07/31/2025 at 03:06 p.m., ADON G stated she was notified of a grievance by the LSW regarding Resident #1 around 05:15 p.m. on 07/28/2025. She stated the allegation was regarding CNA A. ADON G stated Resident #1's family member approached her around 06:00 p.m. on 07/28/2025 and asked her what she was doing and the plan of action regarding the allegation. ADON G stated Resident #1's family member stated he would have hog tied her [CNA A] down. She stated he asked her if she had called the police and if she had not, he would. ADON G stated calling the police was part of the procedure for reporting an abuse allegation but had not done it yet. ADON G stated the threatening statements, I'm going to start shooting everybody, was not part of the initial grievance she had received, and she was first told about the threatening statement by Resident #1's family member around 06:15 p.m. ADON G stated she was not told by Resident #1 or her family member regarding a walker having been thrown. ADON G stated following the allegations and grievance, a skin assessment was completed, the CNA was reassigned, interviewed, and sent home; and the police, the DON, and the ED were notified. ADON G stated Resident #1's skin assessment did not reveal any new skin issues. ADON G stated CNA A told her during her interview on 07/28/2025 that she was overwhelmed, that she was trying to take Resident #1 to the restroom and the roommate's [Resident #2] family grabbed her. ADON G stated CNA A was crying during the interview. During an interview on 07/31/2025 at 04:19 p.m., the LSW stated she had received a grievance from Resident #2 and her family prior to the incident on 07/28/2025. The LSW stated the grievance was regarding food temperature and staff not assisting with the call light. The LSW stated the day following the incident, on 07/29/2025 she spoke with Resident #1's family member and Resident #2's family member. She stated Resident #1's family member stated he did not feel safe with Resident #1 staying at NF B because CNA A stated she would go off on someone and he requested Resident #1's clinicals be sent to NF C. She stated Resident #2's family requested for her clinicals be sent to NF C. During an interview on 08/01/2025 at 01:35 p.m., CNA D stated she switched halls with CNA A on 07/28/2025. CNA D stated she was not given a reason for the assignment change. CNA D stated she was present in the room during the police interview with Resident #1, Resident #2, and their family members. CNA D stated the police officer asked Resident #1 if everyone present could stay and Resident #1 replied yes. CNA D stated Resident #1 did not mention the walker being thrown at her to the police, but Resident #2's family member did mention it. She stated she did not recall Resident #2's family member stating the walker was thrown. She recalled Resident #2's family member stating it was shoved. CNA D stated she had not previously provided care to Resident #1 and Resident #2 and was therefore unable to identify if they had any changes in mood or behaviors. CNA D stated she did not observe any noticeable agitation, crying, or fear while providing care for them on 07/28/2025 evening. CNA D stated Resident #1 and Resident #2 appeared calm. CNA D stated Resident #1's family member notified her he was planning on staying the night. During an interview on 08/01/2025 at 04:03 p.m., CNA A stated she was scheduled to work a 02:00 p.m. to 10:00 p.m. shift on 07/28/2025. CNA A stated during her shift the facility staff were trying to locate a missing wheelchair and she was told they needed to verify the wheelchair in Resident #1 and Resident #2's room was not the missing wheelchair. She stated she removed the wheelchair and for an unknown reason, it was taken to therapy. She stated Resident #1 told her she needed to use the bathroom, and she said okay, let me go get your chair back from therapy. She stated, while in the therapy room, Resident #2's family member grabbed her shoulder and said that, if I didn't hurry up, I would be cleaning urine off the floor. CNA A stated when she returned to the room with the wheelchair, Resident #2's family member started to request multiple things for Resident #2. CNA A stated she said under her breath, I can't do this to herself. CNA A stated she then assisted Resident #1 to the restroom, but while waiting outside the restroom door for Resident #1 to finish, Resident #2's family member again started asking for assistance with Resident #2. CNA A stated after assisting Resident #1 back to bed, she asked Resident #1 if she wanted to change into her pajamas prior to dinner and prior to having her shower. CNA A stated Resident #1 stated she was okay with waiting. CNA A stated following this interaction with Resident #1, Resident #2, and Resident #2's family member, she left to assist with passing out meal trays. CNA A stated while passing out meal trays she was approached by CNA D and was told CNA D was relieving her from her hall and wanted a report on the residents' needs. CNA A stated after she gave CNA D report ADON G told her that she needed to go home and needed to write a statement. CNA A stated she did not know what the statement was supposed to be about and was told to write about the wheelchair incident. CNA A stated she was called on 07/30/2025 by the ED and told to come into the facility for an interview. CNA A stated the ED told her that the allegation was that she pushed a wheelchair into Resident #1 and had stated under her breath that she was going to shoot you or shoot your mother. CNA A stated she told the ED that she did state under her breath that she couldn't do this but did not state she would hurt anyone or say anything like that. CNA A stated she did not say anything about shooting anyone or taking anyone out. CNA A stated the only time she moved the wheelchair, or walker was when she moved them to the bed to assist Resident #1 to stand up and go to the restroom. CNA A stated she did not take her hands off either piece of equipment while moving it. During an interview on 08/01/2025 at 05:22 p.m., the DON stated she also interacted with Resident #1 on 07/29/2025 morning. She stated she entered the room and asked if Resident #1 or Resident #2 had any issues. She stated the residents were laughing and only said one issue, referring to the incident on 07/28/2025 evening. She stated the residents did not voice any concerns to her. The DON stated Resident #2 had a scheduled care planning meeting on 07/28/2025. She stated Resident #2 and her family only mentioned concerns about a banana on the breakfast tray. The DON stated she was notified after she had left the NF by the LSW on 07/28/2025 that Resident #1's family member had made an allegation. She stated she replied that the CNA had to be suspended. She stated education was initiated and the police were called. The DON stated a skin assessment was done, and safe surveys and statements were taken. The DON stated the skin assessment and pain assessment was done on 07/28/2025, with no findings