**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the right of the residents to be free from abuse for 3 of 12 residents (Resident #'s 29, 39, and 41) reviewed for abuse. The facility failed to keep Residents #41 and Resident # 39 free from abuse and neglect. The facility failed to implement interventions after each incident between Resident #29 and Resident #41 to prevent further incidents of abuse. The facility failed to protect the resident by allowing CNA B to work after an abuse allegation was made by Resident #39. The facility failed to ensure residents were not fearful of retaliation. The facility failed to protect resident from abuse by staff. This failure resulted in an Immediate Jeopardy (IJ) identified on 08/23/23. While the IJ was removed on 08/25/23, the facility remained out of compliance at no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy at a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective system This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: 1. Record review of Resident #41's face sheet dated 08/22/2023, indicated Resident #41 was a [AGE] year old female admitted to the facility on [DATE], with a diagnoses which include gastroesophageal reflux disease without esophagitis (acid reflux), weakness, moderate intellectual disabilities (difficulty in social situations and problems with social cues and judgment), moderate protein-calorie malnutrition (is the state of inadequate intake of food) pain unspecified, iron deficiency anemia unspecified (occurs when your body doesn't have enough iron to produce hemoglobin), cocaine abuse, uncomplicated. Record review of Resident # 41's Comprehensive MDS assessment dated [DATE], indicated Resident #41 was understood and was able to understand others. The MDS assessment indicated Resident #41 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #41 had no delusions or hallucinations. The MDS assessment indicated Resident #41 had no physical, verbal, or other behavioral symptoms directed toward others. Record review of Resident #41's comprehensive care plan dated 08/09/2023, indicated Resident #41 exhibits socially inappropriate disruptive behavioral symptom, guarded behavior, attention seeking, and embellishes the truth. Record review of Resident #41's progress notes from 05/09/23 through 08/23/23 revealed no documented incidents regarding Resident #41 having coffee thrown at her or an attempted stabbing with a fork. During Resident council meeting on 08/22/23 at 3:00 PM, revealed Resident #41 stated that she was afraid of Resident #29 because he had poured coffee on her and attempted to stab her in the eye with a fork. Resident #41 stated staff witnessed the incidents, and she called the Administrator to report what had happened. Resident #41 stated that CNA A had witnessed the incidents. During an interview on 8/22/23 at 4:03 PM, Resident # 41 stated she didn't know the exact date the incident occurred. Resident # 41 stated Resident # 29 tried to pour coffee on her after supper. Resident # 41 stated she jumped back quickly but the coffee got on her feet. Resident # 41 stated she told CNA A and CNA A told him to quit. Resident # 41 stated Resident #29 had a fork and tried to hit her in the eye with the fork. Resident # 41 stated she jumped down and Resident #29 missed her. Resident # 41 stated both incidents occurred on the same day in June. Resident #41 stated she told CNA A. Resident # 41 stated CNA A told Resident # 29 he couldn't do that; he would be in jail. Resident #41 stated CNA A witnessed both incidents. During an interview on 8/22/23 at 4:42 PM, CNA A stated she witnessed both incidents. CNA A stated the incident were Resident # 29 poured coffee on Resident #41 happened in the hallway, she intervened and reported it to the charge nurse because ADM was not in the building. CNA A stated she could not remember who the charge nurse was. CNA A stated the incident with the fork happened at the nurse's station with multiple staff members around that witnessed the incident. CNA A stated she intervened and notified the charge nurse due to the Administrator not being in the building. CNA A stated the Administrator was the abuse coordinator. CNA A stated she could not remember the exact date of the incidents, but it was the end May or the first of June. CNA A stated she could not remember the charge nurse she reported the incident to. CNA A stated she could not remember the other staff members that were present. and she could not remember who the charge nurse was. During an interview on 8/22/23 at 8:42 AM, the Administrator stated she investigated the incidents and Resident #41 said it did not happen. The Administrator stated she talked to the staff and the staff said they did not witness the either incident. The Administrator stated she can't remember when the incidents happened, it was back in April. The Administrator stated it had been a long ago, it was not a new allegation, it is an old allegation. The Administrator stated still to this day Resident # 41 says it did not happen. During an interview on 08/23/23 at 9:20 AM, Resident #41 stated the Administrator asked her if she was ok after both incidents, each time and she asked if she wanted to go to the hospital. Resident #41 stated the nurses did assessments on her and she did not have any injuries. Resident #41 stated after the incidents she had to move out of the way to avoid injuries when both incidents occurred. During an interview on 08/23/23 at 11:45 AM, CNA A stated she was not for sure when the incidents happened. CNA A stated staff were picking up trays during dinner that was when Resident #29 threw the coffee on Resident # 41 in the hallway. CNA A stated Resident # 29 got a fork from somewhere and tried to stab Resident #41 at the nurse's station. He did not go to her room. CNA A stated she told Resident # 29 he couldn't do that, and he listened. CNA A stated she took the fork and got rid of it. CNA A stated she wasn't aware of any further incidents. During an interview on 08/23/23 at 4:12 PM, RN D stated the incidents wasn't reported to her. RN D stated Resident# 41 is on the other side of facility. 2. Record review of a face sheet dated 8/25/2023 indicated Resident #39 was a [AGE] year-old-male who originally admitted on [DATE], then readmitted on [DATE] with the diagnoses of diffuse traumatic brain injury with loss of consciousness (injury to the brain resulting from a violent blow or jolt to the head or body), Bipolar disorder (mental illness that causes extreme mood swings from high to low), and other schizophrenia (a severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal). Record review of a Quarterly MDS dated [DATE] indicated Resident #39 was understood by other and understood others. The MDS indicated in the Temporal Orientation section of the MDS indicated Resident #39 answered the month accurate within 5 days. The MDS indicated Resident #39 had no behaviors of inattention, disorganized thinking, or altered level of consciousness. The MDS in Section I indicated Resident #39's active diagnosis included traumatic brain dysfunction. The MDS indicated in Section N Resident #39 received antipsychotic medications on a routine basis. The MDS in Section O indicated Resident #39 did not receive any psychological therapy. During an anonymous telephone interview on 8/23/2023 at 3:04 p.m., the person said the incident between Resident #41 and Resident #29 occurred in July. The person indicated Resident #29 threw coffee on Resident #41's face and hit her on her arm. The person also indicated Resident #29 had attempted to stab Resident #41 with a fork. The person said it was hard to intervene with Resident #29 due to his aggressiveness. The person indicated the Administrator was not present when the incident occurred, but she was notified by phone. The person also said Resident #'s 41, 11, and 21 had voiced fearing retaliation with the Administrator. The person said numerous staff feared voicing any concerns or report abuse to the Administrator for fear of the loss of their jobs. The person said she had witnessed the Administrator yell at Resident #'s 12, 11, 21, and 10 when asking for their resident funds. The person indicated the Administer yelled for them to get out of her office. The person indicated on around July 23, 2023, or July 24, 2023, CNA B refused to change Resident #39 and began cursing him. The person indicated Resident #39 informed the Administrator of the allegation. The person indicated CNA B was allowed to continue to work with the residents and was never sent home for suspension. The person said CNA B boasted the Administrator had sent her a text indicating you are suspended, but I need you so If state comes hide then leave and do not let Resident #39 see you. During an anonymous telephone interview on 8/23/2023 at 3:30 p.m., the person indicated she was aware of the Administrator and other employees being allowed to verbally abuse the residents. The person indicated she had heard CNA s B and F tell residents to, sit your mother fucking ass down. The person said the Administrator would yell and curse at the residents to get out of her office. The person said the maintenance supervisor has told a resident to keep your fucking ass in this room. The person said employees have voiced concerns that the corporate regional director covers for the Administrator, so the employees feel as though there was no one to reach out to tell their concerns. The person said CNA B as allowed to work during her suspension period. The person said lastly the verbal abuse, and retaliation was so horrible at the facility. During a confidential group meeting on 8/22/2023 at 3:00 p.m., residents voiced concern of retaliation when reporting allegations. Record review of CNA A's Employee Timecard report dated 7/01/2023- 7/31/2023 time reporting period was created on 8/23/2023 by the BOM. The report indicated CNA A worked: 7/23/2023 from 6:34 a.m. to 2:02 p.m., there were no other punch times for this day. 7/24/2023 from 2:02 a.m. to 9:44 a.m. with a lunch of 9:44 a.m. to 10:30 a.m. then 10:30 a. m. - 2:17 p.m. 7/25/2023 from 7:34 a.m. to 2:05 p.m. there were no other punch times for this day. 7/26/2023 from 7:36 a.m. to 9:50 a.m. with a lunch 9:50 a.m. to 10:48 a.m. then 10:48 a.m. to 2:07 p.m. 7/27/2023 from 1:01 a.m. to 2:54 a.m. with a lunch 2:54 a.m. to 3:55 a.m. then from 3:55 a.m. to 7:39 a.m. then 2:59 p.m. to 8:11 p.m. During an interview on 8/24/2023 at 4:05 p.m., the DON said the Administrator was the abuse coordinator and she handled the abuse allegations. An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. The Administrator was notified on 08/23/2023 at 1:05 PM, that an immediate jeopardy situation was identified due to the above failures. The Regional Director of Operations and Administrator was provided the immediate jeopardy template on 08/23/23 at 9:47 AM. The templete was amended on 08/23/23 at 5:33 and returned to the he Regional Director of Operations and Administrator. The facility's plan of removal was accepted on 8/24/2023 at 3:04 p.m. and included: Action: Resident #29 was discharged from the facility on 8/22/2023 to a safe alternative location and will not return to the facility Date: 8/22/2023 Action: Administrator, Maintenance Director, and 2 CNAs have been suspended pending investigation to include verbal abuse towards resident (s). Date 8/23/2023 Action: Resident safe surveys completed on all residents that can answer the questions, remainder of the resident (who cannot answer) received head-to-toe assessments. Resident safe survey interviews to include fear of retaliation/comfortable reporting issues related. Date 8/23/2023 Action: Progress notes and event reports reviewed to ensure no other additional resident to resident altercations have occurred without appropriate interventions being place in the care plan, notifications made to psychiatric services and the MD. Date: 8/23/2023 by 3:00 p.m. Action: Employee (all) interviews conducted to include: Have you ever witnessed an employee physically, sexually, or verbally abuse a resident? (If yes proceed to further questions) If yes, who was the employee, who was the resident, and when about did this occur? Were there other witnesses to this event? Did you report this information to anyone and if so, to who? Date: 8/23/2023 Action: Residents involved in resident-to-resident altercations, identified in the previous 30-days, had their care plans reviewed to ensure proper interventions are in place. Any identified lacking proper interventions have been reviewed with the IDT and added. Date: 8/23/2023 at 3:00 p.m. Action: Education provided: All staff-abuse/neglect (key takeaway: thorough investigations and fully completing event reports, person centered care plan interventions, who the abuse coordinator is and when to report-Administrator and immediately, documentation/assessment/follow up.) All staff have been educated on the corporate compliance line. If the Administrator is unavailable, they can call the compliance line and/or notify the Director of Nursing. Nurses-Education provided regarding documentation of events/incidents in the medial record and documented follow up regarding the events. All staff to be in-serviced prior to working their next/first shift. Date 8/23/2023 by 4:00 p.m. All staff-Resident to resident altercation policy (key takeaway: how to respond and what order to respond-ensure resident safety by separating the residents, staying with the aggressor, and notify charge nurse and abuse coordinator). All Staff-Corporate Compliance Line education provided to all staff to understand if they report something and they feel as if appropriate action has not taken place, to reach out to the compliance line. Any issues with the abuse coordinator/administrator to reach out to the compliance line. Action: All resident has been given the corporate compliance line and informed they should call that number if they are fearful of retaliation within the facility and need t report abuse/neglect. Date: 8/24/2023 Action: 1:1 education provided to Administrator and Director of Nursing over the PL17-19 regarding abuse/neglect/reporting. Education regarding investigating allegations and implementing interventions. Date:8/23/2003 by 2:00 p.m. Action Item: Ad hoc QAPI meeting with Medical Director, Administrator, and Director of Nursing completed regarding IJ templates and Plan of Removal Date: 8/23/2023 by 2:00 p.m. Corporate compliance line is monitored by the corporate compliance office. This officer is not affiliated with the center. Once the facility is made aware of an allegation of abuse/neglect by an outside entity (such as our partners at HHSC and The Ombudsman) the facility will initiate an investigation and follow the abuse and neglect policy/protocol. On 8/25/2023 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of Resident #29's medical record indicated he discharged on 8/22/2023 to a sister facility. Record review of an employee memorandum indicated the Administrator was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the Maintenance supervisor was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the CNA B was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the CNA F was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of the safe survey results for the residents. Record review of the employee Abuse Questionnaires. Record review of the education provided regarding documentation of events/incidents in the medical record and documented follow up regarding the events. Record review of the Abuse prevention program resident-to-resident altercations with retaliation towards residents was a form of abuse and could lead to termination. Record review of the 1:1 education provided to Administrator and Director of Nursing over the PL17-19 regarding abuse/neglect/reporting. Record review of the Ad Hoc QAPI meeting completed with the Medical Director was completed on 8/23/2023 at 2:00 p.m. with the physician, the Administrator, Regional Director of Operations, and the Survey Resource staff. Interview of Licensed Nurses (LVN C, LVN E, LVN H, LVN S, LVN AA, LVN DD, RN D, Infection Preventionist, ADON, DON) were performed. During the interviews all licensed nurses were able to correctly identity abuse, when to respond, when to report, who to report to, retaliation, protection, and documentation. Licensed Nurses were able to provide education regarding documentation of event or incident and follow up in the medical records. Licensed Nurses were able to identify whom to contact when they feel appropriate action has not taken place on issues that have been reported. Interview of all staff (DA W, [NAME] P, Housekeeper X, Housekeeper Y, Housekeeper Z, NA BB, NA CC, CNA A, CNA B, CNA F, CNA T, CNA U, CNA V, MA L, AD, DM, DOR, BOM, and Housekeeping Supervisor) were performed. During the interviews all staff were able to correctly identify abuse, when to respond, when to report, who to report to, retaliation, protection, and documentation. All employees were interviewed to inquire about incidents of abuse. All staff members were able to identify whom to contact when they feel appropriate action has not taken place on issues that have been reported. Interview with the residents (Resident #3, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #18, #20, #23, #24, #25, #27, #28, #30, #31, #32, #33, #34, #35, #36, #38, #39, #40, #41, #42, #43, #44, #247) were completed. All residents were able to identify the number they should call if they were fearful of retaliation within the facility and needed to report abuse or neglect. Interview with the DON was completed. The DON was able to correctly identify when and how to report abuse or neglect and how to investigate allegation and implement interventions. Interview with RDO said the employees on the inservice sheets had been educated on abuse/neglect If they signed the sheet for inservice they were educated on abuse and neglect and ways to report and to inform any residents to report to the corporate compliance line and where the number could be found in the building. The RDO showed me the number hanging on hall wall at this time. The Corporate Survey Resource said she would immediately start contacting those employees to go back over the inservice information especially since the Administrator was out of the office for now and the corporate compliance line was always available. Record review of the facility's policy, titled, Abuse Prevention Program, last revised on 06/2021, indicated, . The Administrator is responsible for the overall coordination and implementation of our center's abuse prevention program policies and procedures. