**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 8 residents (Resident #11) reviewed for abuse. The facility failed to ensure CNA A was suspended pending an allegation of abuse or neglect when Resident #11 became combative with care. CNA A did not discontinue care or call for help when Resident #11 became combative. Resident #11 sustained skin tears to his hands, bruising to hands, skin tears to his forearms, and a left-hand fracture. On 6/5/24 at 7:15 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 6/7/24 at 09:15 PM, the facility remained out of compliance at a severity level of potential for more than minimal harm that was not immediate jeopardy and a scope of Isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk of continued victimization, abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Record Review of Resident #11's admission record revealed an [AGE] year-old male initially admitted [DATE] and readmitted on [DATE] with diagnoses to include neurogenerative disorder with Lewy bodies (It is characterized by the presence of Lewy bodies-abnormal protein deposits-in the brain. These deposits affect brain chemicals, leading to problems with thinking, movement, behavior, mood, and other bodily functions), dementia (loss of thinking, remembering, and reasoning skills) without behaviors, and atherosclerotic heart disease (Plaque build-up in the arteries). Record Review of Resident #11's care plan, last updated 4/4/24, stated [Resident #11] has behaviors which include taking the linens off of his bed. He will put them on the chair at the end of his bed and cover himself with items such as the pink pad or other items that are not linens. He also puts his call light on the floor or behind his bed. He can also become combative with care at times. He does not always understand what you are trying to do. [Resident #11] will have 2 people assist them at all times. The interventions included administer medications as doctor has ordered, attempt intervention before resident behavior begins by checking frequently, fall mat at bedside while in bed, make sure resident is not in pain or uncomfortable, [Resident #11] will have two CNAs assisting him at all time, and please tell residents what you are going to do before you begin. 5/2/24 [Resident #11] has potential to demonstrate physical behaviors related to dementia. [Resident #11] can be argumentative, become agitated/ combative with care at times. With interventions to analyze key times, places, circumstance, triggers, and what escalates behavior and document, Assess and anticipate resident needs: move, thirst, toileting needs, comfort level, body positioning, pain ETC., Provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out staff member when agitated, Modify environment: reduce noise, dim light, place familiar objects in room, monitor/document/ report to MD/ hospice/ VA of danger to self or others. 3/32/23 [Resident #11] has impaired cognitive function/ dementia or impaired thought process related to diagnosis of Lewy body dementia. With interventions to ask yes/ no questions in order to determine the residence needs, communication: use the resident preferred name, identify yourself at each interaction, face the revenant in speaking and make eye contact, reduce any distractions- turn off TV, radio, closed door ETC, the resident understands consistent, simple, directive sentences, Provide the resident with necessary cues-stop and return if agitated, cue, reorient and supervise as needed. Record Review of Resident #11's quarterly MDS assessment, dated 5/16/24, reflected Resident #11 had a severely impaired cognition for daily decision making. The MDS indicated Resident #11 did not exhibit rejection of care or physical or verbal behaviors towards others such as hitting or screaming. The MDS indicated the resident was always incontinent of bowel and bladder. The MDS indicated he was dependent for ADLS including oral hygiene, toileting hygiene, shower or bathe, dressing, and personal hygiene. The MDS indicated the resident needed substantial assistance (the helper does more than half the effort) to sit to lying, lying to sit, sit to stand, and did not attempt to walk due to medical condition or safety concerns. Record review of nursing progress notes, dated 3/28/24 through 4/4/24, for Resident #11's stated the following: - 3/28/24 at 10:38 p.m. patient not cooperating with aide during brief change, patient gave himself a skin tear to right lower forearm, top of left hand, left 4th finger cleaned with wound cleanser, and covered with [bandage]. Written by LVN B. - 3/29/24 at 9:45 a.m. Skin tear top of LT (left) hand, ST (skin tear) LT (left) 4th index finger, ST to RT (right) FA (forearm), bruising to Lt hand 1st finger and pinky-finger, swelling to Rt hand .Assessed areas, limited ROM to Rt hand, X-ray ordered to hand/wrist pending X-ray, Patients description of event: unable to verbalize . written by LVN C -3/30/24 at 1:58 p.m.X-Ray to rt. hand done on 3/29/24. Tx (treatment) to all skin issues as ordered. Xray results: No acute fx (fracture/break). Or dislocation seen. mild interphalangeal (finger joints) arthrosis (degenerative arthritis that causes the breakdown of the joints) shown by small degenerative spurring (growth) . written by LVN R - 3/31/24 at 3:57 p.m. Rt hand/wrist swelling, multiple skin tears RFA, top of L hand, Lt 4TH finger .applied steri-strips (Wound closure strips are porous surgical tape strips which can be used to close small wounds. They are applied across the laceration in a manner which pulls the skin on either side of the wound together.) to all skin tears - 4ss (steri-strips) to top Lt hand and 7ss to RT FA . written by LVN C. - 4/1/24 at 2:00 p.m. Late Entry . [Hospice]RN is here with [hospice company] and ordered an x-ray to [Resident #11]'s left hand. I heard her notify [Hospice doctor], [RP], and call in the x-ray. She noted swelling and bruising to [Resident #11]'s hand. Written by the DON. - 4/2/24 at 11:50 a.m. resident presents with discoloration to both upper bilateral extremities and scratched . written by LVN S. - 4/2/24 at 4:30 p.m. Late Entry .I overheard [hospice RN] on the phone with [Hospice Doctor] and then [Medical Director] and she stated that both physicians declined to get further diagnostics. She stated that {Hospice Doctor] told her that the treatment would be the same meaning the hand splint. Written by the DON - 4/2/24 at 7:07 p.m.FX to left hand . Hospice ordered splint stabilizer for left hand fx . written by LVN S - 4/2/24 at 11:06 p.m.left hand fx with splint; multiple skin tears left hand; right hand edema . written by LVN T. -4/3/24 at 9:13 a.m. selling and bruising to the left hand. THERE IS NO CONFIRMED FRACTURE . written by the DON. Record review of x-ray results, dated 4/2/24, stated .Impression: The bones are osteoporotic (a condition where bones become thin and lose their strength, resulting in increased fragility and a higher risk of fractures.). The distal (farthest away from the center) radial (a long bone that extends from the lateral (outside) side of the elbow to the thumb side of the wrist) diametaphyseal (specific region of a long bone or wrist area) irregularity is visualized, the focal (point of) tender (where it was hurting on the resident) correlation (was the same area) and follow up are recommended to exclude a fracture. The moderate wrist and hand osteoarthritis (disorder of the joints characterized by progressive deterioration of cartilage or of the entire joint) is visualized. Record review of the NP's notes, dated 4/3/24, stated Resident #11 was seen for follow up on change in condition to his left wrist for swelling and redness. The note stated .aggressive/combative with care last week, caused some skin tears to left-hand, left-hand X-ray ordered by Hospice for swelling . X-ray resulted- cannot rule out distal radius fracture (distal radius fracture versus chronic osteoarthritis), [Hospice Dr.] Ordered splint . swelling and redness noted to left wrist. The NP ordered 500 mg of cephalexin three times a day for 10 days for cellulitis (bacterial skin infection) to the left upper arm. The medical director reviewed the notes and agreed on 4/24/24. On 6/4/24 at 4:51 p.m. LVN B was attempted by phone an interview and did not answer. On 6/5/24 at 12:00 p.m. LVN T was attempted by phone for an interview and did not answer. On 6/6/24 at 2:00 p.m. The Administrator stated LVN S no longer worked for the facility and was a disgruntled employee. During an interview on 6/5/24 at 11:02 a.m. the DON stated she became aware of the incident the morning of 3/29/24 where Resident #11 became combative during care with CNA A. She stated CNA A was interviewed by phone on 4/3/24 at 4:11 p.m. and told her the resident was combative during care and beat her up, she continued with care because he was naked. CNA A noticed the skin tears after, and reported it the charge nurse or LVN B. The DON stated the other staff working did not witness the incident and the resident was non-interviewable. The DON stated they ordered an x-ray of his right hand on 3/29/24 because most of the swelling and injuries were to his right hand. The DON stated the resident had a history of being combative with care and staff was instructed to just stop care if a resident became combative. The DON stated CNA A did not stop care and finished changing him. The DON stated CNA A still worked at the facility. The DON stated it was treated more like an injury of unknown origin than abuse and neglect because the resident had a history of arthritis and she did not think the CNA A did anything to the resident. The DON stated on 4/2/24 they did an x-ray to his left hand due to new onset swelling and it showed a possible fracture, they reported it to the state on 4/2/24. During an interview on 6/5/24 at 3:59 p.m. CNA A described Resident #11's recent behavior with care as okay after the incident on 3/28/24. CNA A stated she continued to work with Resident #11 at the nursing facility after the incident but mostly worked on the woman's side now. CNA A stated she began working for the facility in March of 2024 and Resident #11 was really combative with care but since then was more familiar with her. CNA A stated on 3/28/24 she was providing incontinent care to Resident #11. CNA A stated this resident's bed was against the wall. CNA A stated she told Resident #11 what she was about to do for care and stated, I went to turn him and put on his brief he did not want to me to change him he kept getting out of the bed. CNA A stated Resident #11 was upset that she was providing peri care and she had to keep him in the bed. CNA A stated Resident #11 let her remove his pants but when she went to put on the clean brief it went on from there. CNA A stated Resident #11 got out of the bed, grabbed her scrub top, ripped her top, and pulled her hair. The CNA A stated she kept helping Resident #11 put his legs back in the bed. She stated, I would explain to him about putting his legs back in the bed. CNA A stated she never left or called for help because she usually could get them to calm down on her own. CNA A stated the resident had no injuries after the incident. CNA A stated she did not know how the resident had injuries to his hands or arms. CNA A stated she was not suspended pending an investigation. CNA A stated she did not know why she would be suspended because that would make it sound like she did something to the resident. CNA A stated she did not have specific training after this incident for handling combative residents. She stated she had recent training after another incident at the facility not related to this resident or her. She stated they also had annual training for abuse and neglect. CNA A stated she should have called for help to have a witness for the resident's safety and her safety. During an interview on 6/5/24 at 3:10 pm. the Administrator stated the DON reported this incident, but she was aware of it. She stated they concluded that because CNA A told them Resident #11 was combative during care, she concluded he hit his hand on the wall possibly causing a fracture. The Administrator stated she could not recall if she saw the resident's injuries but if she did it was nothing she would suspect was abuse or neglect. The Administrator stated they made a police report on 4/2/24 to rule out any potential abuse. The Administrator stated they did not feel there was any abuse and there had never been any other allegation made against CNA A so she continued to work for the facility. The Administrator stated staff should take a break if a resident was resistant to care and call for help. Record review of a police report, dated 4/2/24, stated on April 2nd 2024 I officer . was dispatched . for a information report. Upon arrival I made contact with [the DON] who's stated [Resident #11] was injured sometime in the last couple of days. The [DON] when stated on the 28th staff was dealing with [Resident #11] when he suffered multiple skin tears. The [DON] stated that on this said day X-rays were taken. Results showed that [Resident #11] had a possible fractured left hand. I attempted to speak with [Resident #11], due to [Resident #11's] diagnosis I wasn't able to get side of the story. I photographed [Resident #11]'s injuries which were later uploaded to the . evidence server. The [DON] could not confirm if an assault occurred. The [DON] stated she would conduct an interview over the next few days. due to the [DON] still having to investigate the incident report is for information purposes only pending follow up by the reporting party. Record review CNA A's employee records did not contain any disciplinary forms, suspension, misconduct, or coaching forms. Record review of a document titled in service-abuse, dated 4/2/24, did not contain CNA A or LVN B's signature. Record review of the facility's policy, titled Facility Responsibilities for Reporting Allegations, dated 9/22, stated The following addresses facility responsibilities for reporting allegations/occurrences involving staff-to-resident abuse; resident-to-resident altercations; injuries of unknown source; and misappropriation of resident property/exploitation. Reporting Staff-to-Resident Abuse All allegations/occurrences of all types of staff-to-resident