identified and Resident #1 stated everything was fine. The DON stated Resident #1 did not require treatment. During an interview on 08/01/2025 at 06:14 p.m., the ED stated he was notified of the incident on 07/28/2025 by the DON. The ED stated the DON initially took the lead in the incident response. He stated the DON directed ADON G to speak with CNA A and send CNA A home. The ED stated the DON directed the LSW to get statements and interview residents that were under CNA A's care. In-services were started and the ADONs were directed to gather staff signatures for the in-services. The ED stated on 07/29/2025, he went to interview Resident #1. He stated he had difficulty interviewing Resident #1 because her family member kept interrupting and interjecting. He stated he primarily understood that Resident #1 was not comfortable, she contacted her family member, and Resident #1's family member came to the facility. The ED stated Resident #1's story was consistent with what her family member stated, but when he tried to speak with her, the family member would finish her sentences, and the ED would have to ask Resident #1 to verify. The ED stated Resident #1 appeared calm during his interview with her, but the family member was anxious for Resident #1 to transfer to another facility. The ED stated the DON submitted the self-report, the police were called, and the physician was notified. During an interview on 08/02/2025 at 10:45 a.m., the ED stated the facility door codes were changed the day CNA A was suspended, 07/28/2025. He stated the facility only had two exit/entry doors and both door codes were changed. He stated the Maint Dir was called and the Maint Dir came to the facility, changed the door codes, and alerted the department heads of the new codes. The ED stated CNA A was notified that she was suspended. He stated she was called and scheduled to be interviewed by him on Wednesday, 07/30/2025. Upon her arrival, she was told to stay in the front lobby until called for interview. She was interviewed on 07/30/2025 and told she was on suspension and to not come back without a notice to return. The ED stated staff were educated to know if someone was not supposed to be in the facility, whether it is a staff member or visitor to alert him and to call the police if they refuse to leave. The ED stated this training was part of their in-service training during orientation. The ED stated staff were aware when a staff member was taken off the schedule. During an interview on 08/02/2025 at 11:36 a.m., ADON G stated she was CNA A's direct supervisor. ADON G stated CNA A was easy to work with and never really gave her push back. ADON G stated CNA A was not a quiet person, her voice carried, and she did not really have a filter. ADON G stated if CNA A had an issue, she was open and honest, sometimes providing personal information. ADON G stated CNA A did not have a history of behaviors or resident complaints, but did have a loud voice. ADON G stated CNA A was acting normally prior to the alleged incident on 07/28/2025, but had stated she was overwhelmed, so ADON G had already messaged the staffing coordinator to see if CNA A could have a different assignment. ADON G stated the alleged incident occurred prior to her attempts to address CNA A's concerns. ADON G stated if CNA A came to the facility while being suspended, she would kindly ask CNA A to go back home and if CNA A refused after two times, ADON G would escalate by notifying her upper supervisor and call 911. ADON G stated CNA A would not be able to come into the facility while suspended because the front desk staff were aware of her suspension and someone at the front desk or nurses' station would recognize her. ADON G stated the entry and exit door codes were changed on 07/28/2025. ADON G stated both ADONs and the business personnel were notified when a staff member was out pending an investigation. She stated the ADONs were responsible for notifying their direct staff when a staff member was out pending an investigation. ADON G stated staff were trained to call the ED immediately and notify the supervisor on premises if someone was at the facility when they were on suspension. ADON G stated the staff are trained upon hire on threat response procedures and they receive a badge buddy which included abuse during orientation. During an interview on 08/02/2025 at 12:32 p.m., CNA F stated she had worked with CNA A several times. CNA F stated she and CNA A had argued several times about how CNA A spoke with residents. CNA F stated she had observed CNA A joking with residents and taking the joking to another level, sometimes being rude to residents. CNA F stated CNA A had a very short fuse and seemed to have toddler-like tantrums. CNA F stated she had not witnessed CNA A be abusive or threatening to residents, only rude. CNA F stated she had reported her concerns to multiple charge nurses from different shifts, but nothing had been done following her reports. CNA F declined to identify who she had reported these concerns to or when. CNA F denied having ever witnessed CNA A be physically abusive to residents or ever heard statements such as I am going to shoot everyone up or anything to that effect. During an observation and interview on 08/02/2025 at 03:35 p.m., the Maint Dir stated he changed the facility entry and exit door locks on Monday night, 07/28/2025 at around 09:00 p.m. He stated he changed the locks on 4 exit doors. The Maint Dir was observed indicating the 4 entry/exit doors and the camera feeds for each door visible in 1 of 2 of the facility nurses' stations. The second facility nurses' station was observed to also have visible camera feeds for all 4 entry/exit doors. The camera feeds were observed to allow staff sitting in the facility nurses' stations to see any person entering and exiting the facility via the entry/exit doors. During an interview on 08/02/2025 at 03:40 p.m., Receptionist I stated she worked as the receptionist on Fridays and Saturdays and occasionally picked up additional shifts. She stated the ED notified her of a staff member being on suspension. She stated she was aware of the facility's procedure for if a staff member on suspension came to the facility. She stated she would immediately let the ED know, not unlock the front entry door, explain to the staff member that they are not supposed to be there, and if they refused to leave or per the ED's instruction, call the police. Record review of Resident #1's Progress Notes, dated 07/30/2025 with effective date range 06/30/2025 to 07/31/2025, reflected: - Skin/Wound Note, effective date 07/28/2025 at 08:08 a.m., by RN K noted as LATE ENTRY, reflected Resident admitted to facility with large bruise to left posterior arm, small scabs to right heel, left elbow, and right middle finger due to fall at home.All other skin intact. - Nursing- General Note, effective date 07/28/2025 at 06:27 p.m., by LPN L reflected Skin check completed with [CNA J] per [ADON G] request. Patient states she had a fall 07/21/2025, the following skin issues noted: Large healing bruise to L posterior [back] arm, RLE, R and L ac areas. 