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Our center will not condone any form of resident abuse or neglect. To aide in abuse prevention, all personnel are to report any signs and symptoms of abuse/ neglect to their supervisor and to the Abuse Prevention Coordinator immediately. Our center will protect residents from harm, reprisal, discrimination, or coercion during investigation of abuse allegation. Our center will provide protections for the health, warfare and rights of each resident residing in the center to ensure the reporting of crimes. Develop and implement policies and procedures to aid to our center in preventing abuse, neglect, or mistreatment of our residents. Identify and assess all possible incidents of abuse: investigate and report any allegations of abuse within timeframe as required by federal requirements; protect resident during abuse investigation; the Administrator will suspend immediately any employees who has been accused of resident abuse, pending the outcome of the investigation; all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the center's Administrator, or his/her designee, to the following person or agencies as required: On 8/25/2023 at 3:53 p.m., the Regional Director of Operations was notified the Immediate Jeopardy was removed; however, the facility remained out of compliance at no actual harm with a potential for more than minimal harm that is not immeidate jeopardy at a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and establish policies and procedures to report and investigate such allegations, for 2 of 16 residents (Resident's #29 and Resident #41) reviewed for abuse. The facility failed to thoroughly report to the State when the administrator received a report that Resident #29 attempted to stab Resident #41 in the eye with a fork and threw coffee on her. The facility did not implement policy on reporting abuse when Resident #29's family member visited the facility on 08/13/23 and was yelling at resident and threw his personal belongings outside of his room. The facility did not implement their abuse policy and allowed CNA B to work during her suspension period after an allegation of abuse was made by Resident #39. The facility failed to report the allegations of staff to resident abuse. The facility failed to report the Resident #41's allegations of abuse to HHSC. This failure resulted in an Immediate Jeopardy (IJ) identified on 08/23/23. While the IJ was removed on 08/25/23, the facility remained out of compliance at no actual harm with the potential for more than minimal harm that is not immediate joepardy at a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective system This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: 1. Record review of Resident #41's face sheet dated 08/22/2023, indicated Resident #41 was a [AGE] year old female admitted to the facility on [DATE], with a diagnoses which include gastroesophageal reflux disease without esophagitis (acid reflux), weakness, moderate intellectual disabilities (difficulty in social situations and problems with social cues and judgment), moderate protein-calorie malnutrition (is the state of inadequate intake of food) pain unspecified, iron deficiency anemia unspecified (occurs when your body doesn't have enough iron to produce hemoglobin), cocaine abuse, uncomplicated. Record review of Resident # 41's Comprehensive MDS assessment dated [DATE], indicated Resident #41 was understood and was able to understand others. The MDS assessment indicated Resident #41 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #41 had no delusions or hallucinations. The MDS assessment indicated Resident #41 had no physical, verbal, or other behavioral symptoms directed toward others. Record review of Resident #41's a care plan with dated 08/09/2023, indicated Resident #41 exhibits socially inappropriate disruptive behavioral symptom, guarded behavior, attention seeking, and embellishes the truth. Record review of Resident #41's progress notes from 05/09/23 through 08/23/23 revealed no documented incidents regarding Resident #41 having coffee threw at her or attempted stabbing with a fork. During Resident council meeting on 08/22/23 at 3:00 PM, revealed Resident #41 stated that she was afraid of Resident #29 because he had poured coffee on her and attempted to stab her in the eye with a fork. Resident #41 stated staff witnessed the incidents, and she called the Administrator to report what had happened. Resident #41 stated that CNA A had witnessed the incidents. During an interview on 8/22/23 at 4:03 PM, Resident # 41 stated she didn't know the exact date the incident occurred. Resident # 41 stated Resident # 29 tried to pour coffee on her after supper. Resident # 41 stated she jumped back quickly but the coffee got on her feet. Resident # 41 stated she told CNA A and CNA A told him to quit. Resident # 41 stated Resident #29 had a fork and tried to hit her in the eye with the fork. Resident # 41 stated she jumped down and Resident #29 missed her. Resident # 41 stated both incidents occurred on the same day in June. Resident #41 stated she told CNA A. Resident # 41 stated CNA A told Resident # 29 he couldn't do that; he would be in jail. Resident #41 stated CNA A witnessed both incidents. During an interview on 8/22/23 at 4:42 PM, CNA A stated she witnessed both incidents. CNA A stated the incident were Resident # 29 poured coffee on Resident #41 happened in the hallway, she intervened and reported it to the charge nurse because ADM was not in the building. CNA A stated she could not remember who the charge nurse was. CNA A stated the incident with the fork happened at the nurse's station with multiple staff members around that witnessed the incident. CNA A stated she intervened and notified the charge nurse due to the Administrator not being in the building. CNA A stated the Administrator was the abuse coordinator. CNA A stated she could not remember the exact date of the incidents, but it was the end May or the first of June. CNA A stated she could not remember the charge nurse she reported the incident to. CNA A stated she could not remember the other staff members that were present. and she could not remember who the charge nurse was. During an interview on 8/22/23 at 8:42 AM, the Administrator stated she investigated the incidents and Resident #41 said it did not happen. The Administrator stated she talked to the staff and the staff said they did not witness the either incident. The Administrator stated she can't remember when the incidents happened, it was back in April. The Administrator stated it had been a long ago, it was not a new allegation, it is an old allegation. The Administrator stated still to this day Resident # 41 says it did not happen. During an interview on 08/23/23 at 9:20 AM, Resident #41 stated the Administrator asked her if she was ok after both incidents, each time and she asked if she wanted to go to the hospital. Resident #41 stated the nurses did assessments on her and she did not have any injuries. Resident #41 stated after the incidents she had to move out of the way to avoid injuries when both incidents occurred. During an interview on 08/23/23 at 11:45 AM, CNA A stated she was not for sure when the incidents happened. CNA A stated staff were picking up trays during dinner that was when Resident #29 threw the coffee on Resident # 41 in the hallway. CNA A stated Resident # 29 got a fork from somewhere and tried to stab Resident #41 at the nurse's station. He did not go to her room. CNA A stated she told Resident # 29 he couldn't do that, and he listened. CNA A stated she took the fork and got rid of it. CNA A stated she wasn't aware of any further incidents. During an interview on 08/23/23 at 4:12 PM, RN D stated the incidents wasn't reported to her. RN D stated Resident# 41 is on the other side of facility. Record review of the policy on, Abuse Prevention Program, revised June 2021, indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and injuries of unknown source shall be promptly reported to local, state and federal agencies and thoroughly investigated by Center management .The Administrator has the overall responsibility for the coordination and implementation of the Center's abuse prevention program .The alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately and reported no later than 2 hours if the alleged violation involves abuse. 2. Record review of the face sheet, dated 08/22/23, revealed Resident #29 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of COPD (chronic obstructive pulmonary disease is an inflammatory lung disease that causes obstructed airflow from the lungs), dementia (impaired memory) and Parkinson's disease (disorder that impacts the nervous system and movement). Record review of Resident #29's physician orders indicated lorazepam 1mg three times a day. Record review of the MDS assessment, dated 07/20/23, revealed Resident #29 was usually understood and usually understood others. Resident #29 had a BIMS score of 4 indicating severely impaired. Record review of the comprehensive care plan, edited 08/09/23, revealed Resident #29 had behavioral symptoms combative and elopement. The approach indicated Resident #29 became upset due to his sister came to the facility and was yelling at him and the resident's behaviors stem from his sister visits. Record review of LVN E's progress note dated 08/13/23 indicated Resident #29's family member was in his room throwing Resident #29's clothing outside of the room and yelling at Resident #29. LVN E indicated he notified the nurse supervisor. During an interview on 08/25/23 at 1:42 PM, LVN E stated he was completing his medication pass on 08/13/23 when Resident #29's family member came to the facility. LVN E stated he heard a loud voice and yelling coming from Resident #29's room. LVN E stated when he got closer to the room he observed clothing being thrown out of the room and Resident #29's family member was, Getting loud towards resident and he was upset. LVN E stated he told Resident #29's family member that he would handle the situation if she would tell him what the problem was and then he redirected Resident #29 towards the dresser. LVN E stated he then assisted Resident #29 with picking out what clothing he wanted to wear and stayed with Resident #29 until he calmed down. LVN E stated Resident #29's family member left the building quickly and he notified the DON and Administrator. During an interview on 08/24/23 at 10:23 AM, the DON reported she was not at the facility during the incident so she could not say what happen. The DON reported the Administrator was notified and she was responsible for determining if abuse needed to be reported. During an interview on 08/24/23 at 4:10 PM, the Administrator stated, I would not say the family member was yelling, but if she was yelling at him then it should have been reported. The Administrator stated she should have done an investigation and it should have been reported if it was indicated in the progress note that the family member was yelling at Resident #29. The Administrator stated the importance of reporting abuse was to keep the resident safe and the resident could have been harmed if the incident was not investigated. 3. Record review of a face sheet dated 8/25/2023 indicated Resident #39 was a [AGE] year-old-male who originally admitted on [DATE], then readmitted on [DATE] with the diagnoses of diffuse traumatic brain injury with loss of consciousness (injury to the brain resulting from a violent blow or jolt to the head or body), Bipolar disorder (mental illness that causes extreme mood swings from high to low), and other schizophrenia (a severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal). Record review of a Quarterly MDS dated [DATE] indicated Resident #39 was understood by other and understood others. The MDS indicated in the Temporal Orientation section of the MDS indicated Resident #39 answered the month accurate within 5 days. The MDS indicated Resident #39 had no behaviors of inattention, disorganized thinking, or altered level of consciousness. The MDS in Section I indicated Resident #39's active diagnosis included traumatic brain dysfunction. The MDS indicated in Section N Resident #39 received antipsychotic medications on a routine basis. The MDS in Section O indicated Resident #39 did not receive any psychological therapy. During an anonymous telephone interview on 8/23/2023 at 3:04 p.m., the person said the incident between Resident #41 and Resident #29 occurred in July. The person indicated Resident #29 threw coffee on Resident #41's face and hit her on her arm. The person also indicated Resident #29 had attempted to stab Resident #41 with a fork. The person said it was hard to intervene with Resident #29 due to his aggressiveness. The person indicated the Administrator was not present when the incident occurred, but she was notified by phone. The person also said Resident #'s 41, 11, and 21 had voiced fearing retaliation with the Administrator. The person said numerous staff feared voicing any concerns or report abuse to the Administrator for fear of the loss of their jobs. The person said she had witnessed the Administrator yell at Resident #'s 12, 11, 21, and 10 when asking for their resident funds. The person indicated the Administer yelled for them to get out of her office. The person indicated on around July 23, 2023, or July 24, 2023, CNA B refused to change Resident #39 and began cursing him. The person indicated Resident #39 informed the Administrator of the allegation. The person indicated CNA B was allowed to continue to work with the residents and was never sent home for suspension. The person said CNA B boasted the Administrator had sent her a text indicating you are suspended, but I need you so If state comes hide then leave and do not let Resident #39 see you. During an anonymous telephone interview on 8/23/2023 at 3:30 p.m., the person indicated she was aware of the Administrator and other employees being allowed to verbally abuse the residents. The person indicated she had heard CNA s B and F tell residents to, sit your mother fucking ass down. The person said the Administrator would yell and curse at the residents to get out of her office. The person said the maintenance supervisor has told a resident to keep your fucking ass in this room. The person said employees have voiced concerns that the corporate regional director covers for the Administrator, so the employees feel as though there was no one to reach out to tell their concerns. The person said CNA B was allowed to work during her suspension period. The person said lastly the verbal abuse, and retaliation was so horrible at the facility. During a confidential group meeting on 8/22/2023 at 3:00 p.m., residents voiced concern of retaliation when reporting allegations. Record review of CNA A's Employee Timecard report dated 7/01/2023- 7/31/2023 time reporting period was created on 8/23/2023 by the BOM. The report indicated CNA A worked: 7/23/2023 from 6:34 a.m. to 2:02 p.m., there were no other punch times for this day. 7/24/2023 from 2:02 a.m. to 9:44 a.m. with a lunch of 9:44 a.m. to 10:30 a.m. then 10:30 a. m. - 2:17 p.m. 7/25/2023 from 7:34 a.m. to 2:05 p.m. there were no other punch times for this day. 7/26/2023 from 7:36 a.m. to 9:50 a.m. with a lunch 9:50 a.m. to 10:48 a.m. then 10:48 a.m. to 2:07 p.m. 7/27/2023 from 1:01 a.m. to 2:54 a.m. with a lunch 2:54 a.m. to 3:55 a.m. then from 3:55 a.m. to 7:39 a.m. then 2:59 p.m. to 8:11 p.m. During an interview on 8/24/2023 at 4:05 p.m., the DON said the Administrator was the abuse coordinator and she handled the abuse allegations. An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. The Administrator was notified on 08/23/2023 at 1:05 PM, that an immediate jeopardy situation was identified due to the above failures. The Regional Director of Operations and Administrator was provided the immediate jeopardy template on 08/23/23 at 9:47 AM. The [NAME] was amended on 08/23/23 at 5:33 and returned to the he Regional Director of Operations and Administrator. The facility's plan of removal was accepted on 8/24/2023 at 3:04 p.m. and included: Action: Resident #29 was discharged from the facility on 8/22/2023 to a safe alternative location and will not return to the facility Date: 8/22/2023 Action: Administrator, Maintenance Director, and 2 CNAs have been suspended pending investigation to include verbal abuse towards resident (s). Date 8/23/2023 Action: Resident safe surveys completed on all residents that can answer the questions, remainder of the resident (who cannot answer) received head-to-toe assessments. Resident safe survey interviews to include fear of retaliation/comfortable reporting issues related. Date 8/23/2023 Action: Progress notes and event reports reviewed to ensure no other additional resident to resident altercations have occurred without appropriate interventions being place in the care plan, notifications made to psychiatric services and the MD. Date: 8/23/2023 by 3:00 p.m. Action: Employee (all) interviews conducted to include: Have you ever witnessed an employee physically, sexually, or verbally abuse a resident? (If yes proceed to further questions) If yes, who was the employee, who was the resident, and when about did this occur? Were there other witnesses to this event? Did you report this information to anyone and if so, to who? Date: 8/23/2023 Action: Residents involved in resident-to-resident altercations, identified in the previous 30-days, had their care plans reviewed to ensure proper interventions are in place. Any identified lacking proper interventions have been reviewed with the IDT and added. Date: 8/23/2023 at 3:00 p.m. Action: Education provided: All staff-abuse/neglect (key takeaway: thorough investigations and fully completing event reports, person centered care plan interventions, who the abuse coordinator is and when to report-Administrator and immediately, documentation/assessment/follow up.) All staff have been educated on the corporate compliance line. If the Administrator is unavailable, they can call the compliance line and/or notify the Director of Nursing. Nurses-Education provided regarding documentation of events/incidents in the medial record and documented follow up regarding the events. All staff to be