abuse must be reported to the administrator who serves as the facility abuse coordinator and to other officials, including the State Survey Agency and adult protective services, where state law provides for jurisdiction in nursing homes [see § 483.12(c)]. This includes, but is not limited to: All allegations/occurrences of physical, sexual, mental, and verbal abuse, including deprivation of goods and services by staff, and involuntary seclusion perpetrated by staff (See F600 and F603 for examples of types of abuse); Staff taking or distributing demeaning or humiliating photographs or recordings of residents through social media or multimedia messaging; and All reports from residents of abuse perpetrated by staff; allegations must not be dismissed on the basis of a resident's cognitive impairment(s). Record review of the Texas HHSC Long-Term Care Regulatory Provider Letter, issues July 10,2019, reflected for an abuse incident the facility was to report immediately, but not later than two hours after the incident occurs or is suspected. An Immediate Jeopardy (IJ) was identified on 6/5/24 at 7:15 p.m. and presented to the Administrator, a plan of removal was requested. The following Plan of Removal submitted by the facility was accepted on 6/6/24 at 2:45 PM. PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On 6/5/2024 an investigation on a self-report was initiated at [Nursing Facility and address]. On 6/5/2024 at 7:15 pm, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The Immediate Jeopardy findings were identified in the following areas: F600 Freedom from Abuse. The Facility neglected to put measures in place to prevent Resident #1 from abuse. IMMEDIATE CORRECTIVE ACTIONS FOR REMOVAL OF IMMEDIATE JEOPARDY: On June 5, 2024, at approximately 6:00pm the following actions were initiated upon facility identification of concern: Patient care plan was updated to show Resident #1 has potential to demonstrate physical behaviors related to dementia. Resident #1 can become combative/agitated with care at times. IDT team reviewed and updated patient #1 Care plan on 6/5/2024 to ensure patient had an appropriate focus, goal, and patient specific interventions specific to behaviors. On 6/5/24 100% audit all patients with current behaviors had care plan updated appropriately to ensure appropriate focus goal and interventions are in place. DON/designee completed psychosocial assessment on resident #1, on 6/5/2024, patient exhibited no signs or symptoms of psychosocial distress, nor any residual psychosocial or harm or distress was related to this. CNA A contract terminated on 6/5/2024. IDENTIFICATION OF OTHER AFFECTED: DON/Designee completed an audit of all residents on 6/5/202 through head-to-toe assessments and resident interviews conducted to validate all were free from signs and symptoms of abuse. No residents were identified to have any signs or symptoms of abuse at the completion of this audit. SYSTEMIC CHANGES AND/OR MEASURES: The Administrator/designee will provide education to all staff regarding identifying types of abuse by 6/6/2024. Administrator/Designee provided education to all staff on residents' right to be free from abuse and neglect by 6/6/2024. The Administrator/Designee will provide education to all staff regarding challenging behavior care and interventions for individuals experiencing dementia by 6/6/2024. All staff to include agency and contract staff, will be in-serviced upon assignment via phone and/or in person by the Director of Nursing/Designee before taking assignment in facility regarding resident with combative behaviors. On 6/5/2024, the Clinical Corporate Resource provided education to the Director of Nursing and Administrator regarding the expectation that any staff member involved in allegations of abuse will be suspended immediately pending the outcome of further investigation. Administrator/Designee will utilize a signed staff roster to track those who have received education and to determine those who still require it. Anyone not in attendance at education sessions, as evidenced by missing signatures on the staff roster sheet, due to vacation, sick leave, or casual work status will be educated upon their return, prior to their first shift worked. Ad hoc QAPl meeting held on 6/5/2024 905 PM with IDT team and MD to review findings for immediate jeopardy. TRACKING AND MONITORING: Administrator/Designee will conduct audits of all residents for 7 days, beginning 6/5/2024 to validate that they are free of signs and symptoms of abuse in collaboration with nursing through interviews and examination. Administrator/Designee will implement interventions and education immediately if any concerns are identified with monitoring. Administrator/Designee will conduct staff interviews to determine knowledge of and competence related to: Types of Abuse. Challenging behavior care and interventions for individuals experiencing dementia. Monitoring will occur every shift for 7 days, beginning 6/5/2024, to validate staff knowledge related to Abuse and dealing with residents with challenging behaviors. The Director of Nursing/Designee will track, on a printed staff roster, evaluation of staff interview outcomes and will document corrective actions taken if it is determined that knowledge deficits exist related to types of abuse, abuse/neglect reporting requirements and/or who the designated Abuse Coordinator is. Any trends or concerns will be addressed with the Quality Assurance Performance Committee and monitoring will continue until a lessor frequency is deemed appropriate. Results of audits will be presented by the Administrator or designee at the monthly QAPI meeting with the IDT and Medical Director on or before 6/19/2024 then monthly and as needed thereafter to identify trends and sustainability, If ongoing deficiencies or concerns are noted through these audits, resident interventions and staff education will be implemented immediately. The Administrator/designee will conduct monitoring of all cases of alleged/suspected/confirmed abuse to validate that proper, timely notifications have been made to resident representatives and providers through review of nursing documentation and that involved staff have been suspended timely pending further investigation. Any concerns identified will be corrected with prompt notifications, suspension and staff education/re-education as applicable. Monitoring will occur 7 days a week by Administrator/Designee Monitoring will not be discontinued until the facility completes three consecutive rounds of monthly monitoring that demonstrate sustained compliance as approved by the QAPI committee and medical director. Additional interventions, education and monitoring will be implemented, as needed, based on the recommendations of the QAPI committee for any negative trends identified to ensure sustainability. Administrator The POR verification was accepted on 6/7/24 at 4:15 p.m. as follows: Record review of an in service dated 6/6/24 revealed 42 of 43 staff signed the in-service. LVN T had not completed the inservice because she was returning to work that night and would complete it before her shift per the Administrator. Interview on 06/07/2024 at 9:30 a.m., the Activity Director stated she received an in-service yesterday evening delivered by the ADM related to different types of abuse, the protocol of who to report to, and example of potential abuse and neglect. The Activity Director stated examples included suspicious bruising and noticing aggressive residents the expected protocol when that occurs. The Activity director affirmed understanding of the content. Interview on 06/07/2024 at 9:33 a.m., LVN F stated she received an in-service by the DON in-person yesterday that described who the ANE coordinator was, what example of abuse include, and the expected protocol when noticing potential abuse and neglect. She stated she had received training related to this same content a week prior but was trained on it frequently. She confirmed she understood the training. Interview on 06/07/2024 at 9:39 a.m., PTA J stated he received an in-service by the ADON in-person yesterday regarding abuse, resident rights, and combative residents. He stated the in-service included types of abuse and what to observe for in potential abuse allegations. He stated suspicious bruising was described as a potential concern to inform the ANE coordinator. He stated they also described the expected protocol when providing services to a combative resident was to walk away and come back with help. PTA J stated he understood the in-service. Interview on 06/07/2024 at 9:41 a.m., LVN C stated she received an in-service on abuse and types of abuse from the DON in-person. LVN C stated the in-service included types of abuse, what to look for, and expected protocol when a combative resident requires care. LVN C stated suspicious bruising was a sign to look for and to notify the ADM about. LVN C stated she understood the in-service. Interview on 06/07/2024 at 9:46 a.m., CNA K stated she was an agency CNA who had not worked at the facility in several months but stated she did receive an in-service today. CNA K stated the in-service was provided to her by the DON and discussed protocols when working with residents with behaviors. CNA K stated she was described the expected protocol was to walk away and potentially attempt care again with another staff but first to ensure the resident was safe prior to leaving. CNA K stated she understood the training. Interview on 06/07/2024 at 10:01 a.m., NA L stated she started at the facility two weeks ago but was in-serviced this morning by the DON and ADM regarding abuse, combative residents, and protocols when attempting care with these residents. NA L stated the in-service included the expected protocol to walk away during a combative episode and ensure an additional staff member was present to bear witness in the instance the resident was hurt to confirm what occurred. Interview on 06/07/2024 at 10:24 a.m., CNA H stated she received an in-service today and also last Sunday regarding abuse and neglect, but also regarding protocols when providing care to aggressive or combative residents. CNA H stated the in-service described walking away from the resident and coming back later with another staff member to provide assistance. CNA H stated the in-service also discussed example of abuse and what the expected protocol was when noticing suspicious bruising. Interview on 06/07/2024 at 10:49 a.m., COTA M stated she received an in-service this morning regarding abuse and neglect, as well as expected protocol when providing care to a resident with combative behaviors. COTA M stated she felt confident on the training and stated she received a similar training last month as well. COTA M stated the in-service gave specific description on not attempting care when a resident was aggressive and to return with another staff such as her OT at the facility. COTA M stated she had provided care to aggressive residents as recently as today and stated her action was to inform the DOR and the charge nurse of the aggressive resident so it could be monitored. Interview on 6/7/24 at 12:23 p.m. LVN G stated she received the in service on 6/6/24. She stated they went over signs of abuse, resident right, and if a resident is having an issue with staff she would go into the room to help and report anything that happened to the Administrator. Interview on 06/07/2024 at 12:27 p.m., PTA N stated she received an in-service yesterday related to abuse and neglect, and protocols when providing care to aggressive or combative residents. PTA N stated the in-service included content on the types of abuse, what action to take when noticing potential signs of abuse and neglect, and what expected protocol was when a resident begins to respond physically. PTA N stated the described practice was to attempt to redirect the resident and to return at a later time with another staff member. Interview on 6/7/24 at 12:35 p.m. CNA O stated they received the Inservice on 6/7/24. They talked to her about abuse and neglect, resident rights, and who to report abuse and neglect to. Reports it to Admin. Give the resident space if they get combative and talk to them in a low voice. Interview with LVN P at 12:45 p.m. stated she received the in service on 6/7/24. She stated she only worked at the facility about once a week and was agency. She stated they went over the types of abuse and signs of abuse. She stated they also went over resident rights. She stated when they encounter a combative resident they will try to deescalate and if that does not work then they would take a break and get a second staff. She stated because she does not have an established rapport with all the residents, she will normally get a 2nd person at all times to help. Interview on 06/07/2024 at 12:57 p.m., LVN Q, stated she worked as an agency LVN at the facility for the last two nights during the 6PM - 6AM shift and stated yesterday at the end of her shift she received an in-service regarding abuse and neglect along with protocols while providing care to residents with behaviors. LVN Q stated she understood the content of the in-service and stated she felt it was a sufficient time to discuss the content, in addition to discussing examples of non-explicit resident abuse or neglect that would require reporting to the abuse and neglect coordinator. Interview on 6/7/24 at 1:22 p.m. CNA E stated they had one Inservice over abuse and neglect her last in service was a couple days ago. While giving care to a resident if they are refusing stop your care, make sure they are safe, notify your nurse, and have a second aide with you. She would report abuse and neglect to her nurse and the Admin. Interview on 6/7/24 at 1:06 p.m. the SW stated she completed the in-service on 6/5/24. She stated the admin was the abuse coordinator and report any concerns or incidents to her. If someone was combative, we make sure they are safe and we go get help from a charge nurse. Interview on 06/07/2024 at 1:17 PM, the ADON, the ADM completed an in-service with her on the types of abuse, what the expected protocols when providing care with combative residents, ensure safety, and then to go redirect and get someone else to assist in the care. She stated