1 small scab noted to back of R heel. 1 scab to R hand, middle finger. 3 scratches to L foot. Scars to bil [both sides] chest. 2 scars to bil [both sides] buttocks. Record review of Resident #1's .Skin Check, dated effective 07/28/2025 at 06:30 p.m., reflected a new issue on the right heel. The skin issue was described as scabbing and present on admission with exact date of 07/25/2025. A second new issue was identified on outer left upper arm. The skin issue was described as bruising and present on admission with exact date of 07/25/2025. A third new issue was identified on the right dorsum 3rd digit (middle)- phalanx (back part of the right middle finger). The skin issue was described as on the knuckle, scabbing, and present on admission with exact date of 07/25/2025. A fourth new issue was identified on the left elbow. The skin issue was described as scabbing/scratch and present on admission with exact date of 07/25/2025. A skin issue note revealed Resident admitted to facility with large bruise to left posterior arm, small scabs to right heel, left elbow, and right middle finger due to fall at home. Record review of facility grievances, dated 05/01/2025 to 07/30/2025, reflected: - a grievance reported by Resident #2 family to LSW on 07/28/2025, reflected [Resident #2 family member] stated, [Resident #2] needed assistance with all meals. 7/28/25 Family pushed call light and cna [sic] took over 10 minutes to get oxygen for resident to come to COE meeting. At 4:55 pm resident family stated they want clinicals sent over to [NF C]. - a grievance reported by Resident #1 family to LSW on 07/28/2025, reflected [Resident #1 family member] stated that [CNA A] came into resident room screaming, ‘Im [sic] about to go off on someone.' [Resident #1 family member] stated he did not feel like [Resident #1] was safe at the facility. [Resident #1 family member] stated he wants her clinicals sent to [NF C] for a skilled transfer. Record review of local police department police report, dated as occurred and reported 07/28/2025 at 06:18 p.m., reflected Dispatch advised of a TERRORISTIC THREAT call at the above location [NF B]. Dispatch advised that staff, specifically [CNA A] threatened to shoot up the place & was being removed by staff.When I arrived at the location, I met with the supervisor on duty, later identified as [ADON G]. She advised that in room [Resident #1 and Resident #2 prior room at NF B], a staff member was having a bad day and was frustrated with patients at the facility. She later advised that and occupants of room [Resident #1 and Resident #2 prior room at NF B] were in a verbal dispute. She later heard that the staff told the patient, If y'all don't calm down, I'm going to start shooting. She later advised that the staff was removed from the facility and sent home.[ADON G] stated that she heard this information from the third party and did not believe the statement to be a threat. I then met with family, and specifically the complainant and his [family member, Resident #1]. I spoke with [Resident #1], who advised that she had just started residing in the facility on 07/25/25 and had minimal interaction with [CNA A]. [CNA A] had been verbally aggressive towards her, and at one point, assisted her to the restroom. [CNA A] was upset with [Resident #1] as she was taking a long time, and said that she was going to start shooting. [Resident #1] stated that initially she did not take it seriously but thought about it after a while and it made her feel unsafe. She relayed the information to her [family member], who contacted dispatch. It was later determined that no offense at the time met the elements. [CNA A] was not on scene, and was not able to be questioned. [Resident #1] and [family member] decided to request a transfer to another facility in [neighboring city], after being treated this way by staff and was awaiting approval. At this time, no charges were filed and both parties did not wish to pursue against one another. Observation and record review of ADON G's Badge Buddy on 08/02/2025 at 11:49 a.m., revealed Abuse Coordinator is? Executive Director. All allegations must be reported immediately. Record review of Patient Abuse Investigation Questionnaire forms, dated 07/29/2025 reflected 14 resident forms with 3 incomplete due to Sleeping can't wake up, Couldn't follow questions, and At an appointment. The completed 11 of 14 forms did not reveal concerns or complaints of physical or verbal abuse or misappropriation. Record review of staff in-service training document, dated 07/28/2025, revealed 19 of 19 nursing staff scheduled during 2-10 shift were in-serviced on Abuse and Neglect. Record review of facility policy, Abuse Protocol, dated April 2019 revealed, 1. The Patient has the right to be free from Abuse, neglect, mistreatment of resident property, and exploitation . 2. Our Facility will not condone Patient abuse, neglect, mistreatment or misappropriation.by anyone, including staff members.10. The Abuse Prevention Coordinator will: . e. Take all steps necessary to protect the Facility's Patients from further incidents of Patient Abuse, neglect, exploitation or mistreatment while the investigation is in progress.19. The Facility will provide orientation and regular in-services to employees on abuse prevention practices,. The ED was notified of an Immediate Jeopardy (IJ) on 08/02/2025 at 04:53 p.m., due to the above failures and the IJ Template was provided at 04:53 p.m. The facility's Plan of Removal (POR) was accepted on 08/02/2025 at 07:28 p.m. and included: Removal Plan for F-Tag 600 Date/Time of Notification to the Facility: 08/02/2025 at 4:53pm Concern: The facility failed to ensure that each resident had the right to be free from physical and verbal abuse for 1 of 4 (Resident #1) residents reviewed for abuse. Resident #1 stated on 07/28/2025 CNA A pushed her walker at her, but it did not hit her due to Resident #1 lifting her leg. Resident #1 stated CNA A, later in the afternoon on the same day, while CNA A was in the restroom with her, made the statement, I'm getting ready to shoot people. Resident #1 stated she did not know who CNA A was referring to but felt fearful for her safety. Resident #1 stated she was fearful of retaliation. Resident #1 stated her [family member] stayed with her overnight following the incident due to her safety concerns. Immediate Actions Resident #1 is no longer in the community. - The C.N.A was suspended on 07/28/2025. The Police were notified of the concern and came to the facility at the time of the complaint/concern on 07/28/2025 and interviewed the appropriate parties. - On 08/02/2025 safe surveys were initiated on all interview able residents, no pattern or concerns were identified nor noted. - On 08/02/2025 Head-to-toe assessments were initiated on all nonverbal residents with no pattern or evidence of any deviation from all of the residents' normal baseline status. - On 08/02/2025 The Medical Director