in-serviced prior to working their next/first shift. Date 8/23/2023 by 4:00 p.m. All staff-Resident to resident altercation policy (key takeaway: how to respond and what order to respond-ensure resident safety by separating the residents, staying with the aggressor, and notify charge nurse and abuse coordinator). All Staff-Corporate Compliance Line education provided to all staff to understand if they report something and they feel as if appropriate action has not taken place, to reach out to the compliance line. Any issues with the abuse coordinator/administrator to reach out to the compliance line. Action: All resident has been given the corporate compliance line and informed they should call that number if they are fearful of retaliation within the facility and need t report abuse/neglect. Date: 8/24/2023 Action: 1:1 education provided to Administrator and Director of Nursing over the PL17-19 regarding abuse/neglect/reporting. Education regarding investigating allegations and implementing interventions. Date:8/23/2003 by 2:00 p.m. Action Item: Ad hoc QAPI meeting with Medical Director, Administrator, and Director of Nursing completed regarding IJ templates and Plan of Removal Date: 8/23/2023 by 2:00 p.m. Corporate compliance line is monitored by the corporate compliance office. This officer is not affiliated with the center. Once the facility is made aware of an allegation of abuse/neglect by an outside entity (such as our partners at HHSC and The Ombudsman) the facility will initiate an investigation and follow the abuse and neglect policy/protocol. On 8/25/2023 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of Resident #29's medical record indicated he discharged on 8/22/2023 to a sister facility. Record review of an employee memorandum indicated the Administrator was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the Maintenance supervisor was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the CNA B was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the CNA F was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of the safe survey results for the residents. Record review of the employee Abuse Questionnaires. Record review of the education provided regarding documentation of events/incidents in the medical record and documented follow up regarding the events. Record review of the Abuse prevention program resident-to-resident altercations with retaliation towards residents was a form of abuse and could lead to termination. Record review of the 1:1 education provided to Administrator and Director of Nursing over the PL17-19 regarding abuse/neglect/reporting. Record review of the Ad Hoc QAPI meeting completed with the Medical Director was completed on 8/23/2023 at 2:00 p.m. with the physician, the Administrator, Regional Director of Operations, and the Survey Resource staff. Interview of Licensed Nurses (LVN C, LVN E, LVN H, LVN S, LVN AA, LVN DD, RN D, Infection Preventionist, ADON, DON) were performed. During the interviews all licensed nurses were able to correctly identity abuse, when to respond, when to report, who to report to, retaliation, protection, and documentation. Licensed Nurses were able to provide education regarding documentation of event or incident and follow up in the medical records. Interview of all staff (DA W, [NAME] P, Housekeeper X, Housekeeper Y, Housekeeper Z, NA BB, NA CC, CNA A, CNA B, CNA F, CNA T, CNA U, CNA V, MA L, AD, DM, DOR, BOM, and Housekeeping Supervisor) were performed. During the interviews all staff were able to correctly identify abuse, when to respond, when to report, who to report to, retaliation, protection, and documentation. Interview with the residents (Resident #3, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #18, #20, #23, #24, #25, #27, #28, #30, #31, #32, #33, #34, #35, #36, #38, #39, #40, #41, #42, #43, #44, #247) were completed. All residents were able to identify the number they should call if they were fearful of retaliation within the facility and needed to report abuse or neglect. Interview with the DON was completed. The DON was able to correctly identify when and how to report abuse or neglect and how to investigate allegation and implement interventions. Record review of the facility's policy, titled, Abuse Prevention Program, last revised on 06/2021, indicated, . The Administrator is responsible for the overall coordination and implementation of our center's abuse prevention program policies and procedures. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Our center will not condone any form of resident abuse or neglect. To aide in abuse prevention, all personnel are to report any signs and symptoms of abuse/ neglect to their supervisor and to the Abuse Prevention Coordinator immediately. Our center will protect residents from harm, reprisal, discrimination, or coercion during investigation of abuse allegation. Our center will provide protections for the health, warfare and rights of each resident residing in the center to ensure the reporting of crimes. Develop and implement polices and procedures to aid to our center in preventing abuse, neglect, or mistreatment of our residents. Identify and assess all possible incidents of abuse: investigate and report any allegations of abuse within timeframe as required by federal requirements; protect resident during abuse investigation; the Administrator will suspend immediately any employees who has been accused of resident abuse, pending the outcome of the investigation; all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the center's Administrator, or his/her designee, to the following person or agencies as required: On 8/25/2023 at 3:53 p.m., the Regional Director of Operations was notified the Immediate Jeopardy was removed; however, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not Immediate Jeopardy at a scope of a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an allegation of suspected abuse was thoroughly investigated for 2 of 12 (Resident #'s 39 and 41) residents reviewed for abuse. The facility failed to thoroughly investigate when the administrator received a report that Resident #29 attempted to stab Resident #41 in the eye with a fork and threw coffee on her. The facility failed to thoroughly investigate when Resident #39 reported an allegation of abuse regarding CNA B. The facility failed to report the Resident #'s 39 and 41's allegations of abuse to HHSC. This failure resulted in an Immediate Jeopardy (IJ) identified on 08/23/23. While the IJ was removed on 08/25/23, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective system This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: 1.Record review of Resident #41's face sheet dated 08/22/2023, indicated Resident #41 was a [AGE] year old female admitted to the facility on [DATE], with a diagnoses which include gastroesophageal reflux disease without esophagitis (acid reflux), weakness, moderate intellectual disabilities (difficulty in social situations and problems with social cues and judgment), moderate protein-calorie malnutrition (is the state of inadequate intake of food) pain unspecified, iron deficiency anemia unspecified (occurs when your body doesn't have enough iron to produce hemoglobin), cocaine abuse, uncomplicated. Record review of Resident # 41's Comprehensive MDS assessment dated [DATE], indicated Resident #41 was understood and was able to understand others. The MDS assessment indicated Resident #41 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #41 had no delusions or hallucinations. The MDS assessment indicated Resident #41 had no physical, verbal, or other behavioral symptoms directed toward others. Record review of Resident #41's a care plan with dated 08/09/2023, indicated Resident #41 exhibits socially inappropriate disruptive behavioral symptom, guarded behavior, attention seeking, and embellishes the truth. Record review of Resident #41's progress notes from 05/09/23 through 08/23/23 revealed no documented incidents regarding Resident #41 having coffee threw at her or attempted stabbing with a fork. During Resident council meeting on 08/22/23 at 3:00 PM, revealed Resident #41 stated that she was afraid of Resident #29 because he had poured coffee on her and attempted to stab her in the eye with a fork. Resident #41 stated staff witnessed the incidents, and she called the Administrator to report what had happened. Resident #41 stated that CNA A had witnessed the incidents. During an interview on 8/22/23 at 4:03 PM, Resident # 41 stated she didn't know the exact date the incident occurred. Resident # 41 stated Resident # 29 tried to pour coffee on her after supper. Resident # 41 stated she jumped back quickly but the coffee got on her feet. Resident # 41 stated she told CNA A and CNA A told him to quit. Resident # 41 stated Resident #29 had a fork and tried to hit her in the eye with the fork. Resident # 41 stated she jumped down and Resident #29 missed her. Resident # 41 stated both incidents occurred on the same day in June. Resident #41 stated she told CNA A. Resident # 41 stated CNA A told Resident # 29 he couldn't do that; he would be in jail. Resident #41 stated CNA A witnessed both incidents. During an interview on 8/22/23 at 4:42 PM, CNA A stated she witnessed both incidents. CNA A stated the incident were Resident # 29 poured coffee on Resident #41 happened in the hallway, she intervened and reported it to the charge nurse because ADM was not in the building. CNA A stated she could not remember who the charge nurse was. CNA A stated the incident with the fork happened at the nurse's station with multiple staff members around that witnessed the incident. CNA A stated she intervened and notified the charge nurse due to the Administrator not being in the building. CNA A stated the Administrator was the abuse coordinator. CNA A stated she could not remember the exact date of the incidents, but it was the end May or the first of June. CNA A stated she could not remember the charge nurse she reported the incident to. CNA A stated she could not remember the other staff members that were present. and she could not remember who the charge nurse was. During an interview on 8/22/23 at 8:42 AM, the Administrator stated she investigated the incidents and Resident #41 said it did not happen. The Administrator stated she talked to the staff and the staff said they did not witness the either incident. The Administrator stated she can't remember when the incidents happened, it was back in April. The Administrator stated it had been a long ago, it was not a new allegation, it is an old allegation. The Administrator stated still to this day Resident # 41 says it did not happen. During an interview on 08/23/23 at 9:20 AM, Resident #41 stated the Administrator asked her if she was ok after both incidents, each time and she asked if she wanted to go to the hospital. Resident #41 stated the nurses did assessments on her and she did not have any injuries. Resident #41 stated after the incidents she had to move out of the way to avoid injuries when both incidents occurred. During an interview on 08/23/23 at 11:45 AM, CNA A stated she was not for sure when the incidents happened. CNA A stated staff were picking up trays during dinner that was when Resident #29 threw the coffee on Resident # 41 in the hallway. CNA A stated Resident # 29 got a fork from somewhere and tried to stab Resident #41 at the nurse's station. He did not go to her room. CNA A stated she told Resident # 29 he couldn't do that, and he listened. CNA A stated she took the fork and got rid of it. CNA A stated she wasn't aware of any further incidents. During an interview on 08/23/23 at 4:12 PM RN D stated the incidents wasn't reported to her. RN D stated Resident# 41 is on the other side of facility. 2)Record review of a face sheet dated 8/25/2023 indicated Resident #39 was a [AGE] year-old-male who originally admitted on [DATE], then readmitted on [DATE] with the diagnoses of diffuse traumatic brain injury with loss of consciousness (injury to the brain resulting from a violent blow or jolt to the head or body), Bipolar disorder (mental illness that causes extreme mood swings from high to low), and other schizophrenia (a severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal). Record review of a Quarterly MDS dated [DATE] indicated Resident #39 was understood by other and understood others. The MDS indicated in the Temporal Orientation section of the MDS indicated Resident #39 answered the month accurate within 5 days. The MDS indicated Resident #39 had no behaviors of inattention, disorganized thinking, or altered level of consciousness. The MDS in Section I indicated Resident #39's active diagnosis included traumatic brain dysfunction. The MDS indicated in Section N Resident #39 received antipsychotic medications on a routine basis. The MDS in Section O indicated Resident #39 did not receive any psychological therapy. During an anonymous telephone interview on 8/23/2023 at 3:04 p.m., the person said the incident between Resident #41 and Resident #29 occurred in July. The person indicated Resident #29 threw coffee on Resident #41's face and hit her on her arm. The person also indicated Resident #29 had attempted to stab Resident #41 with a fork. The person said it was hard to intervene with Resident #29 due to his aggressiveness. The person indicated the Administrator was not present when the incident occurred, but she was notified by phone. The person also said Resident #'s 41, 11, and 21 had voiced fearing retaliation with the Administrator. The person said numerous staff feared voicing any concerns or report abuse to the Administrator for fear of the loss of their jobs. The person said she had witnessed the Administrator yell at Resident #'s 12, 11, 21, and 10 when asking for their resident funds. The person indicated the Administer yelled for them to get out of her office. The person indicated on around July 23, 2023, or July 24, 2023, CNA B refused to change Resident #39 and began cursing him. The person indicated Resident #39 informed the Administrator of the allegation. The person indicated CNA B was allowed to continue to work with the residents and was never sent home for suspension. The person said CNA B boasted the Administrator had sent her a text indicating you are suspended, but I need you so If state comes hide then leave and do not let Resident #39 see you. During an anonymous telephone interview on 8/23/2023 at 3:30 p.m., the person indicated she was aware of the Administrator and other employees being allowed to verbally abuse the residents. The person indicated she had heard CNA s B and F tell residents to, sit your mother fucking ass down. The person said the Administrator would yell and curse at the residents to get out of her office. The person said the maintenance supervisor has told a resident to keep your fucking ass in this room. The person said employees have voiced concerns that the corporate regional director covers for the Administrator, so the employees feel as though there was no one to reach out to tell their concerns. The person said CNA B was allowed to work during her suspension period. The person said lastly the verbal abuse, and retaliation was so horrible at the facility. During a confidential group meeting on 8/22/2023 at 3:00 p.m., residents voiced concern of retaliation when reporting allegations. Record review of CNA A's Employee Timecard report dated 7/01/2023- 7/31/2023 time reporting period was created on 8/23/2023 by the BOM. The report indicated CNA A worked: 7/23/2023 from 6:34 a.m. to 2:02 p.m., there were no other punch times for this day. 7/24/2023 from 2:02 a.m. to 9:44 a.m. with a lunch of 9:44 a.m. to 10:30 a.m. then 10:30 a. m. - 2:17 p.m. 7/25/2023 from 7:34 a.m. to 2:05 p.m. there were no other punch times for this day. 7/26/2023 from 7:36 a.m. to 9:50 a.m. with a lunch 9:50 a.m. to 10:48 a.m. then 10:48 a.m. to 2:07 p.m. 7/27/2023 from 1:01 a.m. to 2:54 a.m. with a lunch 2:54 a.m. to 3:55 a.m. then from 3:55 a.m. to 7:39 a.m. then 2:59 p.m. to 8:11 p.m. During an interview on 8/24/2023 at 4:05 p.m., the DON said the Administrator was the abuse coordinator and she handled the abuse allegations. An attempted telephone interview on 08/25/23 at 4:33 p.m. with the Administrator, was unsuccessful. Record review of the facility's policy, titled, Abuse Prevention Program, last revised on 06/2021, indicated, . The Administrator is responsible for the overall coordination and implementation of our center's abuse prevention program policies and procedures. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Our center will not condone any form of resident abuse or neglect. To aide in abuse prevention, all personnel are to report any signs and symptoms of abuse/ neglect to their supervisor and to the Abuse Prevention Coordinator immediately. Our center will protect residents from harm, reprisal, discrimination, or coercion during investigation of abuse allegation. Our center will provide protections for the health, warfare and rights of each resident residing in the center to ensure the reporting of crimes. Develop and implement polices and procedures to aid to our center in preventing abuse, neglect, or mistreatment of our residents. Identify and assess all possible incidents of abuse: investigate and report any allegations of abuse within timeframe as required by federal requirements; protect resident during abuse investigation; the Administrator will suspend immediately any employees who has been accused of resident abuse, pending the outcome of the investigation; all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the center's Administrator, or his/her designee, to the following person or agencies as required: The Administrator was notified on 08/23/2023 at 1:05 PM, that an immediate jeopardy situation was identified due to the above failures. The Regional Director of Operations and Administrator was provided the immediate jeopardy template on 08/23/23 at 9:47 AM. The template was amended on 08/23/23 at 5:33 and returned to the he Regional Director of Operations and Administrator. The facility's plan of removal was accepted on 8/24/2023 at 3:04 p.m. and included: Action: Resident #29 was discharged from the facility on 8/22/2023 to a safe alternative location and will not return to the facility Date: 8/22/2023 Action: Administrator, Maintenance Director, and 2 CNAs have been suspended pending investigation to include verbal abuse towards resident (s). Date 8/23/2023 Action: Resident safe surveys completed on all residents that can answer the questions, remainder of the resident (who cannot answer) received head-to-toe assessments. Resident safe survey interviews to include fear of retaliation/comfortable reporting issues related. Date 8/23/2023 Action: Progress notes and event reports reviewed to ensure no other additional resident to resident altercations have occurred without appropriate interventions being place in the care plan, notifications made to psychiatric services and the MD. Date: 8/23/2023 by 3:00 p.m. Action: Employee (all) interviews conducted to include: Have you ever witnessed an employee physically, sexually, or verbally abuse a resident? (If yes proceed to further questions) If yes, who was the employee, who was the resident, and when about did this occur? Were there other witnesses to this event? Did you report this information to anyone and if so, to who? Date: 8/23/2023 Action: Residents involved in resident-to-resident altercations, identified in the previous 30-days, had their care plans reviewed to ensure proper interventions are in place. Any identified lacking proper interventions have been reviewed with the IDT and added. Date: 8/23/2023 at 3:00 p.m. Action: Education provided: All staff-abuse/neglect (key takeaway: thorough investigations and fully completing event reports, person centered care plan interventions, who the abuse coordinator is and when to report-Administrator and immediately, documentation/assessment/follow up.) All staff have been educated on the corporate compliance line. If the Administrator is unavailable, they can call the compliance line and/or notify the Director of Nursing. Nurses-Education provided regarding documentation of events/incidents in the medial record and documented follow up regarding the events. All staff to be in-serviced prior to working their next/first shift. Date 8/23/2023 by 4:00 p.m. All staff-Resident to resident altercation policy (key takeaway: how to respond and what order to respond-ensure resident safety by separating the residents, staying with the aggressor, and notify charge nurse and abuse coordinator). All Staff-Corporate Compliance Line education provided to all staff to understand if they report something and they feel as if appropriate action has not taken place, to reach out to the compliance line. Any issues with the abuse coordinator/administrator to reach out to the compliance line. Action: All resident has been given the corporate compliance line and informed they should call that number if they are fearful of retaliation within the facility and need t report abuse/neglect. Date: 8/24/2023 Action: 1:1 education provided to Administrator and Director of Nursing over the PL17-19 regarding abuse/neglect/reporting. Education regarding investigating allegations and implementing interventions. Date:8/23/2003 by 2:00 p.m. Action Item: Ad hoc QAPI meeting with Medical Director, Administrator, and Director of Nursing completed regarding IJ templates and Plan of Removal Date: 8/23/2023 by 2:00 p.m. Corporate compliance line is monitored by the corporate compliance office. This officer is not affiliated with the center. Once the facility is made aware of an allegation of abuse/neglect by an outside entity (such as our partners at HHSC and The Ombudsman) the facility will initiate an investigation and follow the abuse and neglect policy/protocol. On 8/25/2023 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of Resident #29's medical record indicated he discharged on 8/22/2023 to a sister facility. Record review of an employee memorandum indicated the Administrator was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the Maintenance supervisor was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the CNA B was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of an employee memorandum indicated the CNA F was provided a Suspension form related to an allegation of abuse dated 8/23/2023. Record review of the safe survey results for the residents. Record review of the employee Abuse Questionnaires. Record review of the education provided regarding documentation of events/incidents in the medical record and documented follow up regarding the events. Record review of the Abuse prevention program resident-to-resident altercations with retaliation towards residents was a form of abuse and could lead to termination. Record review of the 1:1 education provided to Administrator and Director of Nursing over the PL17-19 regarding abuse/neglect/reporting. Record review of the Ad Hoc QAPI meeting completed with the Medical Director was completed on 8/23/2023 at 2:00 p.m. with the physician, the Administrator, Regional Director of Operations, and the Survey Resource staff. Interview of Licensed Nurses (LVN C, LVN E, LVN H, LVN S, LVN AA, LVN DD, RN D, Infection Preventionist, ADON, DON) were performed. During the interviews all licensed nurses were able to correctly identity abuse, when to respond, when to report, who to report to, retaliation, protection, and documentation. Licensed Nurses were able to provide education regarding documentation of event or incident and follow up in the medical records. Interview of all staff (DA W, [NAME] P, Housekeeper X, Housekeeper Y, Housekeeper Z, NA BB, NA CC, CNA A, CNA B, CNA F, CNA T, CNA U, CNA V, MA L, AD, DM, DOR, BOM, and Housekeeping Supervisor) were performed. During the interviews all staff were able to correctly identify abuse, when to respond, when to report, who to report to, retaliation, protection, and documentation. Interview with the residents (Resident #3, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #18, #20, #23, #24, #25, #27, #28, #30, #31, #32, #33, #34, #35, #36, #38, #39, #40, #41, #42, #43, #44, #247) were completed. All residents were able to identify the number they should call if they were fearful of retaliation within the facility and needed to report abuse or neglect. Interview with the DON was completed. The DON was able to correctly identify when and how to report abuse or neglect and how to investigate allegation and implement interventions. On 8/25/2023 at 3:53 p.m., the Regional Director of Operations was notified the Immediate Jeopardy was removed; however, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of a pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 7 of 13 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) reviewed for resident rights. The facility failed to ensure Resident #1 did not experience humiliation when LVN A threw his nebulizer treatments (medication used to help breathe better) at him. The facility failed to ensure Resident #2 did not feel scared of retaliation and intimidated by staff. The facility failed to ensure Resident #2 did not feel humiliated when CNA D rudely refused to get her out of bed. The facility failed to ensure Resident #3 did not feel humiliated and disrespected when LVN A stated, I can't stomach this wound, and NA B told him not to be needy. The facility failed to ensure Resident #4 did not feel humiliated and scared of retaliation when LVN A told him, I'm done with you. The facility failed to ensure Resident #5 was not scared to report when the CNAs yelled at her because she was scared, she would be yelled at again. The facility failed to ensure Resident #6 was not scared to report LVN A after she told him he acted like a three-year-old and he was sorry. The facility failed to ensure Resident #7 did not feel intimidated and belittled when CNA C yelled and cursed at her. This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE] at 3:47PM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: 1. Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, with agitation (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and panic disorder episodic paroxysmal anxiety (intense feeling of fear and discomfort that begins abruptly and rises to a maximum within minutes). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #1 was understood and was able to understand others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #1 had no delusions or hallucinations. The MDS assessment indicated Resident #1 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #1 required supervision for bed mobility, transfers, eating, toilet use, and limited assistance for dressing and personal hygiene. Record review of the Physician Order Report dated [DATE] - [DATE] indicated Resident #1 had an order for Ipratropium Bromide and Albuterol (medication used to help breathe better) 0.5mg/3ml liquid; 0.5mg/3ml, 1 vial every 4 hours at 12:00 AM, 04:00 AM, 08:00 AM, 12:00 PM, 04:00 PM, 08:00 PM. Record review of a care plan last revised [DATE] indicated a problem that Resident #1 exhibited verbally abusive behavioral symptoms such as others were threatened, calling 911, screamed at and cursed at staff related to wanting a breathing treatment due to anxiety and shortness of breath with interventions which included convey an attitude of acceptance toward the resident, maintain a calm environment and reassure the resident by checking his oxygen saturations to assure within normal limits and observe for anxiety and attempt to have resident purse breath. During an interview on [DATE] at 9:44 AM, Resident #1 said LVN A was rude to everybody. Resident #1 said he had asked her for a breathing treatment because he felt like he could not breathe. Resident #1 said LVN A grabbed 5-6 of the nebulizer treatments (medication used to help breathe better) and threw them at him. Resident #1 said he could not remember the date that it happened. Resident #1 said he had gotten used to her being rude that way. Resident #1 said LVN A made him feel humiliated, and he was scared of her retaliating. Resident #1 said he was scared LVN A would get back at him by making him wait until the end for his medicine even if he was the first one in line. Resident #1 said in the past LVN A had made him wait for his medication because she was mad at him. Resident #1 was unable to provide exact dates. Resident #1 said he had told the office staff he was scared LVN A would retaliate against him when he was questioned about the incident with LVN A. Record review of the Provider's Investigation Report dated [DATE] indicated the incident with Resident #1 and LVN A occurred on [DATE]. The Provider's Investigation Report indicated the facility took the following actions post investigation: completed a Head-to-Toe Assessment, Resident Interviews, Staff Interviews, Safe Surveys and Culture sensitivity/Abuse and Neglect Inservice dated [DATE]. The Culture sensitivity/Abuse and Neglect Inservice was not signed by LVN A which indicated she was not in-serviced. Record review of a Performance Improvement Plan implemented on [DATE] indicated LVN A had a 30-day timeline for performance improvement or termination would occur. 2. Record review of a face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 had no delusions or hallucinations. The MDS assessment indicated Resident #2 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #2 did not exhibit rejection of care. The MDS assessment indicated Resident #2 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and supervision for eating. Resident #2 was totally dependent for transfers and bathing. Record review of Resident #2's care plan last revised [DATE] indicated she had a problem of resident must be lifted mechanically and interventions included staff to get resident up out of bed daily 5-7 times a week and required 2 staff members at all times to use the mechanical lift. Resident #2's care plan indicated she had a history of anxiety and interventions included to allow resident to voice thoughts. Resident #2's care plan indicated that she required 2 staff assistance depending on type of bath or shower, required, 1-2 staff for dressing/grooming, and 1-2 staff to provide incontinent care, and her preferred time for bath/shower was once a day on Tuesday, Thursday, and Saturday 2:00 PM- 10:00 PM. Resident #2's care plan indicated to allow her to express her feelings, allow her to participate in daily care and decision/goal making, and to listen carefully and be non-judgmental. Resident #2's care plan did not indicate she refused care. Record review of the electronic health record indicated Resident #2 was discharged to another facility on [DATE]. During an interview on [DATE] at 09:56 AM, the ombudsman said on [DATE] while in the facility she heard screaming and walked into Resident #2's room. The Ombudsman said CNA D yelled at Resident #2, What do you want? Resident #2 said she wanted to get out of bed. CNA D said to Resident #2, you know it ain't your day to get out of bed. Resident #2 said, I know it is not my shower day, but I want to get out of bed to play bingo. CNA D replied to Resident #2 and said, I don't know what to tell you. The Ombudsman said she went and reported this incident to the ADON the same day she witnessed it. During an interview on [DATE] at 3:06 PM, Resident #2 said she moved to a different nursing home approximately 5 days ago. Resident #2 said if she would have stayed at the other facility she would have died. Resident #2 said she had gone without a shower for 10 days, and she told the staff everyday she wanted a shower. Resident #2 said she was told there were not enough CNAs. Resident #2 said CNA C was horrible, cursed and screamed at her, and it broke her heart because she could hear her scream and curse at the resident across the hall from her. Resident #2 said she told him she would jerk him out of his bed, and she could not understand why she talked to everyone like that. Resident #2 said that there were plenty of other residents at the facility that had heard CNA C say the same things to other residents. Resident #2 said when CNA C and another CNA had scrubbed her leg and left a bruise while giving her a shower. Resident #2 said she reported CNA C to the DON, and that did nothing but make CNA C retaliate against her. Resident #2 said when CNA C would go into her room to leave a meal she would not speak to her or make eye contact with her. Resident #2 said the CNAs always told her she could not get up and she could not get showers because they did not have enough staff. Resident #2 said the CNAs told her not to use the call light. Resident # 2 said her family member was very upset and reported this to the DON. Resident #2 said she had to lay in her feces from 11 AM to 7 PM. Resident #2 said she told NA B three times and he kept saying he would be right with her. Resident #2 said that was the most degraded and awful feeling she ever had. Resident #2 was teary eyed. Resident #2 said her family members came to visit her and she was laying in shit. Resident #2 said this messed with her emotions and she would never forget it. Resident #2 said the facility never had the right briefs and her husband would try to supply them so she could get out of bed more. Resident #2 said if her husband did not provide the appropriate size briefs the facility would apply a smaller size and it was causing her belly area to break down. Resident #2 said the CNAs were intimidating, and CNA D was always short and rude. Resident #2 said it was a yucky situation and she felt when she reported the CNAs they retaliated. 3. Record review of a face sheet dated [DATE] indicated Resident #3 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), non-pressure chronic ulcer of skin of other sites with unspecified severity (long-time open sore on the skin), and post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #3 was understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 15, which indicated he was cognitively intact. The MDS assessment indicated Resident #3 had no delusions or hallucinations. The MDS assessment indicated Resident #3 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #3 exhibited rejection 1 to 3 days in the 7-day lookback period. The MDS assessment indicated Resident #3 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, supervision for eating, and total dependence for bathing. The MDS assessment indicated Resident #3 had an open lesion other than ulcers, rashes, and cuts. Record review of Resident #3's care plan last revised [DATE] indicated he exhibited signs and symptoms of anxiety and agitation and was receiving clonazepam (medication used to treat anxiety), interventions included to allow the resident to voice his thoughts and feelings and to explore with resident the reason for anxiety. Resident #3's care plan indicated to allow him to participate in daily care and decision/goal making and to listen carefully and be non-judgmental. Resident #3's care plan indicated he had open lesions related to a history of chronic abdominal wounds and had interventions which included to cleanse area to left abdomen with normal saline, pat dry, apply calcium alginate with silver (absorbent dressing applied to wounds), cover with pads twice a day and cleanse area to left inguinal area with normal saline, pat dry and apply calcium alginate silver twice daily. During an interview and observation on [DATE] at 1:28 PM, Resident #3 said NA B told him not to be needy, referring to Resident #3 using his call light to request assistance, between 7 AM and 9 AM because these were the busiest times of the day. Resident #3 was unable to provide the exact dates. Resident #3 said LVN A did not perform wound care on him when she worked at night. Resident #3 said he had complained to the Administrator and all the other nurses that LVN A was not performing wound care on him. Resident #3 said after he complained to the Administrator, the ADON accompanied LVN A to watch her perform the wound care. While the ADON was observing the wound care, LVN A told the ADON, I cannot stomach this wound. Resident #3 said the incidents with NA B and LVN A made him feel humiliated and disrespected. Resident #3 was teary during the interview. 