the general types of abuse but included examples of potential abuse like restraints and chemical restraints. Interview with the DON on 6/7/24 at 1:26 p.m. the in-service she received was over abuse and neglect, resident rights, challenging behaviors, reporting, and investigating. If she sees or suspect any abuse to report it to the Administrator and get more details on her risk management assessments. They covered training and in servicing staff. Also, in service on the provider letter for reportable, and not reportable. For example, if the injuries are bruises, if we were not there watching it, then it's reportable. We covered distraction techniques, offering snacks, if a resident is combative make sure you leave them in a safe position and let them be, report it to the charge nurse, and try to go back at another time. It depends on what the resident was doing if they go back alone and they are fine then that was ok, or they have a resident who will not eat but will for someone else, so try different people. She will make sure everyone was in serviced before they start their shifts, and we keep asking them what they do if someone was refusing care, she was documenting the interviews or in service with staff. If she has staff involved in an incident, she will immediately suspend them pending investigation. The DON stated they canceled CNA A's contract. Interview with the Administrator 6/7/24 1:59 p.m. she did receive the services they went over resident rights, abuse, and neglect, and caring for challenging residents with behaviors. Residents have the right to be free from abuse and neglect. This was the resident's home, and we need to treat this like this is their home. The types of abuse and listed examples like physical or chemical restraints. If they do not want, you in the room or are having behaviors you make sure they are safe and step away. The clinical nurse went over reporting with them if the resident cannot tell them what happened, and we did not see and if there was an injury, they should report it. If staff is involved in an incident they will suspend them, have a verbal suspension, and they have a suspension form they can use. They plan on using a form to document if someone gets suspended now. After an allegation they will do a 1 to 1 in-service with the staff member over what the al[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation for of 8 residents (Resident #1) reviewed for neglect and abuse, in that; The facility failed to implement its abuse policy and procedures when Resident #11 obtained skin tears, brusising to hands, skin tears to his forearms, and a left-hand fracture after peri-care with CNA A. On 6/5/24 at 7:15 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed prior to exit on 6/7/24, While the IJ was removed on 6/7/24 at 09:15 PM, the facility remained out of compliance at a severity level of potential for more than minimal harm that was not immediate jeopardy and a scope of Isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk of continued victimization, abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Record review of the facility's policy, titled Facility Responsibilities for Reporting Allegations, dated 9/22, stated The following addresses facility responsibilities for reporting allegations/occurrences involving staff-to-resident abuse; resident-to-resident altercations; injuries of unknown source; and misappropriation of resident property/exploitation. Reporting Staff-to-Resident Abuse All allegations/occurrences of all types of staff-to-resident abuse must be reported to the administrator who serves as the facility abuse coordinator and to other officials, including the State Survey Agency and adult protective services, where state law provides for jurisdiction in nursing homes [see § 483.12(c)]. This includes, but is not limited to: All allegations/occurrences of physical, sexual, mental, and verbal abuse, including deprivation of goods and services by staff, and involuntary seclusion perpetrated by staff (See F600 and F603 for examples of types of abuse); Staff taking or distributing demeaning or humiliating photographs or recordings of residents through social media or multimedia messaging; and All reports from residents of abuse perpetrated by staff; allegations must not be dismissed on the basis of a resident's cognitive impairment(s). Record Review of Resident #11's admission record revealed an [AGE] year-old male initially admitted [DATE] and readmitted on [DATE] with diagnoses to include neurogenerative disorder with Lewy bodies (It is characterized by the presence of Lewy bodies-abnormal protein deposits-in the brain. These deposits affect brain chemicals, leading to problems with thinking, movement, behavior, mood, and other bodily functions), dementia (loss of thinking, remembering, and reasoning skills) without behaviors, and atherosclerotic heart disease (Plaque build-up in the arteries). Record Review of Resident #11's care plan, last updated 4/4/24, stated [Resident #11] has behaviors which include taking the linens off of his bed. He will put them on the chair at the end of his bed and cover himself with items such as the pink pad or other items that are not linens. He also puts his call light on the floor or behind his bed. He can also become combative with care at times. He does not always understand what you are trying to do. [Resident #11] will have 2 people assist them at all times. The interventions included administer medications as doctor has ordered, attempt intervention before resident behavior begins by checking frequently, fall mat at bedside while in bed, make sure resident is not in pain or uncomfortable, [Resident #11] will have two CNAs assisting him at all time, and please tell residents what you are going to do before you begin. 5/2/24 [Resident #11] has potential to demonstrate physical behaviors related to dementia. [Resident #11] can be argumentative, become agitated/ combative with care at times. With interventions to analyze key times, places, circumstance, triggers, and what escalates behavior and document, Assess and anticipate resident needs: move, thirst, toileting needs, comfort level, body positioning, pain ETC., Provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out staff member when agitated, Modify environment: reduce noise, dim light, place familiar objects in room, monitor/document/ report to MD/ hospice/ VA of danger to self or others. 3/32/23 [Resident #11] has impaired cognitive function/ dementia or impaired thought process related to diagnosis of Lewy body dementia. With interventions to ask yes/ no questions in order to determine the residence needs, communication: use the resident preferred name, identify yourself at each interaction, face the revenant in speaking and make eye contact, reduce any distractions- turn off TV, radio, closed door ETC, the resident understands consistent, simple, directive sentences, Provide the resident with necessary cues-stop and return if agitated, cue, reorient and supervise as needed. Record Review of Resident #11's quarterly MDS assessment, dated 5/16/24, reflected Resident #11 had a severely impaired cognition for daily decision making. The MDS indicated Resident #11 did not exhibit rejection of care or physical or verbal behaviors towards others such as hitting or screaming. The MDS indicated the resident was always incontinent of bowel and bladder. The MDS indicated he was dependent for ADLS including oral hygiene, toileting hygiene, shower or bathe, dressing, and personal hygiene. The MDS indicated the resident needed substantial assistance (the helper does more than half the effort) to sit to lying, lying to sit, sit to stand, and did not attempt to walk due to medical condition or safety concerns. Record review of nursing progress notes, dated 3/28/24 through 4/4/24, for Resident #11's stated the following: - 3/28/24 at 10:38 p.m. patient not cooperating with aide during brief change, patient gave himself a skin tear to right lower forearm, top of left hand, left 4th finger cleaned with wound cleanser, and covered with [bandage]. Written by LVN B. - 3/29/24 at 9:45 a.m. Skin tear top of LT (left) hand, ST (skin tear) LT (left) 4th index finger, ST to RT (right) FA (forearm), bruising to Lt hand 1st finger and pinky-finger, swelling to Rt hand .Assessed areas, limited ROM to Rt hand, X-ray ordered to hand/wrist pending X-ray, Patients description of event: unable to verbalize . written by LVN C -3/30/24 at 1:58 p.m.X-Ray to rt. hand done on 3/29/24. Tx (treatment) to all skin issues as ordered. Xray results: No acute fx (fracture/break). Or dislocation seen. mild interphalangeal (finger joints) arthrosis (degenerative arthritis that causes the breakdown of the joints) shown by small degenerative spurring (growth) . written by LVN R - 3/31/24 at 3:57 p.m. Rt hand/wrist swelling, multiple skin tears RFA, top of L hand, Lt 4TH finger .applied steri-strips (Wound closure strips are porous surgical tape strips which can be used to close small wounds. They are applied across the laceration in a manner which pulls the skin on either side of the wound together.) to all skin tears - 4ss (steri-strips) to top Lt hand and 7ss to RT FA . written by LVN C. - 4/1/24 at 2:00 p.m. Late Entry . [Hospice]RN is here with [hospice company] and ordered an x-ray to [Resident #11]'s left hand. I heard her notify [Hospice doctor], [RP], and call in the x-ray. She noted swelling and bruising to [Resident #11]'s hand. Written by the DON. - 4/2/24 at 11:50 a.m. resident presents with discoloration to both upper bilateral extremities and scratched . written by LVN S. - 4/2/24 at 4:30 p.m. Late Entry .I overheard [hospice RN] on the phone with [Hospice Doctor] and then [Medical Director] and she stated that both physicians declined to get further diagnostics. She stated that {Hospice Doctor] told her that the treatment would be the same meaning the hand splint. Written by the DON - 4/2/24 at 7:07 p.m.FX to left hand . Hospice ordered splint stabilizer for left hand fx . written by LVN S - 4/2/24 at 11:06 p.m.left hand fx with splint; multiple skin tears left hand; right hand edema . written by LVN T. -4/3/24 at 9:13 a.m. selling and bruising to the left hand. THERE IS NO CONFIRMED FRACTURE . written by the DON. Record review of x-ray results, dated 4/2/24, stated .Impression: The bones are osteoporotic (a condition where bones become thin and lose their strength, resulting in increased fragility and a higher risk of fractures.). The distal (farthest away from the center) radial (a long bone that extends from the lateral (outside) side of the elbow to the thumb side of the wrist) diametaphyseal (specific region of a long bone or wrist area) irregularity is visualized, the focal (point of) tender (where it was hurting on the resident) correlation (was the same area) and follow up are recommended to exclude a fracture. The moderate wrist and hand osteoarthritis (disorder of the joints characterized by progressive deterioration of cartilage or of the entire joint) is visualized. Record review of the NP's notes, dated 4/3/24, stated Resident #11 was seen for follow up on change in condition to his left wrist for swelling and redness. The note stated .aggressive/combative with care last week, caused some skin tears to left-hand, left-hand X-ray ordered by Hospice for swelling . X-ray resulted- cannot rule out distal radius fracture (distal radius fracture versus chronic osteoarthritis), [Hospice Dr.] Ordered splint . swelling and redness noted to left wrist. The NP ordered 500 mg of cephalexin three times a day for 10 days for cellulitis (bacterial skin infection) to the left upper arm. The medical director reviewed the notes and agreed on 4/24/24. On 6/4/24 at 4:51 p.m. LVN B was attempted by phone an interview and did not answer. On 6/5/24 at 12:00 p.m. LVN T was attempted by phone for an interview and did not answer. On 6/6/24 at 2:00 p.m. The Administrator stated LVN S no longer worked for the facility and was a disgruntled employee. During an interview on 6/5/24 at 11:02 a.m. the DON stated she became aware of the incident the morning of 3/29/24 where Resident #11 became combative during care with CNA A. She stated CNA A was interviewed by phone on 4/3/24 at 4:11 p.m. and told her the resident was combative during care and beat her up, she continued with care because he was naked. CNA A noticed the skin tears after, and reported it the charge nurse or LVN B. The DON stated the other staff working did not witness the incident and the resident was non-interviewable. The DON stated they ordered an x-ray of his right hand on 3/29/24 because most of the swelling and injuries were to his right hand. The DON stated the resident had a history of being combative with care and staff was instructed to just stop care if a resident became combative. The DON stated CNA A did not stop care and finished changing him. The DON stated CNA A still worked at the facility. The DON stated it was treated more like an injury of unknown origin than abuse and neglect because the resident had a history of arthritis and she did not think the CNA A did anything to the resident. The DON stated on 4/2/24 they did an x-ray to his left hand due to new onset swelling and it showed a possible fracture, they reported it to the state on 4/2/24. During an interview on 6/5/24 at 3:59 p.m. CNA A described Resident #11's recent behavior with care as okay after the incident on 3/28/24. CNA A stated she continued to work with Resident #11 at the nursing facility after the incident but mostly worked on the woman's side now. CNA A stated she began working for the facility in March of 2024 and Resident #11 was really combative with care but since then was more familiar with her. CNA A stated on 3/28/24 she was providing incontinent care to Resident #11. CNA A stated this resident's bed was against the wall. CNA A stated she told Resident #11 what she was about to do for care and stated, I went to turn him and put on his brief he did not want to me to change him he kept getting out of the bed. CNA A stated Resident #11 was upset that she was providing peri care and she had to keep him in the bed. CNA A stated Resident #11 let her remove his pants but when she went to put on the clean brief it went on