was notified of the immediate jeopardy; the Medical Director was the residents physician. - The Ombudsmen was notified of the content of the immediate jeopardy via email on 08/02/2025. - On 08/02/2025 The community initiated a new protocol to increase the safety of the community by locking the main entry door and only allowing entrance into the community by the facility staff inside. The receptionist and staff were notified and educated of the new protocol via group messaging and in person. - On 08/02/2025 All other entry/exit doors keypad codes were changed. Systematic Approach On 08/02/2025 An ad hoc QAPI meeting was held, in attendance were the: Medical Director (via TEAMS), Executive Director, DON and the Regional [NAME] President of Operations to review appropriate interventions and to review our present Policy and Procedures on: Abuse Prevention, Workplace Aggression/Violence Policy. Review of the present policies was found to be sufficient and met state and federal requirements. Education - On 8/01/2025 The Abuse Coordinator [ED] was in re-serviced by the Regional [NAME] President of Operations, on the Abuse Prevention Protocol, to include a questionnaire and in service on abuse and neglect. - Beginning on 8/1/25-All staff were re-in serviced by the Administrator /Director of Nursing Services and/or Manager on Abuse Prevention Protocol. - On 08/02/2025 Additional Inservice's with competency were added for all staff: Customer Service, Recognizing Employee/Caregiver Burnout and retaliation. In addition, each staff member began in servicing with competency on the Workplace Aggression/Violence policy. ******Any staff who are not present to complete the in-service by 08/02/2025 will be required to complete the in-services at the start of their next shift before beginning work. New Hires, PRN and any agency staff will also be in-serviced prior to the start of their shift. The education will be conducted and monitored by the DON/Designee. Monitoring - Resident safe surveys and/or head to toe assessments will be conducted weekly x 4 weeks on all patients, then monthly x 3 months with oversite from the facility DON and Administrator. - Employees will complete Abuse questionnaires / and in-servicing weekly x 4 weeks then monthly x 3 months with oversite and monitoring from the facility DON and Administrator. Quality Assurance In-servicing on Abuse and Neglect and any associated concerns will be included in the facility's monthly QAPI meeting for 3 months to include the Medical Director with oversight from the facility Administrator and DON. On 08/03/2025 at 12:50 p.m., the investigator began monitoring to determine if the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy with the following: During an observation on 08/03/2025 at 12:47 p.m., a doorbell was noted at the entrance to the nursing facility and staff assistance was required for entry. During an interview on 08/03/2025 at 12:53 p.m., the DON stated CNA A was suspended but will be terminated. During an interview and record review on 08/03/2025 at 03:31 p.m., the MD stated he came to the NF on the night of 08/02/2025 to review and sign the Emergency QAPI Plan. The MD stated he understood the IJ concern and was aware the resident named in the incident had since moved to another nursing facility. During an interview on 08/03/2025 at 04:10 p.m., Receptionist M stated she worked the weekends. She stated the facility front door was now locked all day and she now had to let each person into the facility as they arrived. She stated the front door was previously unlocked from 08:00 a.m. to 06:00 p.m. She stated visitors would continue to be able to exit the facility. She stated the change to having the door locked was done due to a suspended employee. During a dual interview on 08/03/2025 at 04:00 p.m. with the DON and ED, the ED stated the facility only had

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Base of observations, record reviews and interviews the facility failed to develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 4 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when CNA A allegedly physically and verbally assaulted her on 07/28/2025. An IJ (Immediate Jeopardy) was identified on 08/02/2025. The IJ began on 08/02/2025 and was removed on 08/03/2025. The facility took action to remove the IJ before the abbreviated survey began; however, all staff had not been trained on staff-to-resident abuse prevention. The IJ template was provided to the facility on [DATE] at 04:53 p.m. and signed by the ED. While the IJ was removed on 08/03/2025, the facility remained out of compliance at a scope of isolated and severity level 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. This failure could place residents at risk for emotional and physical abuse.The findings included: Record review of Resident #1's admission Record, dated 07/30/2025, reflected Resident #1 was admitted on [DATE] and discharged on 07/29/2025. Resident #1 was noted to be [AGE] years old. Record review of Resident #1's EMR Medical Diagnosis tab, undated and accessed 07/30/2025, reflected Resident #1 was diagnosed with rhabdomyolysis (a condition that causes skeletal muscle to break down rapidly which can result in muscle pain and kidney injury), dorsalgia (back pain), and morbid (severe) obesity (overweight or excess body fat). Record review of Resident #1's EMR MDS tab, undated and accessed 07/30/2025, reflected Resident #1's Entry MDS was the only MDS complete. Record review of Resident #1's .Brief Interview For Mental Status (BIMS) Evaluation, dated effective 07/28/2025, reflected a BIMS score of 15.0, indicating she was cognitively intact. During an interview on 07/30/2025 at 09:08 a.m., Resident #1's family member stated Resident #1 called him on 07/28/2025 around 04:00 p.m. regarding a CNA (CNA A) making threatening statements and throwing a wheelchair at her (Resident #1). He stated he was not present to witness the incident, but Resident #1's roommate, Resident #2 and Resident #2's family were present in the room. He stated he stayed in Resident #1 and Resident #2's room overnight (07/28/2025 to 07/29/2025) following the incident and until both residents were discharged to another facility, due to feeling unsafe. He stated ADON G did not seem to care and only offered to change the CNA assigned to Resident #1 and Resident #2. He stated the facility staff did not immediately the police following the report of CNA A making threatening statements or throwing the wheelchair at Resident #1 until after he told ADON G he reported the incident to the police. During an observation and interview with Resident #1, at NF C, on 07/30/2025 at 02:00 p.m., revealed Resident #1 discharged from NF B and admitted to a different nursing facility, NF C on 07/29/2025. Resident #1 stated an incident occurred on 07/28/2025 at 02:51 p.m. Resident #1 observed to verify the time of the incident by reviewing her text messages to a family member. Resident #1 stated the incident occurred after she had turned on her call