4. Record review of Face Sheet dated [DATE] indicated Resident #4 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Chronic obstructive pulmonary disease (a lack of adequate blood supply to brain cells), other seizures (burst of uncontrolled electrical activity between brain cells), unsteadiness on feet, weakness, pain, dementia (brain impairment of memory loss and judgement), schizoaffective disorder (combination of mood disorder such as depression and bipolar disorder), hypertension, (increased blood pressure), chronic kidney disease stage 3 (mild to moderate kidney damage - less likely to filter). Record review of quarterly MDS dated [DATE] indicated Resident #4 understood others and made himself understood. The MDS indicated Resident #4 was moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #4 did not reject evaluation or care. The MDS indicated Resident #4 required supervision and setup with transferring, dressing and limited assistance with personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #4 was care planned for psychosocial well-being. The care plan indicated interventions included Resident #4 was allowed to express feelings, allowed to participate in daily care and decision/goal making, adhere to customary routines, keep topics of conversation light and cheerful, listen carefully and non-judgmental. Resident #4 was care planned for cognitive loss related to dementia. The care plan indicated interventions included Resident #4 was approached in a calm manner, anticipate needs and observe for non-verbal cues. During an interview and observation on [DATE] at 10:49 AM, Resident #4 said LVN A told him she was done with him in a very hateful way. Resident #4 said LVN A was very bully over the residents. Resident #4 said LVN A hurt his feelings and it made him cry. Resident #4 said LVN A was bullying other patients that night and the rest of the patients came forward after him and wrote their statements. Resident #4 did not remember when the incident occurred. Resident #4 said he was very much intimated by LVN A. Resident #4 was teary when recounting the incident. 5. Record review of the Face Sheet dated [DATE] indicated Resident #5 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Transient cerebral ischemic attack (a lack of adequate blood supply to brain cells), infections of the skin and subcutaneous tissue, Chronic Obstructive pulmonary disease (a lack of adequate blood supply to brain cells), Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the boy that can affect the arms, legs, facial muscles) affecting left dominant side. Record review of the quarterly MDS dated [DATE] indicated Resident #5 had moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #5 did not reject evaluation or care. The MDS indicated Resident #5 required limited assistance with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #5 had episodes of anxiety and had Ativan (medication used to decrease anxiety). The care plan indicated interventions included Resident #5 was allowed to voice thoughts and feelings and to explore with resident the reason for anxiety. During an interview on [DATE] at 2:40 PM, Resident #5 said the CNAs screamed at her, but she was not able to recall who the CNAs were or the date the incident happened. Resident #5 said she was scared to report the CNAs because she did not want them to yell at her again. 6. Record review of Face Sheet dated [DATE] indicated Resident #6 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Diffuse traumatic brain injury, Excoriation (skin picking) disorder, Paraplegic (paralysis of the lower body), Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury, Nausea (urge to vomit), Bipolar Disorder (changes in mood and energy levels), Pain, reduced mobility. Record review of quarterly MDS dated [DATE] indicated Resident #6 understood others and made himself understood. The MDS indicated Resident #6 was cognitively intact with a BIMS score of 15. The MDS indicated Resident #6 did not reject evaluation or care. The MDS indicated Resident #6 required extensive care with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #6 had an activities of daily living (ADL) self-care performance deficit related to paraplegia. The care plan indicated interventions included Resident #6 required assistance x2 for bath/shower 3 times weekly. During an interview and observation on [DATE] at 5:05 PM, Resident #6 said LVN A told him he acted like a 3-year-old. Resident #6 said after LVN A told him he acted like a 3-year-old he said, I'm sorry, and LVN A responded, Yes, you are sorry. Resident #6 said this made him feel intimidated. Resident #6 said he had not reported this to the facility staff because he was scared LVN A would retaliate against him. Resident #6 could not recall when the incident occurred. Resident #6 was tearful during the interview. 7. Record review of the Face Sheet dated [DATE] indicated Resident #7 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease (a lack of adequate blood supply to brain cells), Pain, Muscle Weakness, Pressure ulcer of other site - stage 4, Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury), Partial traumatic amputation at knee level - left lower leg, Dementia (brain impairment of memory loss and judgement), DM Type 2 (a chronic condition that affects the way the body processes blood sugar), Personal history of transient ischemic attack (TIA) (a temporary condition that mimics a stroke), cerebral infarction (a lack of adequate blood supply to brain cells) without residual deficits. Record review of the quarterly MDS dated [DATE] indicated Resident #7 understood others and made herself understood. The MDS indicated Resident #7 was cognitively intact with a BIMS score of 13. The MDS indicated Resident #7 did not reject evaluation or care. The MDS indicated Resident #7 required extensive care with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #7 had an activities of daily living (ADL) self-care performance deficit related to amputation at knee level. The care plan indicated interventions included Resident #7 required assistance x2 for bath/shower 3 times weekly. During an interview on [DATE] at 11:19 AM, Resident #7 said CNA C yelled and cursed at her. Resident #7 said CNA C told her, I don't care who you tell, I have been working here for 20 years. Resident # 7 said when the CNAs yelled or cursed at her it made her feel intimidated and belittled. Resident #7 did not give exact dates of when this happened. Resident #7 said she had told the DON Resident #7 yelled and cursed at her, but nothing had been done. During an interview on [DATE] at 12:57 PM, CNA D said she worked the 6AM - 2PM shift since December of 2022. CNA D said she had never had any problems with any of the residents, had not been complained on, or accused of any allegations. CNA D said she had never told a resident they needed to stay in the bed. CNA D said no residents had been upset on my hall to my knowledge. CNA D said if a resident was upset with her, she would deescalate by finding out why and go get the DON. CNA D said she did not know the abuse coordinator's name because they switch positions often. CNA D said she had not been rude to residents or told the residents not to use their call lights. CNA D said she had not witnessed any of the staff members being rude to anyone. CNA D said she had never been rude or yelled at Resident #2. During an interview on [DATE] at 2:15 PM, CNA F said no residents reported abuse to her and she had not had any problems with any of the residents. CNA F said, I have not witnessed any type of abuse to the residents by any staff member. During an interview on [DATE] at 02:04 PM, CNA E said she had worked at the facility for one year and worked the 6AM - 2PM shift. CNA E said she had never been suspended or accused of yelling at a resident. CNA E said she never yelled at Resident #2 for staying on the call light. CNA E said she never told a resident they could not get out of bed. CNA E said when Resident #2 asked to get up, we would get her up. CNA E said if Resident #2 asked to get up, I got her up even if it was not her get up day. During an interview on [DATE] at 08:59 AM, Anonymous Staff Member #1 said sometimes the facility was short staffed and it fueled the fire on tolerance with the CNAs. Anonymous Staff Member #1 said the CNAs voices did get raised. Anonymous Staff Member #1 said CNA F raised her voice at the residents. Anonymous Staff Member #1 said the CNAs raising their voices at the residents made her feel uncomfortable. Anonymous Staff Member #1 said she reported these incidents to the ADON on multiple occasions. Anonymous Staff Member #1 said the ADON's response was she was doing in-services with the CNAs. Anonymous Staff Member #1 said, If I was the resident and the CNAs talked to me that way, I would feel intimidated by them and I would be scared to ask them for things. Anonymous Staff Member #1 said she did not feel like she had the authority to effectively delegate tasks or reprimand the CNAs for their actions because she felt like she had no authority. Anonymous Staff Member #1 said there were no consequences for the CNAs actions. Anonymous Staff Member #1 said the CNAs did not answer the call lights. Anonymous Staff Member #1 said the residents should have autonomy and be able to make decisions and the staff should accommodate their requests. During an interview on [DATE] at 2:41 PM, NA B said he had worked at the facility for 3 months on all shifts. NA B said, I have never told a resident not to use their call light between 7 AM and 9 AM because it was busy. NA B said, I never witnessed another CNA be rude or yell. NA B said, In some situations you have to treat people different, they cannot all be treated the same. NA B said LVN A had been a police officer. NA B said LVN A was [NAME] so when she spoke it was a loud voice. NA B said I did not make the comment you need to lose weight to any of the residents. NA B said he always got Resident #2 up and never made her stay in the bed. NA B said it was important to respect their right because this was their home if they want to do something we should do it for them. During an interview on [DATE] at 3:56 PM, Anonymous Staff Member #2 said, she had heard the CNAs yelling and cursing at the residents. Anonymous Staff Member #2 said in the past she had witnessed CNA D, CNA E, CNA F, and CNA C yell and curse at any resident that could express themselves or express their needs. In particular Resident #2, Resident #7 and Resident #6. Anonymous Staff Member said they were very mean to Resident #2. Anonymous Staff Member #2 said she witnessed the incident on [DATE] when CNA D and CNA E yelled and cursed at Resident #7 and Resident #2. Anonymous Staff Member #2 said it was CNA D that told Resident #2 that she could not get up. Anonymous Staff Member #2 said she called the Ombudsman to the nurse's station to hear the incident. Anonymous Staff Member #2 said the facility was the residents' home and the residents should be able to get up when they wanted to do so. Anonymous Staff Member #2 said the residents could become depressed because of isolating them. Anonymous Staff Member #2 said verbal abuse would make the residents feel withdrawn and scared to be at the facility. Anonymous Staff Member #2 said she did not feel like she could report abuse to the Administrator at any time. Anonymous Staff Member #2 said when she reported abuse to the Administrator, the Administrator would throw her under the bus, and tell the CNAs she reported them. The CNAs would then tell her to do things herself. During an interview on [DATE] at 8:20 AM, Anonymous staff member #3 said she no longer employed at the facility, and it had been 4-6 weeks since the last time she worked. Anonymous staff member #3 said CNA E and CNA F yelled and cursed at the residents. Anonymous staff member #3 said CNA E and CNA F would tell the residents they were not getting them out of bed. Anonymous staff member #3 said CNA E and CNA F would tell Resident #2 and Resident #7 not to ask to get out of bed because they were not going to do it. Anonymous staff member #3 said CNA E and CNA F made Resident #2 and Resident #7 cry many times. Anonymous staff member #3 said it was like an act of congress to get anyone to help him, referring to the CNAs assisting Resident #3 with his ADLs. Anonymous staff member #3 said Resident #3 was scared to ask the CNAs for assistance. Anonymous staff member #3 said she reported the CNAs yelling, cursing, and not assisting the residents to the DON and Administrator over and over again and there were no consequences for the CNAs. During an attempted phone interview with LVN A on [DATE] at 4:40 PM, LVN A did not respond to phone call. During an interview on [DATE] at 06:19 PM, the ADON said she had been the ADON for 6 - 7 weeks. The ADON said she and the DON were responsible for the oversight and monitoring of clinical staff. The ADON said she was not in Resident #3's room when LVN A said she couldn't stomach the wound. The ADON said Resident #3 reported this incident to her and she did the grievance form, and it was signed by the Administrator and DON. The ADON said she had not witnessed nor had any reports of any of the CNA's yelling or cursing at the residents. During an interview on [DATE] at 06:33 PM, the DON said she was not present during the incident with Resident #1. The DON said Resident #1 did not tell her LVN A threw the nebulizer treatments at him. The DON said Resident #1 said the box fell in his lap and was not a big deal. The DON said Resident #1 was scared of LVN A because he asked her for something and instead of giving it, she belittled him. The DON said that she did not recall the incident with Resident #5 other than provided in-services regarding abuse and educate the staff that this is the resident's home, and they have the right to feel safe and secure in the home. The DON said Resident #2 had reported to her that the CNAs did not want to get her out of bed. The DON said there were multiple times Resident #2 would say she did not get a shower. The DON said I am not saying she never missed a shower because there were problems. The DON said I tried to coordinate that people were getting their showers. The DON said she was aware of the incident with Resident #4. The DON said she took his witness statement because he could not write. The DON said Resident #4 was shaking, scared, upset, and crying. The DON said she was not aware of the incidents with Resident # 3, Resident #7. The DON said she had no complaints about NA B, CNA C, CNA D, CNA E, CNA F. During an interview on [DATE] at 08:18 PM, The Administrator said Resident #5's family member talked to her and confirmed that the incident with the CNAs yelling at Resident #5 did not happen. The Administrator did not specify how this was confirmed. The Administrator said she protected the residents by educating the staff on abuse and neglect and completing safe surveys on the residents. The Administrator said a family member complained to her that the CNAs would not get Resident #2 out of bed. The Administrator said Resident #2 got out of bed every time she wanted. The Administrator said Resident #1 said the nurse dropped the nebulizer treatments in his lap. The Administrator said that Resident #1 did not want to report the incident because it was not a big deal. The Administrator said a Performance Improvement Plan was started on LVN A at this time ([DATE]). The Administrator said LVN A was terminated after the incident with Resident #4. The Administrator said LVN A was terminated on [DATE]. The Administrator said she was not notified of any abuse allegations involving NA B, CNA C, and CNA D. The Administrator said she was the abuse coordinator. The Administrator said she was not aware that the staff or residents were scared to report abuse allegations to her. The Administrator said it was important to protect the residents from abuse for their safety and to prevent emotional harm. The Administrator said it was important to treat the residents with dignity and respect because it was their right. The Administrator said not treating a resident with dignity and respect could affect their well-being and make them feel bad. During an interview on [DATE] at 5:15 PM, LVN A said she had not received notification she was terminated by the facility. LVN A said she quit by not returning to work. LVN A said the last day she worked was [DATE]. LVN A said she quit after she was told she would have to pass out cigarettes during her medication pass time. LVN A said she was not going to stop passing out medications to give the residents their cigarettes. LVN A said she told several of the residents that smoked, including, Resident #4, that she was not going to stop pas[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right of the residents to be free from abuse for 7 of 13 residents reviewed for abuse. (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7) The facility failed to ensure Resident #1 did not experience humiliation when LVN A threw his nebulizer treatments (medication used to help breathe better) at him. The facility failed to ensure Resident #2 did not feel scared of retaliation and intimidated by staff. The facility failed to ensure Resident #2 did not feel humiliated when CNA D rudely refused to get her out of bed. The facility failed to ensure Resident #3 did not feel humiliated and disrespected when LVN A stated, I can't stomach this wound, and NA B told him not to be needy. The facility failed to ensure Resident #4 did not feel humiliated and scared of retaliation when LVN A told him, I'm done with you. The facility failed to ensure Resident #5 was not scared to report when the CNAs yelled at her because she was scared, she would be yelled at again. The facility failed to ensure Resident #6 was not scared to report LVN A after she told him he acted like a three-year-old and he was sorry. The facility failed to ensure Resident #7 did not feel intimidated and belittled when CNA C yelled and cursed at her. This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE] at 3:47PM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: 1. Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, with agitation (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and panic disorder episodic paroxysmal anxiety (intense feeling of fear and discomfort that begins abruptly and rises to a maximum within minutes). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #1 was understood and was able to understand others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #1 had no delusions or hallucinations. The MDS assessment indicated Resident #1 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #1 required supervision for bed mobility, transfers, eating, toilet use, and limited assistance for dressing and personal hygiene. Record review of the Physician Order Report dated [DATE] - [DATE] indicated Resident #1 had an order for Ipratropium Bromide and Albuterol (medication used to help breathe better) 0.5mg/3ml liquid; 0.5mg/3ml, 1 vial every 4 hours at 12:00 AM, 04:00 AM, 08:00 AM, 12:00 PM, 04:00 PM, 08:00 PM. Record review of a care plan last revised [DATE] indicated a problem that Resident #1 exhibited verbally abusive behavioral symptoms such as others were threatened, calling 911, screamed at and cursed at staff related to wanting a breathing treatment due to anxiety and shortness of breath with interventions which included convey an attitude of acceptance toward the resident, maintain a calm environment and reassure the resident by checking his oxygen saturations to assure within normal limits and observe for anxiety and attempt to have resident purse breath. During an interview on [DATE] at 9:44 AM, Resident #1 said LVN A was rude to everybody. Resident #1 said he had asked her for a breathing treatment because he felt like he could not breathe. Resident #1 said LVN A grabbed 5-6 of the nebulizer treatments (medication used to help breathe better) and threw them at him. Resident #1 said he could not remember the date that it happened. Resident #1 said he had gotten used to her being rude that way. Resident #1 said LVN A made him feel humiliated, and he was scared of her retaliating. Resident #1 said he was scared LVN A would get back at him by making him wait until the end for his medicine even if he was the first one in line. Resident #1 said in the past LVN A had made him wait for his medication because she was mad at him. Resident #1 was unable to provide exact dates. Resident #1 said he had told the office staff he was scared LVN A would retaliate against him when he was questioned about the incident with LVN A. Record review of the Provider's Investigation Report dated [DATE] indicated the incident with Resident #1 and LVN A occurred on [DATE]. The Provider's Investigation Report indicated the facility took the following actions post investigation: completed a Head-to-Toe Assessment, Resident Interviews, Staff Interviews, Safe Surveys and Culture sensitivity/Abuse and Neglect Inservice dated [DATE]. The Culture sensitivity/Abuse and Neglect Inservice was not signed by LVN A which indicated she was not in-serviced. Record review of a Performance Improvement Plan implemented on [DATE] indicated LVN A had a 30-day timeline for performance improvement or termination would occur. 2. Record review of a face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 had no delusions or hallucinations. The MDS assessment indicated Resident #2 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #2 did not exhibit rejection of care. The MDS assessment indicated Resident #2 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and supervision for eating. Resident #2 was totally dependent for transfers and bathing. Record review of Resident #2's care plan last revised [DATE] indicated she had a problem of resident must be lifted mechanically and interventions included staff to get resident up out of bed daily 5-7 times a week and required 2 staff members at all times to use the mechanical lift. Resident #2's care plan indicated she had a history of anxiety and interventions included to allow resident to voice thoughts. Resident #2's care plan indicated that she required 2 staff assistance depending on type of bath or shower, required, 1-2 staff for dressing/grooming, and 1-2 staff to provide incontinent care, and her preferred time for bath/shower was once a day on Tuesday, Thursday, and Saturday 2:00 PM- 10:00 PM. Resident #2's care plan indicated to allow her to express her feelings, allow her to participate in daily care and decision/goal making, and to listen carefully and be non-judgmental. Resident #2's care plan did not indicate she refused care. Record review of the electronic health record indicated Resident #2 was discharged to another facility on [DATE]. During an interview on [DATE] at 09:56 AM, the ombudsman said on [DATE] while in the facility she heard screaming and walked into Resident #2's room. The Ombudsman said CNA D yelled at Resident #2, What do you want? Resident #2 said she wanted to get out of bed. CNA D said to Resident #2, you know it ain't your day to get out of bed. Resident #2 said, I know it is not my shower day, but I want to get out of bed to play bingo. CNA D replied to Resident #2 and said, I don't know what to tell you. The Ombudsman said she went and reported this incident to the ADON the same day she witnessed it. During an interview on [DATE] at 3:06 PM, Resident #2 said she moved to a different nursing home approximately 5 days ago. Resident #2 said if she would have stayed at the other facility she would have died. Resident #2 said she had gone without a shower for 10 days, and she told the staff everyday she wanted a shower. Resident #2 said she was told there were not enough CNAs. Resident #2 said CNA C was horrible, cursed and screamed at her, and it broke her heart because she could hear her scream and curse at the resident across the hall from her. Resident #2 said she told him she would jerk him out of his bed, and she could not understand why she talked to everyone like that. Resident #2 said that there were plenty of other residents at the facility that had heard CNA C say the same things to other residents. Resident #2 said when CNA C and another CNA had scrubbed her leg and left a bruise while giving her a shower. Resident #2 said she reported CNA C to the DON, and that did nothing but make CNA C retaliate against her. Resident #2 said when CNA C would go into her room to leave a meal she would not speak to her or make eye contact with her. Resident #2 said the CNAs always told her she could not get up and she could not get showers because they did not have enough staff. Resident #2 said the CNAs told her not to use the call light. Resident # 2 said her family member was very upset and reported this to the DON. Resident #2 said she had to lay in her feces from 11 AM to 7 PM. Resident #2 said she told NA B three times and he kept saying he would be right with her. Resident #2 said that was the most degraded and awful feeling she ever had. Resident #2 was teary eyed. Resident #2 said her family members came to visit her and she was laying in shit. Resident #2 said this messed with her emotions and she would never forget it. Resident #2 said the facility never had the right briefs and her husband would try to supply them so she could get out of bed more. Resident #2 said if her husband did not provide the appropriate size briefs the facility would apply a smaller size and it was causing her belly area to break down. Resident #2 said the CNAs were intimidating, and CNA D was always short and rude. Resident #2 said it was a yucky situation and she felt when she reported the CNAs they retaliated. 3. Record review of a face sheet dated [DATE] indicated Resident #3 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), non-pressure chronic ulcer of skin of other sites with unspecified severity (long-time open sore on the skin), and post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #3 was understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 15, which indicated he was cognitively intact. The MDS assessment indicated Resident #3 had no delusions or hallucinations. The MDS assessment indicated Resident #3 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #3 exhibited rejection 1 to 3 days in the 7-day lookback period. The MDS assessment indicated Resident #3 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, supervision for eating, and total dependence for bathing. The MDS assessment indicated Resident #3 had an open lesion other than ulcers, rashes, and cuts. Record review of Resident #3's care plan last revised [DATE] indicated he exhibited signs and symptoms of anxiety and agitation and was receiving clonazepam (medication used to treat anxiety), interventions included to allow the resident to voice his thoughts and feelings and to explore with resident the reason for anxiety. Resident #3's care plan indicated to allow him to participate in daily care and decision/goal making and to listen carefully and be non-judgmental. Resident #3's care plan indicated he had open lesions related to a history of chronic abdominal wounds and had interventions which included to cleanse area to left abdomen with normal saline, pat dry, apply calcium alginate with silver (absorbent dressing applied to wounds), cover with pads twice a day and cleanse area to left inguinal area with normal saline, pat dry and apply calcium alginate silver twice daily. During an interview and observation on [DATE] at 1:28 PM, Resident #3 said NA B told him not to be needy, referring to Resident #3 using his call light to request assistance, between 7 AM and 9 AM because these were the busiest times of the day. Resident #3 was unable to provide the exact dates. Resident #3 said LVN A did not perform wound care on him when she worked at night. Resident #3 said he had complained to the Administrator and all the other nurses that LVN A was not performing wound care on him. Resident #3 said after he complained to the Administrator, the ADON accompanied LVN A to watch her perform the wound care. While the ADON was observing the wound care, LVN A told the ADON, I cannot stomach this wound. Resident #3 said the incidents with NA B and LVN A made him feel humiliated and disrespected. Resident #3 was teary during the interview. 4. Record review of Face Sheet dated [DATE] indicated Resident #4 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Chronic obstructive pulmonary disease (a lack of adequate blood supply to brain cells), other seizures (burst of uncontrolled electrical activity between brain cells), unsteadiness on feet, weakness, pain, dementia (brain impairment of memory loss and judgement), schizoaffective disorder (combination of mood disorder such as depression and bipolar disorder), hypertension, (increased blood pressure), chronic kidney disease stage 3 (mild to moderate kidney damage - less likely to filter). Record review of quarterly MDS dated [DATE] indicated Resident #4 understood others and made himself understood. The MDS indicated Resident #4 was moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #4 did not reject evaluation or care. The MDS indicated Resident #4 required supervision and setup with transferring, dressing and limited assistance with personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #4 was care planned for psychosocial well-being. The care plan indicated interventions included Resident #4 was allowed to express feelings, allowed to participate in daily care and decision/goal making, adhere to customary routines, keep topics of conversation light and cheerful, listen carefully and non-judgmental. Resident #4 was care planned for cognitive loss related to dementia. The care plan indicated interventions included Resident #4 was approached in a calm manner, anticipate needs and observe for non-verbal cues. During an interview and observation on [DATE] at 10:49 AM, Resident #4 said LVN A told him she was done with him in a very hateful way. Resident #4 said LVN A was very bully over the residents. Resident #4 said LVN A hurt his feelings and it made him cry. Resident #4 said LVN A was bullying other patients that night and the rest of the patients came forward after him and wrote their statements. Resident #4 did not remember when the incident occurred. Resident #4 said he was very much intimated by LVN A. Resident #4 was teary when recounting the incident. 5. Record review of the Face Sheet dated [DATE] indicated Resident #5 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Transient cerebral ischemic attack (a lack of adequate blood supply to brain cells), infections of the skin and subcutaneous tissue, Chronic Obstructive pulmonary disease (a lack of adequate blood supply to brain cells), Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the boy that can affect the arms, legs, facial muscles) affecting left dominant side. Record review of the quarterly MDS dated [DATE] indicated Resident #5 had moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #5 did not reject evaluation or care. The MDS indicated Resident #5 required limited assistance with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #5 had episodes of anxiety and had Ativan (medication used to decrease anxiety). The care plan indicated interventions included Resident #5 was allowed to voice thoughts and feelings and to explore with resident the reason for anxiety. During an interview on [DATE] at 2:40 PM, Resident #5 said the CNAs screamed at her, but she was not able to recall who the CNAs were or the date the incident happened. Resident #5 said she was scared to report the CNAs because she did not want them to yell at her again. 6. Record review of Face Sheet dated [DATE] indicated Resident #6 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Diffuse traumatic brain injury, Excoriation (skin picking) disorder, Paraplegic (paralysis of the lower body), Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury, Nausea (urge to vomit), Bipolar Disorder (changes in mood and energy levels), Pain, reduced mobility. Record review of quarterly MDS dated [DATE] indicated Resident #6 understood others and made himself understood. The MDS indicated Resident #6 was cognitively intact with a BIMS score of 15. The MDS indicated Resident #6 did not reject evaluation or care. The MDS indicated Resident #6 required extensive care with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #6 had an activities of daily living (ADL) self-care performance deficit related to paraplegia. The care plan indicated interventions included Resident #6 required assistance x2 for bath/shower 3 times weekly. During an interview and observation on [DATE] at 5:05 PM, Resident #6 said LVN A told him he acted like a 3-year-old. Resident #6 said after LVN A told him he acted like a 3-year-old he said, I'm sorry, and LVN A responded, Yes, you are sorry. Resident #6 said this made him feel intimidated. Resident #6 said he had not reported this to the facility staff because he was scared LVN A would retaliate against him. Resident #6 could not recall when the incident occurred. Resident #6 was tearful during the interview. 7. Record review of the Face Sheet dated [DATE] indicated Resident #7 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease (a lack of adequate blood supply to brain cells), Pain, Muscle Weakness, Pressure ulcer of other site - stage 4, Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury), Partial traumatic amputation at knee level - left lower leg, Dementia (brain impairment of memory loss and judgement), DM Type 2 (a chronic condition that affects the way the body processes blood sugar), Personal history of transient ischemic attack (TIA) (a temporary condition that mimics a stroke), cerebral infarction (a lack of adequate blood supply to brain cells) without residual deficits. Record review of the quarterly MDS dated [DATE] indicated Resident #7 understood others and made herself understood. The MDS indicated Resident #7 was cognitively intact with a BIMS score of 13. The MDS indicated Resident #7 did not reject evaluation or care. The MDS indicated Resident #7 required extensive care with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #7 had an activities of daily living (ADL) self-care performance deficit related to amputation at knee level. The care plan indicated interventions included Resident #7 required assistance x2 for bath/shower 3 times weekly. During an interview on [DATE] at 11:19 AM, Resident #7 said CNA C yelled and cursed at her. Resident #7 said CNA C told her, I don't care who you tell, I have been working here for 20 years. Resident # 7 said when the CNAs yelled or cursed at her it made her feel intimidated and belittled. Resident #7 did not give exact dates of when this happened. Resident #7 said she had told the DON Resident #7 yelled and cursed at her, but nothing had been done. During an interview on [DATE] at 12:57 PM, CNA D said she worked the 6AM - 2PM shift since December of 2022. CNA D said she had never had any problems with any of the residents, had not been complained on, or accused of any allegations. CNA D said she had never told a resident they needed to stay in the bed. CNA D said no residents had been upset on my hall to my knowledge. CNA D said if a resident was upset with her, she would deescalate by finding out why and go get the DON. CNA D said she did not know the abuse coordinator's name because they switch positions often. CNA D said she had not been rude to residents or told the residents not to use their call lights. CNA D said she had not witnessed any of the staff members being rude to anyone. CNA D said she had never been rude or yelled at Resident #2. During an interview on [DATE] at 2:15 PM, CNA F said no residents reported abuse to her and she had not had any problems with any of the residents. CNA F said, I have not witnessed any type of abuse to the residents by any staff member. During an interview on [DATE] at 02:04 PM, CNA E said she had worked at the facility for one year and worked the 6AM - 2PM shift. CNA E said she had never been suspended or accused of yelling at a resident. CNA E said she never yelled at Resident #2 for staying on the call light. CNA E said she never told a resident they could not get out of bed. CNA E said when Resident #2 asked to get up, we would get her up. CNA E said if Resident #2 asked to get up, I got her up even if it was not her get up day. During an interview on [DATE] at 08:59 AM, Anonymous Staff Member #1 said sometimes the facility was short staffed and it fueled the fire on tolerance with the CNAs. Anonymous Staff Member #1 said the CNAs voices did get raised. Anonymous Staff Member #1 said CNA F raised her voice at the residents. Anonymous Staff Member #1 said the CNAs raising their voices at the residents made her feel uncomfortable. Anonymous Staff Member #1 said she reported these incidents to the ADON on multiple occasions. Anonymous Staff Member #1 said the ADON's response was she was doing in-services with the CNAs. Anonymous Staff Member #1 said, If I was the resident and the CNAs talked to me that way, I would feel intimidated by them and I would be scared to ask them for things. Anonymous Staff Member #1 said she did not feel like she had the authority to effectively delegate tasks or reprimand the CNAs for their actions because she felt like she had no authority. Anonymous Staff Member #1 said there were no consequences for the CNAs actions. Anonymous Staff Member #1 