from there. CNA A stated Resident #11 got out of the bed, grabbed her scrub top, ripped her top, and pulled her hair. The CNA A stated she kept helping Resident #11 put his legs back in the bed. She stated, I would explain to him about putting his legs back in the bed. CNA A stated she never left or called for help because she usually could get them to calm down on her own. CNA A stated the resident had no injuries after the incident. CNA A stated she did not know how the resident had injuries to his hands or arms. CNA A stated she was not suspended pending an investigation. CNA A stated she did not know why she would be suspended because that would make it sound like she did something to the resident. CNA A stated she did not have specific training after this incident for handling combative residents. She stated she had recent training after another incident at the facility not related to this resident or her. She stated they also had annual training for abuse and neglect. CNA A stated she should have called for help to have a witness for the resident's safety and her safety. During an interview on 6/5/24 at 3:10 pm. the Administrator stated the DON reported this incident, but she was aware of it. She stated they concluded that because CNA A told them Resident #11 was combative during care, she concluded he hit his hand on the wall possibly causing a fracture. The Administrator stated she could not recall if she saw the resident's injuries but if she did it was nothing she would suspect was abuse or neglect. The Administrator stated they made a police report on 4/2/24 to rule out any potential abuse. The Administrator stated they did not feel there was any abuse and there had never been any other allegation made against CNA A so she continued to work for the facility. The Administrator stated staff should take a break if a resident was resistant to care and call for help. Record review of a police report, dated 4/2/24, stated on April 2nd 2024 I officer . was dispatched . for a information report. Upon arrival I made contact with [the DON] who's stated [Resident #11] was injured sometime in the last couple of days. The [DON] when stated on the 28th staff was dealing with [Resident #11] when he suffered multiple skin tears. The [DON] stated that on this said day X-rays were taken. Results showed that [Resident #11] had a possible fractured left hand. I attempted to speak with [Resident #11], due to [Resident #11's] diagnosis I wasn't able to get side of the story. I photographed [Resident #11]'s injuries which were later uploaded to the . evidence server. The [DON] could not confirm if an assault occurred. The [DON] stated she would conduct an interview over the next few days. due to the [DON] still having to investigate the incident report is for information purposes only pending follow up by the reporting party. Record review CNA A's employee records did not contain any disciplinary forms, suspension, misconduct, or coaching forms. Record review of a document titled in service-abuse, dated 4/2/24, did not contain CNA A or LVN B's signature. Record review of the Texas HHSC Long-Term Care Regulatory Provider Letter, issues July 10,2019, reflected for an abuse incident the facility was to report immediately, but not later than two hours after the incident occurs or is suspected. An Immediate Jeopardy (IJ) was identified on 6/5/24 at 7:15 p.m. and presented to the Administrator, a plan of removal was requested. The following Plan of Removal submitted by the facility was accepted on 6/6/24 at 2:45 PM. PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it May Concern, Summary of details which leads to outcomes. On 6/5/2024 an investigation on a self-report was initiated at [Nursing Facility and address]. On 6/5/2024 at 7:15 pm, a surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The Immediate Jeopardy findings were identified in the following areas: F600 Freedom from Abuse. The Facility neglected to put measures in place to prevent Resident #1 from abuse. IMMEDIATE CORRECTIVE ACTIONS FOR REMOVAL OF IMMEDIATE JEOPARDY: On June 5, 2024, at approximately 6:00pm the following actions were initiated upon facility identification of concern: Patient care plan was updated to show Resident #1 has potential to demonstrate physical behaviors related to dementia. Resident #1 can become combative/agitated with care at times. IDT team reviewed and updated patient #1 Care plan on 6/5/2024 to ensure patient had an appropriate focus, goal, and patient specific interventions specific to behaviors. On 6/5/24 100% audit all patients with current behaviors had care plan updated appropriately to ensure appropriate focus goal and interventions are in place. DON/designee completed psychosocial assessment on resident #1, on 6/5/2024, patient exhibited no signs or symptoms of psychosocial distress, nor any residual psychosocial or harm or distress was related to this. CNA A contract terminated on 6/5/2024. IDENTIFICATION OF OTHER AFFECTED: DON/Designee completed an audit of all residents on 6/5/202 through head-to-toe assessments and resident interviews conducted to validate all were free from signs and symptoms of abuse. No residents were identified to have any signs or symptoms of abuse at the completion of this audit. SYSTEMIC CHANGES AND/OR MEASURES: The Administrator/designee will provide education to all staff regarding identifying types of abuse by 6/6/2024. Administrator/Designee provided education to all staff on residents' right to be free from abuse and neglect by 6/6/2024. The Administrator/Designee will provide education to all staff regarding challenging behavior care and interventions for individuals experiencing dementia by 6/6/2024. All staff to include agency and contract staff, will be in-serviced upon assignment via phone and/or in person by the Director of Nursing/Designee before taking assignment in facility regarding resident with combative behaviors. On 6/5/2024, the Clinical Corporate Resource provided education to the Director of Nursing and Administrator regarding the expectation that any staff member involved in allegations of abuse will be suspended immediately pending the outcome of further investigation. Administrator/Designee will utilize a signed staff roster to track those who have received education and to determine those who still require it. Anyone not in attendance at education sessions, as evidenced by missing signatures on the staff roster sheet, due to vacation, sick leave, or casual work status will be educated upon their return, prior to their first shift worked. Ad hoc QAPl meeting held on 6/5/2024 905 PM with IDT team and MD to review findings for immediate jeopardy. TRACKING AND MONITORING: Administrator/Designee will conduct audits of all residents for 7 days, beginning 6/5/2024 to validate that they are free of signs and symptoms of abuse in collaboration with nursing through interviews and examination. Administrator/Designee will implement interventions and education immediately if any concerns are identified with monitoring. Administrator/Designee will conduct staff interviews to determine knowledge of and competence related to: Types of Abuse. Challenging behavior care and interventions for individuals experiencing dementia. Monitoring will occur every shift for 7 days, beginning 6/5/2024, to validate staff knowledge related to Abuse and dealing with residents with challenging behaviors. The Director of Nursing/Designee will track, on a printed staff roster, evaluation of staff interview outcomes and will document corrective actions taken if it is determined that knowledge deficits exist related to types of abuse, abuse/neglect reporting requirements and/or who the designated Abuse Coordinator is. Any trends or concerns will be addressed with the Quality Assurance Performance Committee and monitoring will continue until a lessor frequency is deemed appropriate. Results of audits will be presented by the Administrator or designee at the monthly QAPI meeting with the IDT and Medical Director on or before 6/19/2024 then monthly and as needed thereafter to identify trends and sustainability, If ongoing deficiencies or concerns are noted through these audits, resident interventions and staff education will be implemented immediately. The Administrator/designee will conduct monitoring of all cases of alleged/suspected/confirmed abuse to validate that proper, timely notifications have been made to resident representatives and providers through review of nursing documentation and that involved staff have been suspended timely pending further investigation. Any concerns identified will be corrected with prompt notifications, suspension and staff education/re-education as applicable. Monitoring will occur 7 days a week by Administrator/Designee Monitoring will not be discontinued until the facility completes three consecutive rounds of monthly monitoring that demonstrate sustained compliance as approved by the QAPI committee and medical director. Additional interventions, education and monitoring will be implemented, as needed, based on the recommendations of the QAPI committee for any negative trends identified to ensure sustainability. Administrator The POR verification was accepted on 6/7/24 at 4:15 p.m. as follows: Record review of an in service dated 6/6/24 revealed 42 of 43 staff signed the in-service. LVN T had not completed the inservice because she was returning to work that night and would complete it before her shift per the Administrator. Interview on 06/07/2024 at 9:30 a.m., the Activity Director stated she received an in-service yesterday evening delivered by the ADM related to different types of abuse, the protocol of who to report to, and example of potential abuse and neglect. The Activity Director stated examples included suspicious bruising and noticing aggressive residents the expected protocol when that occurs. The Activity director affirmed understanding of the content. Interview on 06/07/2024 at 9:33 a.m., LVN F stated she received an in-service by the DON in-person yesterday that described who the ANE coordinator was, what example of abuse include, and the expected protocol when noticing potential abuse and neglect. She stated she had received training related to this same content a week prior but was trained on it frequently. She confirmed she understood the training. Interview on 06/07/2024 at 9:39 a.m., PTA J stated he received an in-service by the ADON in-person yesterday regarding abuse, resident rights, and combative residents. He stated the in-service included types of abuse and what to observe for in potential abuse allegations. He stated suspicious bruising was described as a potential concern to inform the ANE coordinator. He stated they also described the expected protocol when providing services to a combative resident was to walk away and come back with help. PTA J stated he understood the in-service. Interview on 06/07/2024 at 9:41 a.m., LVN C stated she received an in-service on abuse and types of abuse from the DON in-person. LVN C stated the in-service included types of abuse, what to look for, and expected protocol when a combative resident requires care. LVN C stated suspicious bruising was a sign to look for and to notify the ADM about. LVN C stated she understood the in-service. Interview on 06/07/2024 at 9:46 a.m., CNA K stated she was an agency CNA who had not worked at the facility in several months but stated she did receive an in-service today. CNA K stated the in-service was provided to her by the DON and discussed protocols when working with residents with behaviors. CNA K stated she was described the expected protocol was to walk away and potentially attempt care again with another staff but first to ensure the resident was safe prior to leaving. CNA K stated she understood the training. Interview on 06/07/2024 at 10:01 a.m., NA L stated she started at the facility two weeks ago but was in-serviced this morning by the DON and ADM regarding abuse, combative residents, and protocols when attempting care with these residents. NA L stated the in-service included the expected protocol to walk away during a combative episode and ensure an additional staff member was present to bear witness in the instance the resident was hurt to confirm what occurred. Interview on 06/07/2024 at 10:24 a.m., CNA H stated she received an in-service today and also last Sunday regarding abuse and neglect, but also regarding protocols when providing care to aggressive or combative residents. CNA H stated the in-service described walking away from the resident and coming back later with another staff member to provide assistance. CNA H stated the in-service also discussed example of abuse and what the expected protocol was when noticing suspicious bruising. Interview on 06/07/2024 at 10:49 a.m., COTA M stated she received an in-service this morning regarding abuse and neglect, as well as expected protocol when providing care to a resident with combative behaviors. COTA M stated she felt confident on the training and stated she received a similar training last month as well. COTA M stated the in-service gave specific description on not attempting care when a resident was aggressive and to return with another staff such as her OT at the facility. COTA M stated she had provided care to aggressive residents as recently as today and stated her action was to inform the DOR and the charge nurse of the aggressive resident so it could be monitored. Interview on 6/7/24 at 12:23 p.m. LVN G stated she received the in service on 6/6/24. She stated they went over signs of abuse, resident right, and if a resident is having an issue with staff she would go into the room to help and report anything that happened to the Administrator. Interview on 06/07/2024 at 12:27 p.m., PTA N stated she received an in-service yesterday related to abuse and neglect, and protocols when providing care to aggressive or combative residents. PTA N stated the in-service included content on the types of abuse, what action to take when noticing potential signs of abuse and neglect, and what expected protocol was when a resident begins to respond physically. PTA N stated the described practice was to attempt to redirect the resident and to return at a later time with another staff