light due to needing assistance to go to the restroom. She stated CNA A came into her room, took the wheelchair that was in the room and removed it from the room. She stated the facility staff seemed to be trying to locate a missing wheelchair for another resident and that was why CNA A took the wheelchair out of the room. She stated she told CNA A that she needed to go to the restroom and CNA A replied by pushing a walker at her. Resident #1 stated the only reason the walker didn't hit her was because she lifted her leg out of the way. Resident #1 was observed to indicate her leg with no visible injury. Resident #1 stated after CNA A returned and assisted her to the restroom on the day of incident, 07/28/2025, she overheard CNA A say under her breath, I'm getting ready to shoot people and later stated I'm fixing to start busting people. Resident #1 stated she would have normally taken CNA A's statements as expressions of annoyance or frustration but because CNA A had been visibly getting more and more heated prior to those statements, she took the statements as threats and didn't know what people CNA A was referring to, the other staff or the residents. Resident #1 stated after the incident her family could not leave due to her and her roommate's concerns for safety. Resident #1 stated she and her roommate transferred to a different nursing facility due to concerns for quality of care and safety. Record review of Resident #2's admission Record, dated 07/30/2025, reflected Resident #2 was admitted on [DATE] and discharged on 07/29/2025. Resident #2 was noted to be [AGE] years old. Record review of Resident #2's EMR Medical Diagnosis tab, undated and accessed 07/30/2025, reflected Resident #2 was diagnosed with cerebral infarction (a disruption in the brain's blood flow), fracture (break) of right patella (kneecap), and type 2 diabetes mellitus (DM2; a condition that develops with the way the body regulates and uses sugar as fuel). Record review of Resident #2's EMR MDS tab, undated and accessed 07/30/2025, reflected Resident #2's Entry MDS was the only MDS complete. Record review of Resident #2's .Brief Interview For Mental Status (BIMS) Evaluation, dated effective 07/23/2025, reflected a BIMS score of 15.0, indicating she was cognitively intact. During an observation and interview with Resident #2, at NF C, on 07/30/2025 at 04:40 p.m., revealed Resident #2 discharged from NF B and admitted to a different nursing facility, NF C on 07/29/2025. Resident #2 was observed to be Resident #1's roommate at NF C. Resident #2 stated she was Resident #1's roommate at NF B and transferred with Resident #1 following the incident that occurred on 07/28/2025. Resident #2 stated she had several quality-of-care concerns with staff prior to the incident. Resident #2 stated she had not had previous concerns regarding CNA A; however, after the incident on 07/28/2025 CNA A was mad at her. Resident #2 stated she was unable to hear or witness the alleged statements or the walker having been thrown due to the positioning and location of her bed in NF B. Resident #2 stated CNA A had told her prior to the incident on 07/28/2025 that she (CNA A) had a bad temper. During an interview on 07/31/2025 at 11:01 a.m., Resident #2's family member stated she was present in Resident #1 and Resident #2's room at the time of the incident on 07/28/2025. She stated she was unable to hear CNA A's alleged threatening statements during the incident. She stated she did observe CNA A storm out of Resident #1 and Resident #2's room while facility staff were trying to locate a missing wheelchair and then later re-entered the room and threw a walker toward Resident #1. She stated Resident #1 would have been hit if Resident #1 wasn't paying attention and was able to lean back and out of the way. During an interview on 07/31/2025 at 03:06 p.m., ADON G stated she was notified of a grievance by the LSW regarding Resident #1 around 05:15 p.m. on 07/28/2025. She stated the allegation was regarding CNA A. ADON G stated Resident #1's family member approached her around 06:00 p.m. on 07/28/2025 and asked her what she was doing and the plan of action regarding the allegation. ADON G stated Resident #1's family member stated he would have hog tied her [CNA A] down. She stated he asked her if she had called the police and if she had not, he would. ADON G stated calling the police was part of the procedure for reporting an abuse allegation but had not done it yet. ADON G stated the threatening statements, I'm going to start shooting everybody, was not part of the initial grievance she had received, and she was first told about the threatening statement by Resident #1's family member around 06:15 p.m. ADON G stated she was not told by Resident #1 or her family member regarding a walker having been thrown. ADON G stated following the allegations and grievance, a skin assessment was completed, the CNA was reassigned, interviewed, and sent home; and the police, the DON, and the ED were notified. ADON G stated Resident #1's skin assessment did not reveal any new skin issues. ADON G stated CNA A told her during her interview on 07/28/2025 that she was overwhelmed, that she was trying to take Resident #1 to the restroom and the roommate's [Resident #2] family grabbed her. ADON G stated CNA A was crying during the interview. During an interview on 07/31/2025 at 04:19 p.m., the LSW stated she had received a grievance from Resident #2 and her family prior to the incident on 07/28/2025. The LSW stated the grievance was regarding food temperature and staff not assisting with the call light. The LSW stated the day following the incident, on 07/29/2025 she spoke with Resident #1's family member and Resident #2's family member. She stated Resident #1's family member stated he did not feel safe with Resident #1 staying at NF B because CNA A stated she would go off on someone and he requested Resident #1's clinicals be sent to NF C. She stated Resident #2's family requested for her clinicals be sent to NF C. During an interview on 08/01/2025 at 01:35 p.m., CNA D stated she switched halls with CNA A on 07/28/2025. CNA D stated she was not given a reason for the assignment change. CNA D stated she was present in the room during the police interview with Resident #1, Resident #2, and their family members. CNA D stated the police officer asked Resident #1 if everyone present could stay and Resident #1 replied yes. CNA D stated Resident #1 did not mention the walker being thrown at her to the police, but Resident #2's family member did mention it. She stated she did not recall Resident #2's family member stating the walker was thrown. She recalled Resident #2's family member stating it was shoved. CNA D stated she had not previously provided care to Resident #1 and Resident #2 and was therefore unable to identify if they had any changes in mood or behaviors. CNA D stated she did not observe any noticeable agitation, crying, or fear while providing care for them on 07/28/2025 evening. CNA D stated Resident #1 and Resident #2 appeared calm. CNA D stated Resident #1's family member notified her he was planning on staying the night. During an interview on 08/01/2025 at 04:03 p.m., CNA A stated she was scheduled to work a 02:00 p.m. to 10:00 p.m. shift on 07/28/2025. CNA A stated during her shift the facility staff were trying to locate a missing wheelchair and she was told they needed to verify the wheelchair in Resident #1 and Resident #2's room was not the missing wheelchair. She stated she removed the wheelchair and for an unknown reason, it was taken to therapy. She stated Resident #1 told her she needed to use the bathroom, and she said okay, let me go get your chair back from therapy. She stated, while in the therapy room, Resident #2's family member grabbed her shoulder and said that, if I didn't hurry up, I would be cleaning urine off the floor. CNA A stated when she returned to the room with the wheelchair, Resident #2's family member started to request multiple things for Resident #2. CNA A stated she said under her breath, I can't do this to herself. CNA A stated she then assisted Resident #1 to the restroom, but while waiting outside the restroom door for Resident #1 to finish, Resident #2's family member again started asking for assistance with Resident #2. CNA A stated after assisting Resident #1 back to bed, she asked Resident #1 if she wanted to change into her pajamas prior to dinner and prior to having her shower. CNA A stated Resident #1 stated she was okay with waiting. CNA A stated following this interaction with Resident #1, Resident #2, and Resident #2's family member, she left to assist with passing out meal trays. CNA A stated while passing out meal trays she was approached by CNA D and was told CNA D was relieving her from her hall and wanted a report on the residents' needs. CNA A stated after she gave CNA D report ADON G told her that she needed to go home and needed to write a statement. CNA A stated she did not know what the statement was supposed to be about and was told to write about the wheelchair incident. CNA A stated she was called on 07/30/2025 by the ED and told to come into the facility for an interview. CNA A stated the ED told her that the allegation was that she pushed a wheelchair into Resident #1 and had stated under her breath that she was going to shoot you or shoot your mother. CNA A stated she told the ED that she did state under her breath that she couldn't do this but did not state she would hurt anyone or say anything like that. CNA A stated she did not say anything about shooting anyone or taking anyone out. CNA A stated the only time she moved the wheelchair, or walker was when she moved them to the bed to assist Resident #1 to stand up and go to the restroom. CNA A stated she did not take her hands off either piece of equipment while moving it. During an interview on 08/01/2025 at 05:22 p.m., the DON stated she also interacted with Resident #1 on 07/29/2025 morning. She stated she entered the room and asked if Resident #1 or Resident #2 had any issues. She stated the residents were laughing and only said one issue, referring to the incident on 07/28/2025 evening. She stated the residents did not voice any concerns to her. The DON stated Resident #2 had a scheduled care planning meeting on 07/28/2025. She stated Resident #2 and her family only mentioned concerns about a banana on the breakfast tray. The DON stated she was notified after she had left the NF by the LSW on 07/28/2025 that Resident #1's family member had made an allegation. She stated she replied that the CNA had to be suspended. She stated education was initiated and the police were called. The DON stated a skin assessment was done, and safe surveys and statements were taken. The DON stated the skin assessment and pain assessment was done on 07/28/2025, with no findings identified and Resident #1 stated everything was fine. The DON stated Resident #1 did not require treatment. During an interview on 08/01/2025 at 06:14 p.m., the ED stated he was notified of the incident on 07/28/2025 by the DON. The ED stated the DON initially took the lead in the incident response. He stated the DON directed ADON G to speak with CNA A and send CNA A home. The ED stated the DON directed the LSW to get statements and interview residents that were under CNA A's care. In-services were started and the ADONs were directed to gather staff signatures for the in-services. The ED stated on 07/29/2025, he went to interview Resident #1. He stated he had difficulty interviewing Resident #1 because her family member kept interrupting and interjecting. He stated he primarily understood that Resident #1 was not comfortable, she contacted her family member, and Resident #1's family member came to the facility. The ED stated Resident #1's story was consistent with what her family member stated, but when he tried to speak with her, the family member would finish her sentences, and the ED would have to ask Resident #1 to verify. The ED stated Resident #1 appeared calm during his interview with her, but the family member was anxious for Resident #1 to transfer to another facility. The ED stated the DON submitted the self-report, the police were called, and the physician was notified. During an interview on 08/02/2025 at 10:45 a.m., the ED stated the facility door codes were changed the day CNA A was suspended, 07/28/2025. He stated the facility only had two exit/entry doors and both door codes were changed. He stated the Maint Dir was called and the Maint Dir came to the facility, changed the door codes, and alerted the department heads of the new codes. The ED stated CNA A was notified that she was suspended. He stated she was called and scheduled to be interviewed by him on Wednesday, 07/30/2025. Upon her arrival, she was told to stay in the front lobby until called for interview. She was interviewed on 07/30/2025 and told she was on suspension and to not come back without a notice to return. The ED stated staff were educated to know if someone was not supposed to be in the facility, whether it is a staff member or visitor to alert him and to call the police if they refuse to leave. The ED stated this training was part of their in-service training during orientation. The ED stated staff were aware when a staff member was taken off the schedule. During an interview on 08/02/2025 at 11:36 a.m., ADON G stated she was CNA A's direct supervisor. ADON G stated CNA A was easy to work with and never really gave her push back. ADON G stated CNA A was not a quiet person, her voice carried, and she did not really have a filter. ADON G stated if CNA A had an issue, she was open and honest, sometimes providing personal information. ADON G stated CNA A did not have a history of behaviors or resident complaints, but did have a loud voice. ADON G stated CNA A was acting normally prior to the alleged incident on 07/28/2025, but had stated she was overwhelmed, so ADON G had already messaged the staffing coordinator to see if CNA A could have a different assignment. ADON G stated the alleged