said the CNAs did not answer the call lights. Anonymous Staff Member #1 said the residents should have autonomy and be able to make decisions and the staff should accommodate their requests. During an interview on [DATE] at 2:41 PM, NA B said he had worked at the facility for 3 months on all shifts. NA B said, I have never told a resident not to use their call light between 7 AM and 9 AM because it was busy. NA B said, I never witnessed another CNA be rude or yell. NA B said, In some situations you have to treat people different, they cannot all be treated the same. NA B said LVN A had been a police officer. NA B said LVN A was [NAME] so when she spoke it was a loud voice. NA B said I did not make the comment you need to lose weight to any of the residents. NA B said he always got Resident #2 up and never made her stay in the bed. NA B said it was important to respect their right because this was their home if they want to do something we should do it for them. During an interview on [DATE] at 3:56 PM, Anonymous Staff Member #2 said, she had heard the CNAs yelling and cursing at the residents. Anonymous Staff Member #2 said in the past she had witnessed CNA D, CNA E, CNA F, and CNA C yell and curse at any resident that could express themselves or express their needs. In particular Resident #2, Resident #7 and Resident #6. Anonymous Staff Member said they were very mean to Resident #2. Anonymous Staff Member #2 said she witnessed the incident on [DATE] when CNA D and CNA E yelled and cursed at Resident #7 and Resident #2. Anonymous Staff Member #2 said it was CNA D that told Resident #2 that she could not get up. Anonymous Staff Member #2 said she called the Ombudsman to the nurse's station to hear the incident. Anonymous Staff Member #2 said the facility was the residents' home and the residents should be able to get up when they wanted to do so. Anonymous Staff Member #2 said the residents could become depressed because of isolating them. Anonymous Staff Member #2 said verbal abuse would make the residents feel withdrawn and scared to be at the facility. Anonymous Staff Member #2 said she did not feel like she could report abuse to the Administrator at any time. Anonymous Staff Member #2 said when she reported abuse to the Administrator, the Administrator would throw her under the bus, and tell the CNAs she reported them. The CNAs would then tell her to do things herself. During an interview on [DATE] at 8:20 AM, Anonymous staff member #3 said she no longer employed at the facility, and it had been 4-6 weeks since the last time she worked. Anonymous staff member #3 said CNA E and CNA F yelled and cursed at the residents. Anonymous staff member #3 said CNA E and CNA F would tell the residents they were not getting them out of bed. Anonymous staff member #3 said CNA E and CNA F would tell Resident #2 and Resident #7 not to ask to get out of bed because they were not going to do it. Anonymous staff member #3 said CNA E and CNA F made Resident #2 and Resident #7 cry many times. Anonymous staff member #3 said it was like an act of congress to get anyone to help him, referring to the CNAs assisting Resident #3 with his ADLs. Anonymous staff member #3 said Resident #3 was scared to ask the CNAs for assistance. Anonymous staff member #3 said she reported the CNAs yelling, cursing, and not assisting the residents to the DON and Administrator over and over again and there were no consequences for the CNAs. During an attempted phone interview with LVN A on [DATE] at 4:40 PM, LVN A did not respond to phone call. During an interview on [DATE] at 06:19 PM, the ADON said she had been the ADON for 6 - 7 weeks. The ADON said she and the DON were responsible for the oversight and monitoring of clinical staff. The ADON said she was not in Resident #3's room when LVN A said she couldn't stomach the wound. The ADON said Resident #3 reported this incident to her and she did the grievance form, and it was signed by the Administrator and DON. The ADON said she had not witnessed nor had any reports of any of the CNA's yelling or cursing at the residents. During an interview on [DATE] at 06:33 PM, the DON said she was not present during the incident with Resident #1. The DON said Resident #1 did not tell her LVN A threw the nebulizer treatments at him. The DON said Resident #1 said the box fell in his lap and was not a big deal. The DON said Resident #1 was scared of LVN A because he asked her for something and instead of giving it, she belittled him. The DON said that she did not recall the incident with Resident #5 other than provided in-services regarding abuse and educate the staff that this is the resident's home, and they have the right to feel safe and secure in the home. The DON said Resident #2 had reported to her that the CNAs did not want to get her out of bed. The DON said there were multiple times Resident #2 would say she did not get a shower. The DON said, I am not saying she never missed a shower because there were problems. The DON said she tried to coordinate that people were getting their showers. The DON said she was aware of the incident with Resident #4. The DON said she took his witness statement because he could not write. The DON said Resident #4 was shaking, scared, upset, and crying. The DON said she was not aware of the incidents with Resident # 3, Resident #7. The DON said she had no complaints about NA B, CNA C, CNA D, CNA E, CNA F. During an interview on [DATE] at 08:18 PM, The Administrator said Resident #5's family member talked to her and confirmed that the incident with the CNAs yelling at Resident #5 did not happen. The Administrator did not specify how this was confirmed. The Administrator said she protected the residents by educating the staff on abuse and neglect and completing safe surveys on the residents. The Administrator said a family member complained to her that the CNAs would not get Resident #2 out of bed. The Administrator said Resident #2 got out of bed every time she wanted. The Administrator said Resident #1 said the nurse dropped the nebulizer treatments in his lap. The Administrator said that Resident #1 did not want to report the incident because it was not a big deal. The Administrator said a Performance Improvement Plan was started on LVN A at this time ([DATE]). The Administrator said LVN A was terminated after the incident with Resident #4. The Administrator said LVN A was terminated on [DATE]. The Administrator said she was not notified of any abuse allegations involving NA B, CNA C, and CNA D. The Administrator said she was the abuse coordinator. The Administrator said she was not aware that the staff or residents were scared to report abuse allegations to her. The Administrator said it was important to protect the residents from abuse for their safety and to prevent emotional harm. Record review of LVN A's personnel file did not indicate any previous disciplinary actions. LVN A's personnel file did not indicate a termination date. During an interview on [DATE] at 5:15 PM (LVN A returned phone call after facility exit), LVN A said she had not received notification she was terminated by the facility. LVN A said she quit by not returning to work. LVN A said the last day she worked was [DATE]. LVN A said she quit after she was told she would have to pass out cigarettes during her medication pass time. LVN A said she was not going to stop passing out medications to give the residents their cigarettes. LVN A said she told several of the residents that smoked, including, Resident #4, that she was not going to stop passing out medications to give them their cigarettes. LVN A said after she told them this Resident #4 got really pissed of[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement their written policies and procedures to prohibit neglect and abuse for 7 of 13 residents reviewed for abuse. (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6 and Resident #7). The facility failed to ensure Resident #1 did not experience humiliation when LVN A threw his nebulizer treatments (medication used to help breathe better) at him. The facility failed to ensure Resident #2 did not feel scared of retaliation and intimidated by staff. The facility failed to ensure Resident #2 did not feel humiliated when CNA D rudely refused to get her out of bed. The facility failed to ensure Resident #3 did not feel humiliated and disrespected when LVN A stated, I can't stomach this wound, and NA B told him not to be needy. The facility failed to ensure Resident #4 did not feel humiliated and scared of retaliation when LVN A told him, I'm done with you. The facility failed to ensure Resident #5 was not scared to report when the CNAs yelled at her because she was scared, she would be yelled at again. The facility failed to ensure Resident #6 was not scared to report LVN A after she told him he acted like a three-year-old and he was sorry. The facility failed to ensure Resident #7 did not feel intimidated and belittled when CNA C yelled and cursed at her. The facility abuse coordinator failed to ensure staff were able to report allegations of abuse without fear of reprisal. This failure resulted in an Immediate Jeopardy (IJ) identified on [DATE] at 3:47PM. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This failure could place residents at risk of unreported abuse, neglect, exploitation and a decreased quality of life. Findings included: 1. Record review of a face sheet dated [DATE] indicated Resident #1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, with agitation (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and panic disorder episodic paroxysmal anxiety (intense feeling of fear and discomfort that begins abruptly and rises to a maximum within minutes). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #1 was understood and was able to understand others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #1 had no delusions or hallucinations. The MDS assessment indicated Resident #1 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #1 required supervision for bed mobility, transfers, eating, toilet use, and limited assistance for dressing and personal hygiene. Record review of the Physician Order Report dated [DATE] - [DATE] indicated Resident #1 had an order for Ipratropium Bromide and Albuterol (medication used to help breathe better) 0.5mg/3ml liquid; 0.5mg/3ml, 1 vial every 4 hours at 12:00 AM, 04:00 AM, 08:00 AM, 12:00 PM, 04:00 PM, 08:00 PM. Record review of a care plan last revised [DATE] indicated a problem that Resident #1 exhibited verbally abusive behavioral symptoms such as others were threatened, calling 911, screamed at and cursed at staff related to wanting a breathing treatment due to anxiety and shortness of breath with interventions which included convey an attitude of acceptance toward the resident, maintain a calm environment and reassure the resident by checking his oxygen saturations to assure within normal limits and observe for anxiety and attempt to have resident purse breath. During an interview on [DATE] at 9:44 AM, Resident #1 said LVN A was rude to everybody. Resident #1 said he had asked her for a breathing treatment because he felt like he could not breathe. Resident #1 said LVN A grabbed 5-6 of the nebulizer treatments (medication used to help breathe better) and threw them at him. Resident #1 said he could not remember the date that it happened. Resident #1 said he had gotten used to her being rude that way. Resident #1 said LVN A made him feel humiliated, and he was scared of her retaliating. Resident #1 said he was scared LVN A would get back at him by making him wait until the end for his medicine even if he was the first one in line. Resident #1 said in the past LVN A had made him wait for his medication because she was mad at him. Resident #1 was unable to provide exact dates. Resident #1 said he had told the office staff he was scared LVN A would retaliate against him when he was questioned about the incident with LVN A. Record review of the Provider's Investigation Report dated [DATE] indicated the incident with Resident #1 and LVN A occurred on [DATE]. The Provider's Investigation Report indicated the facility took the following actions post investigation: completed a Head-to-Toe Assessment, Resident Interviews, Staff Interviews, Safe Surveys and Culture sensitivity/Abuse and Neglect Inservice dated [DATE]. The Culture sensitivity/Abuse and Neglect Inservice was not signed by LVN A which indicated she was not in-serviced. Record review of a Performance Improvement Plan implemented on [DATE] indicated LVN A had a 30-day timeline for performance improvement or termination would occur. 2. Record review of a face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness and paralysis after a stroke), and type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #2 was understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 had no delusions or hallucinations. The MDS assessment indicated Resident #2 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #2 did not exhibit rejection of care. The MDS assessment indicated Resident #2 required extensive assistance for bed mobility, dressing, toilet use, personal hygiene, and supervision for eating. Resident #2 was totally dependent for transfers and bathing. Record review of Resident #2's care plan last revised [DATE] indicated she had a problem of resident must be lifted mechanically and interventions included staff to get resident up out of bed daily 5-7 times a week and required 2 staff members at all times to use the mechanical lift. Resident #2's care plan indicated she had a history of anxiety and interventions included to allow resident to voice thoughts. Resident #2's care plan indicated that she required 2 staff assistance depending on type of bath or shower, required, 1-2 staff for dressing/grooming, and 1-2 staff to provide incontinent care, and her preferred time for bath/shower was once a day on Tuesday, Thursday, and Saturday 2:00 PM- 10:00 PM. Resident #2's care plan indicated to allow her to express her feelings, allow her to participate in daily care and decision/goal making, and to listen carefully and be non-judgmental. Resident #2's care plan did not indicate she refused care. Record review of the electronic health record indicated Resident #2 was discharged to another facility on [DATE]. During an interview on [DATE] at 09:56 AM, the ombudsman said on [DATE] while in the facility she heard screaming and walked into Resident #2's room. The Ombudsman said CNA D yelled at Resident #2, What do you want? Resident #2 said she wanted to get out of bed. CNA D said to Resident #2, you know it ain't your day to get out of bed. Resident #2 said, I know it is not my shower day, but I want to get out of bed to play bingo. CNA D replied to Resident #2 and said, I don't know what to tell you. The Ombudsman said she went and reported this incident to the ADON the same day she witnessed it. During an interview on [DATE] at 3:06 PM, Resident #2 said she moved to a different nursing home approximately 5 days ago. Resident #2 said if she would have stayed at the other facility she would have died. Resident #2 said she had gone without a shower for 10 days, and she told the staff everyday she wanted a shower. Resident #2 said she was told there were not enough CNAs. Resident #2 said CNA C was horrible, cursed and screamed at her, and it broke her heart because she could hear her scream and curse at the resident across the hall from her. Resident #2 said she told him she would jerk him out of his bed, and she could not understand why she talked to everyone like that. Resident #2 said that there were plenty of other residents at the facility that had heard CNA C say the same things to other residents. Resident #2 said when CNA C and another CNA had scrubbed her leg and left a bruise while giving her a shower. Resident #2 said she reported CNA C to the DON, and that did nothing but make CNA C retaliate against her. Resident #2 said when CNA C would go into her room to leave a meal she would not speak to her or make eye contact with her. Resident #2 said the CNAs always told her she could not get up and she could not get showers because they did not have enough staff. Resident #2 said the CNAs told her not to use the call light. Resident # 2 said her family member was very upset and reported this to the DON. Resident #2 said she had to lay in her feces from 11 AM to 7 PM. Resident #2 said she told NA B three times and he kept saying he would be right with her. Resident #2 said that was the most degraded and awful feeling she ever had. Resident #2 was teary eyed. Resident #2 said her family members came to visit her and she was laying in shit. Resident #2 said this messed with her emotions and she would never forget it. Resident #2 said the facility never had the right briefs and her husband would try to supply them so she could get out of bed more. Resident #2 said if her husband did not provide the appropriate size briefs the facility would apply a smaller size and it was causing her belly area to break down. Resident #2 said the CNAs were intimidating, and CNA D was always short and rude. Resident #2 said it was a yucky situation and she felt when she reported the CNAs they retaliated. 