member. Interview on 6/7/24 at 12:35 p.m. CNA O stated they received the Inservice on 6/7/24. They talked to her about abuse and neglect, resident rights, and who to report abuse and neglect to. Reports it to Admin. Give the resident space if they get combative and talk to them in a low voice. Interview with LVN P at 12:45 p.m. stated she received the in service on 6/7/24. She stated she only worked at the facility about once a week and was agency. She stated they went over the types of abuse and signs of abuse. She stated they also went over resident rights. She stated when they encounter a combative resident they will try to deescalate and if that does not work then they would take a break and get a second staff. She stated because she does not have an established rapport with all the residents, she will normally get a 2nd person at all times to help. Interview on 06/07/2024 at 12:57 p.m., LVN Q, stated she worked as an agency LVN at the facility for the last two nights during the 6PM - 6AM shift and stated yesterday at the end of her shift she received an in-service regarding abuse and neglect along with protocols while providing care to residents with behaviors. LVN Q stated she understood the content of the in-service and stated she felt it was a sufficient time to discuss the content, in addition to discussing examples of non-explicit resident abuse or neglect that would require reporting to the abuse and neglect coordinator. Interview on 6/7/24 at 1:22 p.m. CNA E stated they had one Inservice over abuse and neglect her last in service was a couple days ago. While giving care to a resident if they are refusing stop your care, make sure they are safe, notify your nurse, and have a second aide with you. She would report abuse and neglect to her nurse and the Admin. Interview on 6/7/24 at 1:06 p.m. the SW stated she completed the in-service on 6/5/24. She stated the admin was the abuse coordinator and report any concerns or incidents to her. If someone was combative, we make sure they are safe and we go get help from a charge nurse. Interview on 06/07/2024 at 1:17 PM, the ADON, the ADM completed an in-service with her on the types of abuse, what the expected protocols when providing care with combative residents, ensure safety, and then to go redirect and get someone else to assist in the care. She stated the general types of abuse but included examples of potential abuse like restraints and chemical restraints. Interview with the DON on 6/7/24 at 1:26 p.m. the in-service she received was over abuse and neglect, resident rights, challenging behaviors, reporting, and investigating. If she sees or suspect any abuse to report it to the Administrator and get more details on her risk management assessments. They covered training and in servicing staff. Also, in service on the provider letter for reportable, and not reportable. For example, if the injuries are bruises, if we were not there watching it, then it's reportable. We covered distraction techniques, offering snacks, if a resident is combative make sure you leave them in a safe position and let them be, report it to the charge nurse, and try to go back at another time. It depends on what the resident was doing if they go back alone and they are fine then that was ok, or they have a resident who will not eat but will for someone else, so try different people. She will make sure everyone was in serviced before they start their shifts, and we keep asking them what they do if someone was refusing care, she was documenting the interviews or in service with staff. If she has staff involved in an incident, she will immediately suspend them pending investigation. The DON stated they canceled CNA A's contract. Interview with the Administrator 6/7/24 1:59 p.m. she did receive the services they went over resident rights, abuse, and neglect, and caring for challenging residents with behaviors. Residents have the right to be free from abuse and neglect. This was the resident's home, and we need to treat this like this is their home. The types of abuse and listed examples like physical or chemical restraints. If they do not want, you in the room or are having behaviors you make sure they are safe and step away. The clinical nurse went over reporting with them if the resident cannot tell them what happened, and we did not see and if there was an injury, they should report it. If staff is involved in an incident they will suspend them, have a verbal suspension, and they have a suspension form they can use. They plan on using a form to document if someone gets suspended now. After an allegation they will do a 1 to 1 in-service with the staff member over what the allegation was and training and document it with their signature. She will c[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 2 of 8 residents (Residents #1 and Resident #5) reviewed for abuse, in that: 1. The facility failed to ensure Resident #1 was free from physical abuse when RN A and NA H restrained the resident using a gait belt wrapped around the resident's abdomen from 10/08/2023 to 3/01/2024 and secured to his wheelchair behind the resident to prevent the resident from standing, used furniture to prevent movement by Resident #1 in his wheelchair and emotional abuse from RN A. 2. The facility failed to ensure Resident's #1 and #5 were free from verbal abuse when RN A used derogatory language and profanity directed at the residents. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 4/18/2024 at 5:27 p.m. The IJ template was provided to the facility on 4/18/2024 at 5:31 p.m. While the IJ was removed on 4/21/2024 the facility remained out of compliance at a level of potential harm with a scope identified as pattern until interventions were put in place to ensure staff members were in compliance with identifying and reporting abuse. These failures could place residents at risk of physical, mental and emotional decline, psychosocial harm and physical injury and could result in a decline in isolation and withdrawal and result in a decline in health. The findings included: 1. Record review of Form 3613 -A, Provider Investigative Report dated 3/08/2024 and signed by the Administrator revealed an allegation of abuse was confirmed. The report indicated on 3/01/2024 a CNA (unidentified) alleged RN A used a gait belt to keep a resident in the wheelchair and used profanity when she spoke to a resident. The report indicated Resident #1 was the victim. The report also indicated RN A told Resident #5 to shut the f%&$ up but Resident #5 was unable to recall foul language. Record review of a photocopy of text conversation (undated) between the DON and RN A revealed the DON sent a text to RN A that indicated she had been trying to reach RN A by phone to let her know she was suspended pending investigation because it was reported she used a gait belt to restrain Resident #1 and profanity when speaking to Resident #5. The DON indicated in the text she had to report it to state. RN A responded by asking if she should go to work on Monday and Tuesday. RN A stated, I did use a gait belt, but I don't recall using profanity with any resident .sorry about the belt but I was just trying to keep him from falling. The DON responded by telling RN A not to go to work Monday or Tuesday. This document was signed by the DON. Record review of a handwritten document dated 3/01/2024 and signed by the DON revealed agency CNA B called her (the DON) and told her RN A on the night shift was using a gait belt to restrain Resident #1 in his wheelchair at night. The document indicated CNA B could not give specific dates or times. Record review of a handwritten document dated 3/04/2024 and signed by the DON revealed CNA D stated she had witnessed RN A use a gait belt to restrain Resident #1 in his wheelchair. The document indicated CNA D could not remember exact dates and times and stated CNA D did not report it because she was scared of retaliation from RN A. Record review of a handwritten document dated 3/04/2024 and signed by the DON revealed CNA N stated she had witnessed RN A use a gait belt to restrain Resident #1 at night. She stated she did not report it because she was afraid of retaliation and could not remember exact dates and times. Record review of Resident #1's face sheet dated 4/15/2024 revealed an admission date of 1/21/2021 with readmission date of 4/15/2024 with diagnoses which included: dementia moderate with behavioral disturbance, unsteadiness on feet and generalized muscle weakness. Record review of Resident #1's significant change MDS assessment dated [DATE] revealed a BIMS score of could not be assessed because the resident was rarely or never understood. The assessment indicated Resident #1 required moderate assistance to go from sitting to standing, moderate assistance to walk and was totally dependent on staff for ADL care. The assessment indicated Resident #1 had two or more falls since admission to the facility and no restraints were being used. Record review of Resident #1's Care Plan for falls dated 9/28/2023 revealed a revision 2/21/2024 for an intervention which included that Resident #1 would be seated in the front dining room within eyesight when not in his bed. Also, on 2/21/2024 an intervention was added that read Resident #1 will have seat belt attached to wheelchair and must be locked when in wheelchair and seatbelt must be released every 2 hours, it was revised on 2/26/2024 and removed from the active care plan. Record review of Resident #1's Care Plan for elopement dated 8/11/2021 revealed the resident liked to wander and was disoriented to place, had impaired safety awareness and a cognitive impairment and had verbalized wanting to leave the facility with a history of wandering which included: distract Resident #1 by offering pleasant diversions, structured activities, food, conversation, television, book. Resident #1 prefers to socialize with peers in common area. Record review of the Resident #1's consents revealed there were no consents for physical restraints. Record review of Resident #1's physician orders history from admission to current revealed no orders for restraints. During an observation/interview on 4/15/2024 at 10:16 p.m. revealed there were no residents in the main common area or near the nurse's station. The facility lights were low, and the atmosphere was calm/quiet. CNA B was observed near the nurse's station in the hallway. CNA B stated Resident #1 had returned from the hospital today and had been confused and combative with staff which she described as normal behavior for the resident. CNA B stated Resident #1 kept wandering to different hallways saying he was going to beat someone up. She stated she approached him in a calm way, redirected him and just talked to him which was how she was trained to respond. She stated although he was confused, she eventually got him to bed. During an observation on 4/15/2024 at 10:19 p.m., Resident #1 was observed on a low bed, with fall mat in place. The resident was sleeping and had the covers pulled up over his head. During an observation on 4/15/2024 at 10:45 p.m., Resident #1 remained asleep in his bed. During an observation/interview on 4/16/2024 at 3:26 p.m., Resident #1 was observed seated in his wheelchair in the main front living/dining area nearest the nurse's station. Resident #1 moved almost constantly and kept scooting up toward the edge of his wheelchair where he was redirected calmly by staff . Resident #1 was alert and smiled when spoken to but did not respond when questions were asked. Resident #1 did not have any obvious injuries. During an observation on evening shift at 4/16/2024 at 8:22 p.m., Resident #1 was observed asleep in his bed with the covers over his head, low bed with fall mat in place. During an interview on 4/16/2024 at 10:04 a.m., the DON stated she was the facility ADON until 1/01/2024 when she became the DON. She stated Resident #1 had a fall history and had run out of new interventions to try. She stated after every fall she updated Resident #1's care plan. She stated the most effective intervention was to keep Resident #1 within eyesight. She stated on 4/04/2024 she put a goal for him to be up in his wheelchair out of his room when awake to prevent Resident #1 from ambulating unassisted. The DON stated there was no pattern of time for the falls because they happened on every shift. She stated the falls were not happening with one particular staff person. She stated she had terminated RN A on night shift for restraining Resident #1 in his wheelchair with a gait belt. The DON stated Resident #1 was more active on night shift. The DON stated she did have enough staff to care for him. She stated he was so unsteady on his feet that by the time the staff saw him stand up it was too late. The DON stated she did not know how often or how many days Resident #1 was restrained. The DON stated when she asked staff about it she could not get a good answer. The DON stated the staff said they did not report the restraint earlier because they were scared of retaliation. The DON stated the facility did discuss restraining Resident #1 because a family member brought it up. The family member wanted Resident #1 restrained. The DON stated she briefly added restraint to Resident #1's care plan, but he never had an order for restraint. She stated they presented it to their legal team, and it did not pass through. She stated legal said, absolutely not. The DON stated she never got as far as assessing Resident #1 to see if he could undo a seatbelt in the wheelchair because it never got that far. She stated RN A was not using a seatbelt she was using a gait belt as a restraint, and he could not undo it. The DON stated the facility did not have cameras in the facility. The DON stated RN A admitted to doing it but would not give a time frame, or an exact date. The DON stated RN A admitted to restraining Resident #1 2-3 times, but she was very vague. 