incident occurred prior to her attempts to address CNA A's concerns. ADON G stated if CNA A came to the facility while being suspended, she would kindly ask CNA A to go back home and if CNA A refused after two times, ADON G would escalate by notifying her upper supervisor and call 911. ADON G stated CNA A would not be able to come into the facility while suspended because the front desk staff were aware of her suspension and someone at the front desk or nurses' station would recognize her. ADON G stated the entry and exit door codes were changed on 07/28/2025. ADON G stated both ADONs and the business personnel were notified when a staff member was out pending an investigation. She stated the ADONs were responsible for notifying their direct staff when a staff member was out pending an investigation. ADON G stated staff were trained to call the ED immediately and notify the supervisor on premises if someone was at the facility when they were on suspension. ADON G stated the staff are trained upon hire on threat response procedures and they receive a badge buddy which included abuse during orientation. During an interview on 08/02/2025 at 12:32 p.m., CNA F stated she had worked with CNA A several times. CNA F stated she and CNA A had argued several times about how CNA A spoke with residents. CNA F stated she had observed CNA A joking with residents and taking the joking to another level, sometimes being rude to residents. CNA F stated CNA A had a very short fuse and seemed to have toddler-like tantrums. CNA F stated she had not witnessed CNA A be abusive or threatening to residents, only rude. CNA F stated she had reported her concerns to multiple charge nurses from different shifts, but nothing had been done following her reports. CNA F declined to identify who she had reported these concerns to or when. CNA F denied having ever witnessed CNA A be physically abusive to residents or ever heard statements such as I am going to shoot everyone up or anything to that effect. During an observation and interview on 08/02/2025 at 03:35 p.m., the Maint Dir stated he changed the facility entry and exit door locks on Monday night, 07/28/2025 at around 09:00 p.m. He stated he changed the locks on 4 exit doors. The Maint Dir was observed indicating the 4 entry/exit doors and the camera feeds for each door visible in 1 of 2 of the facility nurses' stations. The second facility nurses' station was observed to also have visible camera feeds for all 4 entry/exit doors. The camera feeds were observed to allow staff sitting in the facility nurses' stations to see any person entering and exiting the facility via the entry/exit doors. During an interview on 08/02/2025 at 03:40 p.m., Receptionist I stated she worked as the receptionist on Fridays and Saturdays and occasionally picked up additional shifts. She stated the ED notified her of a staff member being on suspension. She stated she was aware of the facility's procedure for if a staff member on suspension came to the facility. She stated she would immediately let the ED know, not unlock the front entry door, explain to the staff member that they are not supposed to be there, and if they refused to leave or per the ED's instruction, call the police. Record review of Resident #1's Progress Notes, dated 07/30/2025 with effective date range 06/30/2025 to 07/31/2025, reflected: - Skin/Wound Note, effective date 07/28/2025 at 08:08 a.m., by RN K noted as LATE ENTRY, reflected Resident admitted to facility with large bruise to left posterior arm, small scabs to right heel, left elbow, and right middle finger due to fall at home.All other skin intact. - Nursing- General Note, effective date 07/28/2025 at 06:27 p.m., by LPN L reflected Skin check completed with [CNA J] per [ADON G] request. Patient states she had a fall 07/21/2025, the following skin issues noted: Large healing bruise to L posterior [back] arm, RLE, R and L ac areas. 1 small scab noted to back of R heel. 1 scab to R hand, middle finger. 3 scratches to L foot. Scars to bil [both sides] chest. 2 scars to bil [both sides] buttocks. Record review of Resident #1's .Skin Check, dated effective 07/28/2025 at 06:30 p.m., reflected a new issue on the right heel. The skin issue was described as scabbing and present on admission with exact date of 07/25/2025. A second new issue was identified on outer left upper arm. The skin issue was described as bruising and present on admission with exact date of 07/25/2025. A third new issue was identified on the right dorsum 3rd digit (middle)- phalanx (back part of the right middle finger). The skin issue was described as on the knuckle, scabbing, and present on admission with exact date of 07/25/2025. A fourth new issue was identified on the left elbow. The skin issue was described as scabbing/scratch and present on admission with exact date of 07/25/2025. A skin issue note revealed Resident admitted to facility with large bruise to left posterior arm, small scabs to right heel, left elbow, and right middle finger due to fall at home. Record review of facility grievances, dated 05/01/2025 to 07/30/2025, reflected: - a grievance reported by Resident #2 family to LSW on 07/28/2025, reflected [Resident #2 family member] stated, [Resident #2] needed assistance with all meals. 7/28/25 Family pushed call light and cna [sic] took over 10 minutes to get oxygen for resident to come to COE meeting. At 4:55 pm resident family stated they want clinicals sent over to [NF C]. - a grievance reported by Resident #1 family to LSW on 07/28/2025, reflected [Resident #1 family member] stated that [CNA A] came into resident room screaming, ‘Im [sic] about to go off on someone.' [Resident #1 family member] stated he did not feel like [Resident #1] was safe at the facility. [Resident #1 family member] stated he wants her clinicals sent to [NF C] for a skilled transfer. Record review of local police department police report, dated as occurred and reported 07/28/2025 at 06:18 p.m., reflected Dispatch advised of a TERRORISTIC THREAT call at the above location [NF B]. Dispatch advised that staff, specifically [CNA A] threatened to shoot up the place & was being removed by staff.When I arrived at the location, I met with the supervisor on duty, later identified as [ADON G]. She advised that in room [Resident #1 and Resident #2 prior room at NF B], a staff member was having a bad day and was frustrated with patients at the facility. She later advised that and occupants of room [Resident #1 and Resident #2 prior room at NF B] were in a verbal dispute. She later heard that the staff told the patient, If y'all don't calm down, I'm going to start shooting. She later advised that the staff was removed from the facility and sent home.