3. Record review of a face sheet dated [DATE] indicated Resident #3 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), non-pressure chronic ulcer of skin of other sites with unspecified severity (long-time open sore on the skin), and post-traumatic stress disorder (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #3 was understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 15, which indicated he was cognitively intact. The MDS assessment indicated Resident #3 had no delusions or hallucinations. The MDS assessment indicated Resident #3 had no physical, verbal, or other behavioral symptoms directed toward others. The MDS assessment indicated Resident #3 exhibited rejection 1 to 3 days in the 7-day lookback period. The MDS assessment indicated Resident #3 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, supervision for eating, and total dependence for bathing. The MDS assessment indicated Resident #3 had an open lesion other than ulcers, rashes, and cuts. Record review of Resident #3's care plan last revised [DATE] indicated he exhibited signs and symptoms of anxiety and agitation and was receiving clonazepam (medication used to treat anxiety), interventions included to allow the resident to voice his thoughts and feelings and to explore with resident the reason for anxiety. Resident #3's care plan indicated to allow him to participate in daily care and decision/goal making and to listen carefully and be non-judgmental. Resident #3's care plan indicated he had open lesions related to a history of chronic abdominal wounds and had interventions which included to cleanse area to left abdomen with normal saline, pat dry, apply calcium alginate with silver (absorbent dressing applied to wounds), cover with pads twice a day and cleanse area to left inguinal area with normal saline, pat dry and apply calcium alginate silver twice daily. During an interview and observation on [DATE] at 1:28 PM, Resident #3 said NA B told him not to be needy, referring to Resident #3 using his call light to request assistance, between 7 AM and 9 AM because these were the busiest times of the day. Resident #3 was unable to provide the exact dates. Resident #3 said LVN A did not perform wound care on him when she worked at night. Resident #3 said he had complained to the Administrator and all the other nurses that LVN A was not performing wound care on him. Resident #3 said after he complained to the Administrator, the ADON accompanied LVN A to watch her perform the wound care. While the ADON was observing the wound care, LVN A told the ADON, I cannot stomach this wound. Resident #3 said the incidents with NA B and LVN A made him feel humiliated and disrespected. Resident #3 was teary during the interview. 4. Record review of Face Sheet dated [DATE] indicated Resident #4 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Chronic obstructive pulmonary disease (a lack of adequate blood supply to brain cells), other seizures (burst of uncontrolled electrical activity between brain cells), unsteadiness on feet, weakness, pain, dementia (brain impairment of memory loss and judgement), schizoaffective disorder (combination of mood disorder such as depression and bipolar disorder), hypertension, (increased blood pressure), chronic kidney disease stage 3 (mild to moderate kidney damage - less likely to filter). Record review of quarterly MDS dated [DATE] indicated Resident #4 understood others and made himself understood. The MDS indicated Resident #4 was moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #4 did not reject evaluation or care. The MDS indicated Resident #4 required supervision and setup with transferring, dressing and limited assistance with personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #4 was care planned for psychosocial well-being. The care plan indicated interventions included Resident #4 was allowed to express feelings, allowed to participate in daily care and decision/goal making, adhere to customary routines, keep topics of conversation light and cheerful, listen carefully and non-judgmental. Resident #4 was care planned for cognitive loss related to dementia. The care plan indicated interventions included Resident #4 was approached in a calm manner, anticipate needs and observe for non-verbal cues. During an interview and observation on [DATE] at 10:49 AM, Resident #4 said LVN A told him she was done with him in a very hateful way. Resident #4 said LVN A was very bully over the residents. Resident #4 said LVN A hurt his feelings and it made him cry. Resident #4 said LVN A was bullying other patients that night and the rest of the patients came forward after him and wrote their statements. Resident #4 did not remember when the incident occurred. Resident #4 said he was very much intimated by LVN A. Resident #4 was teary when recounting the incident. 5. Record review of the Face Sheet dated [DATE] indicated Resident #5 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Transient cerebral ischemic attack (a lack of adequate blood supply to brain cells), infections of the skin and subcutaneous tissue, Chronic Obstructive pulmonary disease (a lack of adequate blood supply to brain cells), Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the boy that can affect the arms, legs, facial muscles) affecting left dominant side. Record review of the quarterly MDS dated [DATE] indicated Resident #5 had moderate cognitive impairment with a BIMS score of 12. The MDS indicated Resident #5 did not reject evaluation or care. The MDS indicated Resident #5 required limited assistance with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #5 had episodes of anxiety and had Ativan (medication used to decrease anxiety). The care plan indicated interventions included Resident #5 was allowed to voice thoughts and feelings and to explore with resident the reason for anxiety. During an interview on [DATE] at 2:40 PM, Resident #5 said the CNAs screamed at her, but she was not able to recall who the CNAs were or the date the incident happened. Resident #5 said she was scared to report the CNAs because she did not want them to yell at her again. 6. Record review of Face Sheet dated [DATE] indicated Resident #6 was [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis including Diffuse traumatic brain injury, Excoriation (skin picking) disorder, Paraplegic (paralysis of the lower body), Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury, Nausea (urge to vomit), Bipolar Disorder (changes in mood and energy levels), Pain, reduced mobility. Record review of quarterly MDS dated [DATE] indicated Resident #6 understood others and made himself understood. The MDS indicated Resident #6 was cognitively intact with a BIMS score of 15. The MDS indicated Resident #6 did not reject evaluation or care. The MDS indicated Resident #6 required extensive care with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #6 had an activities of daily living (ADL) self-care performance deficit related to paraplegia. The care plan indicated interventions included Resident #6 required assistance x2 for bath/shower 3 times weekly. During an interview and observation on [DATE] at 5:05 PM, Resident #6 said LVN A told him he acted like a 3-year-old. Resident #6 said after LVN A told him he acted like a 3-year-old he said, I'm sorry, and LVN A responded, Yes, you are sorry. Resident #6 said this made him feel intimidated. Resident #6 said he had not reported this to the facility staff because he was scared LVN A would retaliate against him. Resident #6 could not recall when the incident occurred. Resident #6 was tearful during the interview. 7. Record review of the Face Sheet dated [DATE] indicated Resident #7 was [AGE] year-old female, admitted to the facility on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease (a lack of adequate blood supply to brain cells), Pain, Muscle Weakness, Pressure ulcer of other site - stage 4, Neuromuscular dysfunction of bladder (lack of bladder control due to a spinal, brain or nerve injury), Partial traumatic amputation at knee level - left lower leg, Dementia (brain impairment of memory loss and judgement), DM Type 2 (a chronic condition that affects the way the body processes blood sugar), Personal history of transient ischemic attack (TIA) (a temporary condition that mimics a stroke), cerebral infarction (a lack of adequate blood supply to brain cells) without residual deficits. Record review of the quarterly MDS dated [DATE] indicated Resident #7 understood others and made herself understood. The MDS indicated Resident #7 was cognitively intact with a BIMS score of 13. The MDS indicated Resident #7 did not reject evaluation or care. The MDS indicated Resident #7 required extensive care with transferring, dressing and personal hygiene. Record review of the comprehensive care plan updated [DATE] indicated Resident #7 had an activities of daily living (ADL) self-care performance deficit related to amputation at knee level. The care plan indicated interventions included Resident #7 required assistance x2 for bath/shower 3 times weekly. During an interview on [DATE] at 11:19 AM, Resident #7 said CNA C yelled and cursed at her. Resident #7 said CNA C told her, I don't care who you tell, I have been working here for 20 years. Resident # 7 said when the CNAs yelled or cursed at her it made her feel intimidated and belittled. Resident #7 did not give exact dates of when this happened. Resident #7 said she had told the DON Resident #7 yelled and cursed at her, but nothing had been done. During an interview on [DATE] at 12:57 PM, CNA D said she worked the 6AM - 2PM shift since December of 2022. CNA D said she had never had any problems with any of the residents, had not been complained on, or accused of any allegations. CNA D said she had never told a resident they needed to stay in the bed. CNA D said no residents had been upset on my hall to my knowledge. CNA D said if a resident was upset with her, she would deescalate by finding out why and go get the DON. CNA D said she did not know the abuse coordinator's name because they switch positions often. CNA D said she had not been rude to residents or told the residents not to use their call lights. CNA D said she had not witnessed any of the staff members being rude to anyone. CNA D said she had never been rude or yelled at Resident #2. During an interview on [DATE] at 2:15 PM, CNA F said no residents reported abuse to her and she had not had any problems with any of the residents. CNA F said, I have not witnessed any type of abuse to the residents by any staff member. During an interview on [DATE] at 02:04 PM, CNA E said she had worked at the facility for one year and worked the 6AM - 2PM shift. CNA E said she had never been suspended or accused of yelling at a resident. CNA E said she never yelled at Resident #2 for staying on the call light. CNA E said she never told a resident they could not get out of bed. CNA E said when Resident #2 asked to get up, we would get her up. CNA E said if Resident #2 asked to get up, I got her up even if it was not her get up day. During an interview on [DATE] at 08:59 AM, Anonymous Staff Member #1 said sometimes the facility was short staffed and it fueled the fire on tolerance with the CNAs. Anonymous Staff Member #1 said the CNAs voices did get raised. Anonymous Staff Member #1 said CNA F raised her voice at the residents. Anonymous Staff Member #1 said the CNAs raising their voices at the residents made her feel uncomfortable. Anonymous Staff Member #1 said she reported these incidents to the ADON on multiple occasions. Anonymous Staff Member #1 said the ADON's response was she was doing in-services with the CNAs. Anonymous Staff Member #1 said, If I was the resident and the CNAs talked to me that way, I would feel intimidated by them and I would be scared to ask them for things. Anonymous Staff Member #1 said she did not feel like she had the authority to effectively delegate tasks or reprimand the CNAs for their actions because she felt like she had no authority. Anonymous Staff Member #1 said there were no consequences for the CNAs actions. Anonymous Staff Member #1 said the CNAs did not answer the call lights. Anonymous Staff Member #1 said the residents should have autonomy and be able to make decisions and the staff should accommodate their requests. During an interview on [DATE] at 2:41 PM, NA B said he had worked at the facility for 3 months on all shifts. NA B said, I have never told a resident not to use their call light between 7 AM and 9 AM because it was busy. NA B said, I never witnessed another CNA be rude or yell. NA B said, In some situations you have to treat people different, they cannot all be treated the same. NA B said LVN A had been a police officer. NA B said LVN A was [NAME] so when she spoke it was a loud voice. NA B said I did not make the comment you need to lose weight to any of the residents. NA B said he always got Resident #2 up and never made her stay in the bed. NA B said it was important to respect their right because this was their home if they want to do something we should do it for them. During an interview on [DATE] at 3:56 PM, Anonymous Staff Member #2 said, she had heard the CNAs yelling and cursing at the residents. Anonymous Staff Member #2 said in the past she had witnessed CNA D, CNA E, CNA F, and CNA C yell and curse at any resident that could express themselves or express their needs. In particular Resident #2, Resident #7 and Resident #6. Anonymous Staff Member said they were very mean to Resident #2. Anonymous Staff Member #2 said she witnessed the incident on [DATE] when CNA D and CNA E yelled and cursed at Resident #7 and Resident #2. Anonymous Staff Member #2 said it was CNA D that told Resident #2 that she could not get up. Anonymous Staff Member #2 said she called the Ombudsman to the nurse's station to hear the incident. Anonymous Staff Member #2 said the facility was the residents' home and the residents should be able to get up when they wanted to do so. Anonymous Staff Member #2 said the residents could become depressed because of isolating them. Anonymous Staff Member #2 said verbal abuse would make the residents feel withdrawn and scared to be at the facility. Anonymous Staff Member #2 said she did not feel like she could report abuse to the Administrator at any time. Anonymous Staff Member #2 said when she reported abuse to the Administrator, the Administrator would throw her under the bus, and tell the CNAs she reported them. The CNAs would then tell her to do things herself. During an interview on [DATE] at 8:20 AM, Anonymous staff member #3 said she no longer employed at the facility, and it had been 4-6 weeks since the last time she worked. Anonymous staff member #3 said CNA E and CNA F yelled and cursed at the residents. Anonymous staff member #3 said CNA E and CNA F would tell the residents they were not getting them out of bed. Anonymous staff member #3 said CNA E and CNA F would tell Resident #2 and Resident #7 not to ask to get out of bed because they were not going to do it. Anonymous staff member #3 said CNA E and CNA F made Resident #2 and Resident #7 cry many times. Anonymous staff member #3 said it was like an act of congress to get anyone to help him, referring to the CNAs assisting Resident #3 with his ADLs. Anonymous staff member #3 said Resident #3 was scared to ask the CNAs for assistance. Anonymous staff member #3 said she reported the CNAs yelling, cursing, and not assisting the residents to the DON and Administrator over and over again and there were no consequences for the CNAs. During an attempted phone interview with LVN A on [DATE] at 4:40 PM, LVN A did not respond to phone call. During an interview on [DATE] at 06:19 PM, the ADON said she had been the ADON for 6 - 7 weeks. The ADON said she and the DON were responsible for the oversight and monitoring of clinical staff. The ADON said she was not in Resident #3's room when LVN A said she couldn't stomach the wound. The ADON said Resident #3 reported this incident to her and she did the grievance form, and it was signed by the Administrator and DON. The ADON said she had not witnessed nor had any reports of any of the CNA's yelling or cursing at the residents. During an interview on [DATE] at 06:33 PM, the DON said she was not present during the incident with Resident #1. The DON said Resident #1 did not tell her LVN A threw the nebulizer treatments at him. The DON said Resident #1 said the box fell in his lap and was not a big deal. The DON said Resident #1 was scared of LVN A because he asked her for something and instead of giving it, she belittled him. The DON said that she did not recall the incident with Resident #5 other than provided in-services regarding abuse and educate the staff that this is the resident's home, and they have the right to feel safe and secure in the home. The DON said Resident #2 had reported to her that the CNAs did not want to get her out of bed. The DON said there were multiple times Resident #2 would say she did not get a shower. The DON said I am not saying she never missed a shower because there were problems. The DON said I tried to coordinate that people were getting their showers. The DON said she was aware of the incident with Resident #4. The DON said she took his witness statement because he could not write. The DON said Resident #4 was shaking, scared, upset, and crying. The DON said she was not aware of the incidents with Resident # 3, Resident #7. The DON said she had no complaints about NA B, CNA C, CNA D, CNA E, CNA F. The DON said it was important to follow the abuse policy because it was the residents' right not to be abused. The DON said the abuse policy needed to be followed so that people understood they could not abuse the residents. The DON said the abuse policy protected the residents from abuse and gave the facility a guideline to follow so abuse could be identified and reported. The DON said if the residents experienced verbal abuse it could result in them being scared, withdrawn and cause failure to thrive. During an interview on [DATE] at 08:18 PM, The Administrator said Resident #5's family member talked to her and confirmed that the incident with the CNAs yelling at Resident #5 did not happen. The Administrator did not specify how this was confirmed. The Administrator said she protected the residents by educating the staff on abuse and neglect and completing safe surveys on the residents. The Administrator said a family member complained to her that the CNAs would not get Resident #2 out of bed. The Administrator said Resident #2 got out of bed every time she wanted. The Administrator said Resident #1 said the nurse dropped the nebulizer treatments in his lap. The Administrator said that Resident #1 did not want to report the incident because it was not a big deal. The Administrator said a Performance Improvement Plan was started on LVN A at this time ([DATE]). The Administrator said LVN A was terminated after the incident with Resident #4. The Administrator said LVN A was terminated on [DATE]. The Administrator said she was not notified of any abuse allegations involving NA B, CNA C, and CNA D. The Administrator said she was the abuse coordinator. The Administrator said she was not aware that the staff or residents were scared to report abuse allegations to her. The Administrator said it was important to protect the residents from abuse for their safety and to prevent emotional harm. The Administrator said in-services were provided to the staff. The Administrator said she expected all of the staff to follow the abuse policy. The Administrator said it was important to follow the abuse policy to ensure the safety of the residents. The Administrator said not follow[TRUNCATED]