2. Record review of Resident #5's face sheet dated 4/18/2024 revealed an admission date of 4/07/2021 with diagnoses which included: Alzheimer's disease, psychotic disorder with delusions due to known physiological condition and recurrent major depressive disorder. Record review of Resident #5's quarterly MDS assessment dated [DATE] revealed a BIMS score of 6 which indicated a severe cognitive impairment. Record review of Resident #5's annual MDS assessment dated [DATE] revealed a BIMS score was not assessed. Record review of Resident #5's Care Plan dated last revised on 3/27/2023 revealed Resident #5 sometimes had behaviors which included shouting with interventions which included: attempt interventions before behavior escalates, make sure resident not in pain or uncomfortable. Record review of Resident #5's psychosocial assessment dated [DATE] revealed Resident #5's memory recall included staff faces and names and that he was in a facility. The assessment indicated the resident understand his surroundings and had severely impaired decision-making skills and socially inappropriate behaviors with a note anxiety, yells, prefers to be alone in room The assessment revealed Resident denies that anyone has told him anything to upset him. During on observation on 4/15/2024 at 10:25 p.m., Resident #5 was observed sleeping in bed, low bed, fall mat in place. During an interview on 4/17/2024 at 3:17 p.m., the DON stated none of the residents in the facility were reliable for an interview due to dementia. She stated all residents in the facility had a diagnosis of dementia with memory issues. She stated some of the residents also had hallucinations/delusions and would not be able to give a reliable interview regarding restraint/abuse. The DON stated RN A worked night shift from 6 pm to 6 am. She stated she had two witnesses who worked from 6 pm to 10 pm who confirmed the allegations of abuse against RN A, CNA C and CNA D . The DON stated she initially suspended RN A when the allegation surfaces (date unknown) but right away she thought she was going to have to let RN A go. The DON stated since RN A admitted the allegation , they let her go. The DON stated there would have been a bigger investigation had she denied the allegations. The DON stated RN A told her she was the only person who restrained a resident, but she was really vague. The DON stated she asked RN A about the times and dates, but RN A did not know how long it had occurred. The DON stated she interviewed Resident #5 about the verbal abuse , and he said everyone was nice to him, but he could not remember, and he had no complaints from other residents. She stated she interviewed CNA E who worked for an agency, but she denied seeing abuse and the other regular staff member (unknown name) said she didn't see it either. The DON stated on 3/01/2024 when she received the allegations of abuse, she had approximately 31 staff. She stated she in-serviced 19 of those staff on abuse and neglect. The DON stated when she called the meeting for the in-service CNA F (night shift) had worked the whole week and she did her a favor by picking up extra shifts, so she excused CNA F from the in-service and the other person (CNA E) from night shift was an agency person. The DON stated agency staff had their own in-services through their agency. She stated if the agency staff are in the building when the meeting was called, they would attend. The DON stated she did not in-service night shift staff because she does not see the night shift people because they occur during the daytime . The DON stated as part of the abuse investigation she completed a skin assessment of Resident #1 and found no new skin conditions . During an observation/interview on 4/17/2024 at 3:30 p.m., Resident #5 was seated on his bed with his clothes thrown on the floor beside him. There were no visible injuries noted. Resident #5 stated he was fine. He stated he had lived at the facility for 74 years (which showed confusion) and was stated he did not know who any of the people were in the numerous personal photos posted near his bed on the wall. Resident #5 had a childlike demeanor. He was unable to answer detailed interview questions and did not have memory recall of answer questions about past events. During an interview on 4/17/2024 at 3:46 p.m., CNA B stated she worked for a staffing agency and first began working at the facility in August 2023. CNA B stated on 3/01/2024 (unknown time) she notified the DON via text that she needed to talk to her. CNA B stated CNA E notified the DON by talking to her and text that RN A was doing stuff to the residents on the same night. CNA B stated she did not talk to the DON about what was occurring until the next morning which was 3/01/2024 when the DON came to the facility. CNA B stated Resident #1 wandered and would go into rooms. She stated RN A did not want him to wander so he started to get aggressive. She stated he was pulling on the handrails and kicking. CNA B stated RN A told the CNA's to go get a gait belt and tie Resident #1 down. CNA B stated we (CNA B and CNA E) told her they were not going to do it. CNA B stated CNA E took RN A a gait belt and gave it to her (RN A) but CNA E did not use it. CNA B stated RN A stated fine, it was going to be on her anyways (meaning she was the one who would get in trouble), like RN A did not care and tied him down anyway. CNA B stated the DON asked her the dates and it was two shifts prior so it would have been on 2/28/2024 around med pass time which was approximately 8:00 p.m. CNA B stated she also told the DON it really bothered her that RN A wanted to restrain Resident #1. She stated she also let the DON know it was not the first time. CNA B stated she did not tell the DON because she forgot about it until now, but RN A would also get the big couch in the main living area and block the entrance to prevent Resident #1 from coming out of the room. CNA B stated she knew that was also a restraint. She stated Resident #1 knew he could not get out of the room, so he just sat there in his wheelchair. She stated RN A stated she wanted to keep him there because he was wandering and trying to get into rooms, and she did not want him to move while she was sitting down and the CNA's were down the halls working. CNA B stated one day, (date unknown) Resident #1 was having a good day and was in a good mood. He looked at RN A and stated, I love you and RN A looked right at him and stated, I hate you. CNA B stated it really broke her heart. She stated she told RN A wow and just walked off. CNA B stated Resident #1 did not say anything, but he knew. She stated she could see it in his eyes that he knew. CNA B stated one night (date unknown) Resident #5 could smell her dinner when she was warming it up and he yelled he wanted a cheeseburger. CNA B stated RN A yelled Shut the fuck up. CNA B stated Resident #5 was in his room and got quiet. CNA B stated after she reported it to the DON a lot of other staff started talking. These were not one day events. No one had wanted to report it. She stated CNA E and CNA K both had talked about the abuse, and both had information. CNA B stated she wrote a witness statement. She stated a lot of staff wrote witness statements to the DON. CNA B stated she had not spoken to the Administrator and did not even know who the Administrator was. She stated she was trained to report abuse which was what she did. CNA B stated after this event there was a training. She stated they were told to read and sign something, but she could not remember what it was about. During an interview on 4/17/2024 at 4:11 p.m., CNA D stated she was regular full-time staff at the facility. She stated she did not work with RN A often. CNA D stated RN A was loud, and she was rude, but she never saw abuse. CNA D stated the handwritten statement written by the DON was not accurate. CNA D stated when the DON called her and asked her about the gait belt on Resident #1, she told the DON, no. CNA D stated she thought the DON misunderstood her. CNA D stated RN A did ask her to put a gait belt on as a restraint on Resident #1, but she did not understand what the meant. CNA D stated she responded to RN A by telling her she was going to lay him down in bed. She stated she did lay him down and he stayed in bed. CNA D stated RN A told her to get the gait belt because Resident #1 was trying to walk. She stated this occurred before 9:30 p.m. because she did her last rounds at 9:30 p.m. and left by 10:00 p.m. She stated this occurs sometimes before Christmas. She stated she thought it was somewhere between October and November 2023. She stated it was hard to remember the dates. CNA D stated she did not think using a gait belt to restrain Resident #1 was abuse. She stated she did not understand. She stated it was not until the DON told her what was going on (unknown date) and there were other reports of abuse and the use of restraint by RN A that she told the DON what she knew about RN A. CNA D stated she never saw any other resident with a gait belt on or a restraint. She stated RN A was just rude and loud. She would tell the residents things like it's enough already. CNA D stated it was not the way she personally would talk to the residents, but it was not abusive. She stated she never heard RN A cuss at a resident. CNA D stated after the events they had a meeting where they talked about restraint, abuse, and neglect but she could not remember what was taught. She stated they had to watch some videos and take a quiz. She stated she was trained to report abuse immediately to the Administrator. During an interview on 4/17/2024 at 4:31 p.m., CNA E stated she worked with an agency and had worked at the facility regularly for 3-4 months, mostly on the weekends with RN A. CNA E stated RN A told her Resident #1 was problematic and aggressive. CNA E stated RN A told her the facility used a gait belt restrain on him because he was a fall risk and did not sit still. CNA E stated she asked RN A if there was a doctor's order for the restraint and she said no. CNA E stated once she learned there was no doctors order she no longer assisted. CNA E stated RN A stated it was okay to use it because she was going to take the fall for it (she was the one who would get in trouble). CNA E stated she took pictures and sent them to her agency and also told the DON about it. CNA E stated she did not want to work at the facility anymore because of it. CNA E stated it was just Resident #1 that she was witness to. She stated she did not have knowledge of any other residents. CNA E stated there were other aides who assisted in strapping Resident #1 down, including NA H . She stated she could not remember the names of the other aides. She stated Resident #1 would not cooperate with RN A. He would try to go from sitting to standing. She stated it was the way RN A spoke to Resident #1, he would regularly hit RN A and be aggressive with her. CNA E stated RN A would tie Resident #1 down by putting him either in his wheelchair or a regular chair and she would loop the gait belt around his abdomen and then loop the buckle in the back where he would not reach it or untie it. CNA E stated RN A would put the gait belt on pretty tight. CNA E stated LVN L, a morning nurse asked about the redness on Resident #1's abdomen and she told the nurse RN A straps Resident #1 down. She stated LVN L asked me additional information and then asked if she had informed the DON. CNA E stated LVN L said there were no orders for restraint. CNA E stated she told the DON the third time she saw it. She stated this started in January 2023. She stated she told the DON, RN A makes her do things she was not supposed to do. She stated she told the DON on the week of 2/23/2024-2/27/2024 but was not sure the exact day. She stated she also talked on the phone with the DON on 2/11/2024-2/12/2024 about it. She stated the DON was surprised and listened to her side of the story. She stated after she initially told the DON on 2/11/2024-2/12/2024, RN A called the DON and complained about her. CNA E stated she specifically told the DON she (RN A) strapped Resident #1 down with a gait belt word for word. CNA E stated the DON stated she would talk to RN A. CNA E stated RN A was not sent home and continued to work at the facility. She stated multiple other staff also reported it to the DON (unknown staff, unknown dates). CNA E stated RN A was verbally abusive to residents as well. She stated she was nasty and unkind to Resident #5. CNA E stated RN A would say shut up and fuck off to the residents. She stated or RN A would tell them they smell, or they were not loved. CNA E stated she told the DON she would never work with RN A again. CNA E stated She stated she was trained to report abuse to her agency. She stated her agency was a data base and she entered it into the data base but could not remember when this occurred, she stated she thought she reported it to her agency in January 2023. During an interview on 4/17/2024 at 5:11 p.m., CNA N stated on a Monday in February 2024 she stayed over from day shift to work until 10 p.m. with RN A and agency CNA E. She stated on that Monday, CNA E told her RN A was making the aides put Resident #1 in a chair with a gait belt. She stated they strapped him to the chair like a restraint and then was mean to the residents telling them to shut up and called them stupid. CNA N stated CNA E told her RN A and CNA E got into and she called the DON. CNA N stated on Tuesday, the next day she again stayed until 10 p.m. with RN A. She stated Resident #1 was in the front main living/dining room area trying to stand up. CNA N stated RN A was passing meds and could see Resident #1 from where she was standing. CNA N stated RN A yelled at her to grab Resident #1 and then get a gait belt and put it around him. CNA N stated she told RN A no. CNA N stated RN A yanked the gait belt out of her hand and stated she was doing it herself. CNA N stated she again told RN A no, and told her she would sit with Resident #1 so he would not need a restraint. CNA N stated RN A tried to put the gait belt around Resident #1, but she (CNA N) put her hand out and stopped RN A from wrapping it around him. CNA N demonstrated how RN A took the gait belt and reached around the front of the resident with the gait belt with intentions to strap it around his abdomen and secure it in the back. CNA N stated she believes if she had not been there to stop her RN A would have strapped Resident #1 down with the gait belt. CNA A stated RN A walked off. CNA N stated she asked CNA E and CNA G what had happened with RN A. She stated they told her RN A had asked them to put a gait