[ADON G] stated that she heard this information from the third party and did not believe the statement to be a threat. I then met with family, and specifically the complainant and his [family member, Resident #1]. I spoke with [Resident #1], who advised that she had just started residing in the facility on 07/25/25 and had minimal interaction with [CNA A]. [CNA A] had been verbally aggressive towards her, and at one point, assisted her to the restroom. [CNA A] was upset with [Resident #1] as she was taking a long time, and said that she was going to start shooting. [Resident #1] stated that initially she did not take it seriously but thought about it after a while and it made her feel unsafe. She relayed the information to her [family member], who contacted dispatch. It was later determined that no offense at the time met the elements. [CNA A] was not on scene, and was not able to be questioned. [Resident #1] and [family member] decided to request a transfer to another facility in [neighboring city], after being treated this way by staff and was awaiting approval. At this time, no charges were filed and both parties did not wish to pursue against one another. Observation and record review of ADON G's Badge Buddy on 08/02/2025 at 11:49 a.m., revealed Abuse Coordinator is? Executive Director. All allegations must be reported immediately. Record review of Patient Abuse Investigation Questionnaire forms, dated 07/29/2025 reflected 14 resident forms with 3 incomplete due to Sleeping can't wake up, Couldn't follow questions, and At an appointment. The completed 11 of 14 forms did not reveal concerns or complaints of physical or verbal abuse or misappropriation. Record review of staff in-service training document, dated 07/28/2025, revealed 19 of 19 nursing staff scheduled during 2-10 shift were in-serviced on Abuse and Neglect. Record review of facility policy, Abuse Protocol, dated April 2019 revealed, 1. The Patient has the right to be free from Abuse, neglect, mistreatment of resident property, and exploitation . 2. Our Facility will not condone Patient abuse, neglect, mistreatment or misappropriation.by anyone, including staff members, other Patient, consultants, volunteers, staff of other agencies serving the patient, family members, legal guardians, sponsors, friends, or other individual 3. our facility will screen potential employees for a history of abuse, neglect or mistreatment of Patients as defined by the applicable legal requirements. This will include attempting to obtain information from previous and/or current employers and checking with the appropriate licensing boards and registries. (See PCMS 15-Personnel). (Screening) 4. The Executive Director, and in his/her absence, the Director of Nursing, will perform the duties of the Abuse prevention Coordinator. 5. The Abuse Coordinator will assure the Facility staff is in-serviced on recognizing abuse, abuse prevention, and abuse reporting upon employment, and as necessary to maintain an abuse free environment. Patient and family members are educated on what constitutes patient Abuse, how to recognize Patient Abuse, how to minimize the potential for patients abuse, how to respond to patient Abuse or other inappropriate behavior when it is observed or suspected, and how to appropriately report Patient Abuse. (Training) 6. Our facility will not retaliate against any person who in good faith reports an allegation. Accidents and Incidents must be reported both internally and externally in accordance with the Reportable Incident Protocol (see Protocol 3-C) a. Staff will be made aware of the name and contact phone number for the Abuse Prevention coordinator. b. All persons who report an allegation of Abuse or Neglect will be kept confidential by the Abuse Prevention Coordinator. c. A person who believes he or she has been subjected to retaliation as a result of reporting an allegation, or who believes an allegation has been ignored, may contact the Abuse Prevention Coordinator the DADS office or the Office of the Attorney General. d. The Facility may take disciplinary action, including termination, against any person who engages in retaliation. e. Our Facility will post a notice indicating the Facility's retaliation policy and the person's rights to file a complaint. 7. The following definitions are provided to assist our Facility staff members in recognizing incidents of patient abuse: a. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical mental and psychosocial well-being. Instances of abuse of all patient/Resident, irrespective of any physical or mental condition, cause physical harm, pain, or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. b. Taking or using photographs ore recordings in any manner that would demean or humiliate a Patient. This includes using any type of equipment (e.g. cameras, smart phones and other electronic devices) to take, keep or distribute photographs and recordings on social media. c. Misappropriation of Patient property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of patient's belongings or money without the patients consent. d. Verbal abuse is defined as any use of oral, written or gestured language that includes disparaging and derogatory terms to Patients or their families, or within their hearing distance, to describe Patients regardless of their age, ability to comprehend, or disability. e. Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual assault, or any non-consensual sexual contact of any type with the Patient. f. Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. g. Involuntary seclusion is defined as separation of a patient from other Patients or from his or her room against the patients will, or the will of the patients legal guardian or representative. Note; temporary monitored separation from other Patients will not be considered involuntary seclusion and may be permitted when used as a therapeutic intervention to reduce agitation as determined by the Medical Director, and/or the Director of Nursing, and such actions is consistent with the Patients Care Plan. h. Mental abuse is defines as but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. (identifying) i. Adverse event is an untoward, undesirable, and usually unanticipated event that cause death or serious injury, or the risk thereof. j. Exploitation means taking advantage of a Patients for personal gain through use of manipulation, intimidation, threats, or coercion. k. Mistreatment means inappropriate treatment or exploitation of a patient l. Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. m. Person centered care means to focus on the patient as the locus of control and support the patient in making their own choices and having control over their daily lives. 8. Any person observing an incident of patient abuse or suspecting patient abuse must immediately report such incidents to the charge nurse. The following information should be reported to the charge nurse: a. The name of the patient involved, B. The date and time that the incident occurred; See. Where the incident took place; D. The names of the person committing the incident, if known; E. The names of any witnesses to the incident; F. The types of abuse that was committed (i.e verbal, physical, sexual, etc.); And G. Other information that may be requested by the charge nurse. 9. The Charge nurse will immediatel