belt restraint on Resident #1 and they did because RN A told them to. CNA N stated on Friday, RN A was still working at the facility, and said she guessed it was not a big deal and she was not in trouble because someone had told on her and she was still working. CNA N stated she let the DON and the Administrator know what RN A said about not getting in trouble. She stated that was on a Friday (date unknown). CNA N stated it then became a big deal and she has not seen RN A since. CNA N stated to her knowledge no other residents were not involved. CNA N stated RN A was not verbally the nicest, but more like she was inconvenienced by the residents rather than abusive towards them. CNA N stated she never heard name called. She stated RN A did use profanity but not directed towards the residents. CNA N stated the first time she told anyone about it was that Friday 3/01/2024. She stated CNA E was very upset about the way RN A was treating the residents. CNA N stated she told the DON and the Administrator together what she had witnessed. She stated she also told the DON and Administrator that RN A was walking around making fun of it, like it was a big joke that she had been doing it and was not getting in any trouble. She stated RN A was slamming drawers on the med carts around the residents. She stated she told all of this to management. CNA N stated Resident #1 did not seem up set because of his dementia but some of the staff was upset about it, including CNA E. She stated the residents do not understand because of their dementia. CNA N stated she had been trained to report abuse to the Administrator immediately. She stated she waited to report it because CNA E stated she had already reported it and at that point she had not seen it herself. She stated when RN A tried it, she was able to stop her. CNA N stated by Friday, 3/01/2024 she decided they needed to hear her side of the story. She stated she did not see any injuries to Resident #1. She stated management responded by saying there would be a state investigation. CNA N stated she was not asked to write a witness statement from facility management. She stated she would be willing to write out her version on a piece of paper in front of this surveyor for proof. During an interview on 4/17/2024 at 6:10 p.m., the ADON was presented as a witness by the DON. The ADON stated CNA D told her she did see RN A strap Resident #1 to a chair with a gait belt but because RN A was a registered nurse, she did not report it because Who are they going to believe a RN or a CNA? The ADON stated CNA D stated she actually witnessed it and told the ADON approximately one month ago. The ADON stated she was a charge nurse when this occurred and did not become the ADON until 3/01/2024. The ADON stated the first time she knew anything about the situation was when all the chatter started about it when the facility reported it to state (3/01/2024). She stated she hard NA H and CNA C talk about it, but this was after it was already reported. The ADON stated she never heard any residents complain and did not see any change in any resident behaviors. The ADON stated restraint was abuse. The ADON stated she heard RN A state things like go over there or leave that alone in a loud voice but never heard her cuss or call a resident a name. She stated she never heard RN A raise her voice at a resident, she just used a loud voice. The ADON stated she has come to assist night shift before when they needed help but did not know where that was. She stated it was to do extra work. She stated she was new to the job and was still training. The ADON stated there had never been a discussion between management staff about monitoring night shift. The ADON stated she was not responsible for training any of the staff. During an observation and interview on 4/17/2024 at 6:35 p.m., the Maintenance Director measured the opening of the main living area to be 93 inches and the couch in the main living area was 74 inches. When placed in the middle of the doorway there was a 4.5 inch opening on each side of the couch which was too small for wither a wheelchair or a person to be able to walk through. The Maintenance Director stated there used to be two couches in the main living area, but one was thrown away on an unknown date. During an interview on 4/17/2024 at 6:45 p.m. CNA F stated she was regular full-time staff at the facility and worked many extra shifts. CNA F stated she saw Resident #1 restrained by RN A with her own eyes. CNA F stated RN A stated it was for his own protection. CNA F stated RN A stated she knew it was wrong and she knew she was going to take the blame for it. CNA F stated she saw RN A get a gait belt out of the closet because she kept having to get Resident #1 to sit down. CNA F stated RN A stated she could not keep watching him, so she strapped him down for his own safety. CNA F stated RN A used the gait belt across Resident #1's stomach and buckled in behind the resident in the back. CNA F stated Resident #1 responded by just sitting there. She stated he fiddled with it but did not scream or holler and did not try to get out. CNA F stated Resident #1 normally tried to stand up and his was off balance. CNA F denied participating in strapping Resident #1 to the chair or seeing any other staff member doing it. She stated she did witness RN A applying the straps. CNA F stated CNA E got in a heated exchange of words with RN A about strapping Resident #1 down. CNA F stated she could not remember when this occurred. She stated she could not remember what months this occurs. She stated she saw it maybe 2-3 times. She stated she thought the first time she saw it was before Christmas, but she could not be sure. CNA F stated she never reported it because RN A stated she was going to take the blame for it. CNA F stated she knows restraint was a form of abuse. She stated she did not report the abuse because she relied on RN A's word that she was going to take the blame. CNA F stated she knows she should have reported it. CNA F denied knowledge of any other resident abuse. She denied knowledge of verbal/emotional abuse. CNA F stated RN A had a very hard deep voice, a very strong voice. She stated when RN A spoke at the nurses station, she could be heard all the way down at the end of the hall but it was not in a disrespectful way. CNA F stated RN A was a really good nurse. CNA F stated she did see RN move the couch and put in blocking the entrance/exit of the main living room to keep Resident #1 from getting out of the room. CNA F stated they normally work with one nurse and two aides at night. She stated they would all take turns watching the residents. She stated some of the residents do not sleep at night and there had been some chaotic nights. She stated on the chaotic nights they still made sure the residents needs were met. CNA F stated she did not complete the abuse training in-service after the incident and still had not completed it as of this interview. She stated she worked to help the DON out by working an extra shift and the DON gave her permission to be excluded from the abuse class. CNA F stated she had taken abuse training in the past and she had been trained to report restraint, abuse including physical, verbal and sexual abuse immediately to the Administrator. During an interview on 4/17/2024 at 7:10 p.m. LVN J stated there were two-night shift nurses. She was one of them and RN A was the other one. She stated they did not work on the same nights. LVN J stated she had no knowledge of the restraint of Resident #1 or any other resident. She stated she learned about it when RN A was fired. She stated she knows RN A worked a lot of hours and did not have full time aides and was given agency staff to work with. LVN J stated it was not RN A's fault. She stated RN A did they best she could. LVN J stated the facility was a restraint free facility. She stated they could not use restraints because it was a dignity issue, and the residents could hurt themselves if restrained. She stat[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents are free from physical or chemical restraints imposed for purpose of discipline or convenience and that are required to treat the resident's medical symptoms for 1 of 8 (Resident #1) residents reviewed for restraint, in that; The facility failed to ensure that Resident #1 was free from restraint when RN A and NA H tied Resident #1 to a wheelchair with a gait belt wrapped around his abdomen and secured behind the resident out of reach and by using furniture to block his movement while in the wheelchair on multiple occasions from 10/082023-03/01/2024. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 4/18/2023 at 5:27 p.m. The IJ template was provided to the facility on 4/18/2024 at 5:31 p.m. While the IJ was removed on 4/21/2024 the facility remained out of compliance at a level of potential harm with a scope identified as pattern until interventions were put in place to ensure staff members were in compliance with identifying and reporting abuse. This failure could affect residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm. The findings included: 1. Record review of Form 3613-A, Provider Investigative Report dated 3/08/2024 and signed by the Administrator revealed an allegation of abuse was confirmed. The report indicated on 3/01/2024 a CNA alleged RN A used a gait belt to keep a resident in the wheelchair. The report indicated Resident #1 was the victim. Record review of a photocopy of text conversation between the DON and RN A (undated) revealed the DON sent a text to RN A that indicated she had been trying to reach RN A by phone to let her know she was suspended pending investigation because it was reported she used a gait belt to restrain Resident #1 . The DON indicated she had to report it to state. RN A responded by asking if she should go to work on Monday and Tuesday. RN A stated, I did use a gait belt .sorry about the belt but I was just trying to keep him from falling. The DON responded by telling RN A not to go to work Monday or Tuesday. This document was signed by the DON. Record review of a handwritten document dated 3/01/2024 and signed by the DON revealed agency CNA B called her (the DON) and told her RN A on the night shift was using a gait belt to restrain Resident #1 in his wheelchair at night. The document indicated CNA B could not give specific dates or times. Record review of a handwritten document dated 3/04/2024 and signed by the DON revealed CNA D stated she had witnessed RN A use a gait belt to restrain Resident #1 in his wheelchair. The document indicated CNA D could not remember exact dates and times and stated CNA did not report it because she was scared of retaliation from RN A. Record review of a handwritten document dated 3/04/2024 and signed by the DON revealed CNA N stated she had witnessed RN A use a gait belt to restrain Resident #1 at night. She stated she did not report it because she was afraid of retaliation and could not remember exact dates and times. Record review of Resident #1's face sheet dated 4/15/2024 revealed an admission date of 1/21/2021 with readmission date of 4/15/2024 with diagnoses which included: dementia moderate with behavioral disturbance, unsteadiness on feet and generalized muscle weakness. Record review of Resident #1's significant change MDS assessment dated [DATE] revealed a BIMS score of could not be assessed because the resident was rarely or never understood. The assessment indicated Resident #1 required moderate assistance to go from sitting to standing, moderate assistance to walk and was totally dependent on staff for ADL care. The assessment indicated Resident #1 had two or more falls since admission to the facility and no restraints were being used. Record review of Resident #1's Care Plan for falls dated 9/28/2023 revealed a revision 2/21/2024 for an intervention which included that Resident #1 would be seated in the front dining room within eyesight when not in his bed. Also, on 2/21/2024 an intervention was added that read Resident #1 will have seat belt attached to wheelchair and must be locked when in wheelchair and seatbelt must be released every 2 hours, it was revised on 2/26/2024 and removed from the active care plan. Record review of Resident #1's Care Plan for elopement dated 8/11/2021 revealed the resident liked to wander and was disoriented to place, had impaired safety awareness and a cognitive impairment and had verbalized wanting to leave the facility with a history of wandering which included: distract Resident #1 by offering pleasant diversions, structured activities, food, conversation, television, book. Resident #1 prefers to socialize with peers in common area. Record review of the Resident #1's consents revealed there were no consents for physical restraints. Record review of Resident #1's physician orders history from admission to current revealed no orders for restraints. During an observation/interview on 4/15/2024 at 10:16 p.m. revealed there were no residents in the main common area or near the nurse's station. The facility lights were low, and the atmosphere was calm/quiet. CNA B was observed near the nurse's station in the hallway. CNA B stated Resident #1 had returned from the hospital today and had been confused and combative with staff which she described as normal behavior for the resident. CNA B stated Resident #1 kept wandering to different hallways saying he was going to beat someone up. She stated she approached him in a calm way, redirected him and just talked to him which was how she was trained to respond. She stated although he was confused, she eventually got him to bed. During an observation on 4/15/2024 at 10:19 p.m., Resident #1 was observed on a low bed, with fall mat in place. The resident was sleeping and had the covers pulled up over his head. During an observation on 4/15/2024 at 10:45 p.m., Resident #1 remained asleep in his bed. During an observation/interview on 4/16/2024 at 3:26 p.m., Resident #1 was observed seated in his wheelchair in the main front living/dining area nearest the nurse's station. Resident #1 moved almost constantly and kept scooting up toward the edge of his wheelchair where he was redirected calmly by staff. Resident #1 was alert and smiled when spoken to but did not respond when questions were asked. Resident #1 did not have any obvious injuries. During an observation on evening shift at 4/16/2024 at 8:22 p.m., Resident #1 was observed asleep in his bed with the covers over his head, low bed with fall mat in place. During an interview on 4/16/2024 at 10:04 a.m., the DON stated she was the facility ADON until 1/01/2024 when she became the DON. She stated Resident #1 had a fall history and had run out of new interventions to try. She stated after every fall she updated Resident #1's care plan. She stated the most effective intervention was to keep Resident #1 within eyesight. She stated on 4/04/2024 she put a goal for him to be up in his wheelchair out of his room when awake to prevent Resident #1 from ambulating unassisted. The DON stated there was no pattern of time for the falls because they happened on every shift. She stated the falls were not happening with one particular staff person. She stated she had terminated RN A on night shift for restraining Resident #1 in his wheelchair with a gait belt. The DON stated Resident #1 was more active on night shift. The DON stated she did have enough staff to care for him. She stated he was so unsteady on his feet that by the time the staff saw him stand up it was too late. The DON stated she did not know how often or how many days Resident #1 was restrained. The DON stated when she asked staff about it, she could not get a good answer. The DON stated the staff said they did not report the restraint earlier because they were scared of retaliation. The DON stated the facility did discuss restraining Resident #1 because a family member brought it up. The family member wanted Resident #1 restrained. The DON stated she briefly added restraint to Resident #1's care plan, but he never had an order for restraint. She stated they presented it to their legal team, and it did not pass through. She stated legal said, absolutely not. The DON stated she never got as far as assessing Resident #1 to see if he could undo a seatbelt in the wheelchair because it never got that far. She stated RN A was not using a seatbelt she was using a gait belt as a restraint, and he could not undo it. The DON stated the facility did not have cameras in the facility. The DON stated RN A admitted to doing it but would not give a time frame, or an exact date. The DON stated RN A admitted to restraining Resident #1 2-3 times, but she was very vague. During an interview on 4/17/2024 at 3:17 p.m., the DON stated none of the residents in the facility were reliable for an interview due to dementia. She stated all residents in the facility had a diagnosis of dementia with memory issues. She stated some of the residents also had hallucinations/delusions and would not be able to give a reliable interview regarding restraint/abuse. The DON stated RN A worked night shift from 6 pm to 6 am. She stated she had two witnesses who worked from 6 pm to 10 pm who confirmed the allegations of abuse against RN A, CNA C and CNA D. The DON stated she initially suspended RN A when the allegation surfaces (date unknown) but right away she thought she was going to have to let RN A go. The DON stated since RN A admitted the allegation, they let her go. The DON stated there would have been a bigger investigation had she denied the allegations. The DON stated RN A told her she was the only person who restrained a resident, but she was really vague. The DON stated she asked RN A about the times and dates, but RN A did not know how long it had occurred. She stated she interviewed CNA E who worked for an agency, but she denied seeing abuse and the other regular staff member (unknown name) said she didn't see it either. The DON stated on 3/01/2024 when she received the allegations of abuse, she had approximately 31 staff. She stated she in-serviced 19 of those staff on abuse and neglect. The DON stated when she called the meeting for the in-service CNA F (night shift) had worked the whole week and she did her a favor by picking up extra shifts, so she excused CNA F from the in-service and the other person (CNA E) from night shift was an agency person. The DON stated agency staff had their own in-services through their agency. She stated if the agency staff are in the building when the meeting was called, they would attend. The DON stated she did not in-service night shift staff because she does not see the night shift people because they occur during the daytime. The DON stated as part of the abuse investigation she completed a skin assessment of Resident #1 and found no new skin conditions. During an interview on 4/17/2024 at 3:46 p.m., CNA B stated she worked for a staffing agency and first began working at the facility in August 2023. CNA B stated on 3/01/2024 (unknown time) she notified the DON via text that she needed to talk to her. CNA B stated CNA E notified the DON by talking to her and text that RN A was doing stuff to the residents on the same night. CNA B stated she did not talk to the DON about what was occurring until the next morning which was 3/01/2024 when the DON came to the facility. CNA B stated Resident #1 wandered and would go into rooms. She stated RN A did not want him to wander so he started to get aggressive. She stated he was pulling on the handrails and kicking. CNA B stated RN A told the CNAs to go get a gait belt and tie Resident #1 down. CNA B stated we (CNA B and CNA E) told her they were not going to do it. She stated CNA E took RN A a gait belt and gave it to her but CNA E did not use it. CNA B stated RN A stated fine, it was going to be on her anyways (meaning she was the one who would get in trouble), like she did not care and tied him down anyway. CNA B stated the DON asked her the dates and it was two shifts prior so it would have been on 2/28/2024 around med pass time which was approximately 8:00 p.m. CNA B stated she also told the DON; it really bothered her that RN A wanted to restrain Resident #1. She stated she also let the DON know it was not the first time. CNA B stated she did not tell the DON because she forgot about it until now, but RN A would also get the big couch in the main living area and block the entrance to prevent Resident #1 from coming out of the room. CNA B stated she knew that was also a restraint. She stated Resident #1 knew he could not get out of the room, so he just sat there in his wheelchair. She stated RN A stated she wanted to keep him there because he was wandering and trying to get into rooms, and she did not want him to move while she was sitting down and the CNAs were down the halls working. She stated, these were not one day events. No one had wanted to report it. She stated CNA E and CNA K both had talked about the abuse, and both had information. CNA B stated she wrote a witness statement. She stated a lot of staff wrote witness statements to the DON. CNA B stated she had not spoken to the Administrator and did not even know who the Administrator was. She stated she was trained to report abuse which is what she did. CNA B stated after this event there was a training. She stated they were told to read and sign something, but she could not remember what it was about. During an interview on 4/17/2024 at 4:11 p.m., CNA D stated she was regular full-time staff at the facility. She stated she did not work with RN A often. CNA D stated RN A was loud, and she was rude, but she never saw abuse. CNA D stated the handwritten statement written by the DON was not accurate. CNA D stated when the DON called her and asked her about the gait belt on Resident #1, she told the DON, no. CNA D stated she thought the DON misunderstood her. CNA D stated RN A did ask her to put a gait belt on as a restraint on Resident #1 but she did not understand what the meant. CNA D stated she responded to RN A by telling her she was going to lay him down in bed. She stated she did lay him down and he stayed in bed. CNA D stated RN A told her to get the gait belt because Resident #1 was trying to walk. She stated this occurred before 9:30 p.m. because she did her last rounds at 9:30 p.m. and left by 10:00 p.m. She stated this occurs sometimes before Christmas. She stated she thought it was somewhere between October and November 2023. She stated it was hard to remember the dates. CNA D stated she did not think using a gait belt to restrain Resident #1 was abuse. She stated she did not understand. She stated it was not until the DON told her what was going on (unknown date) and there were other reports of abuse and the use of restraint by RN A that she told the DON what she knew about RN A. CNA D stated she never saw any other resident with a gait belt on or a restraint. CNA D stated after the events they had a meeting where they talked about restraint, abuse, and neglect but she could not remember what was taught. She stated they had to watch some videos and take a quiz. She stated she was trained to report abuse immediately to the Administrator. During an interview on 4/17/2024 at 4:31 p.m., CNA E stated she worked with an agency and had worked at the facility regularly for 3-4 months, mostly on the weekends with RN A. CNA E stated RN A told her Resident #1 was problematic and aggressive. CNA E stated RN A told her the facility used a gait belt restrain on him because he was a fall risk and did not sit still. CNA E stated she asked RN A if there was a doctor's order for the restraint and she said no. CNA E stated once she learned there was no doctors order she no longer assisted. CNA E stated RN A stated it was okay to use it because she was going to take the fall for it (she was the one who would get in trouble). CNA E stated she took pictures and sent them to her agency and also told the DON about it. CNA E stated she did not want to work at the facility anymore because of it. CNA E stated it was just Resident #1 that she was witness to. She stated she did not have knowledge of any other residents. CNA E stated there were other aides who assisted in strapping Resident #1 down, including NA H. She stated she could not remember the names of the other aides. She stated Resident #1 would not cooperate with RN A. He would try to go from sitting to standing. She stated it was the way RN A spoke to Resident #1, he would regularly hit RN A and be aggressive with her. CNA E stated RN A would tie Resident #1 down by putting him either in his wheelchair or a regular chair and she would loop the gait belt around his abdomen and then loop the buckle in the back where he would not reach it or untie it. CNA E stated RN A would put the gait belt on pretty tight. CNA E stated LVN L, a morning nurse asked about the redness on Resident #1's abdomen, and she told the nurse RN A straps Resident #1 down. She stated LVN L asked me additional information and then asked if she had informed the DON. CNA E stated LVN L said there were no orders for restraint. CNA E stated she told the DON the third time she saw it. She stated this started in January 2023. She stated she told the DON; RN A made her do things she was not supposed to do. She stated she told the DON on the week of 2/23/2024-2/27/2024 but was not sure the exact day. She stated she also talked on the phone with the DON on 2/11/2024-2/12/2024 about it. She stated the DON was surprised and listened to her side of the story. She stated after she initially told the DON on 2/11/2024-2/12/2024, RN A called the DON and complained about her. CNA E stated she specifically told the DON She (RN A) strapped Resident #1 down with a gait belt word for word. CNA E stated the DON stated she would talk to RN A. CNA E stated RN A was not sent home and continued to work at the facility. She stated multiple other staff also reported it to the DON (unknown staff, unknown dates). CNA E stated She stated she was trained to report abuse to her agency. She stated her agency was a data base and she entered it into the data base but could not remember when this occurred, she stated she thought she reported it to her agency in January 2023. During an interview on 4/17/2024 at 5:11 p.m., CNA N stated on a Monday in February 2024 she stayed over from day shift to work until 10 p.m. with RN A and agency CNA E. She stated on that Monday, CNA E told her RN A was making the aides put Resident #1 in a chair with a gait belt. She stated they strapped him to the chair like a restraint. CNA N stated CNA E told her RN A and CNA E got into and she called the DON. CNA N stated on Tuesday, the next day she again stayed until 10 p.m. with RN A. She stated Resident #1 was in the front main living/dining room area trying to stand up. CNA N stated RN A was passing meds and could see Resident #1 from where she was standing. CNA N stated RN A yelled at her to grab Resident #1 and then get a gait belt and put it around him. CNA N stated she told RN A no. CNA N stated RN A yanked the gait belt out of her hand and stated she was doing it herself. CNA N stated she again told RN A no and told her she would sit with Resident #1 so he would not need a restraint. CNA N stated RN A tried to put the gait belt around Resident #1, but she (CNA N) put her hand out and stopped RN A from wrapping it around him. CNA N demonstrated how RN A took the gait belt and reached around the front of the resident with the gait belt with intentions to strap it around his abdomen and secure it in the back. CNA N stated she believes if she had not been there to stop her RN A would have strapped Resident #1 down with the gait belt. CNA A stated RN A walked off. CNA N stated she asked CNA E and CNA G what had happened with RN A. She stated they told her RN A had asked them to put a gait belt restraint on Resident #1 and they did because RN A told them to. CNA N stated on Friday, RN A was still working at the facility, and said she guessed it was not a big deal and she was not in trouble because someone had told on her and she was still working. CNA N stated she let the DON and the Administrator know what RN A said about not getting in trouble. She stated that was on a Friday (3/01/2024). CNA N stated it then became a big deal and she has not seen RN A since. CNA N stated to her knowledge no other residents were not involved. She stated CNA E was very upset about the way RN A was treating the residents. CNA N stated she told the DON and the Administrator together what she had witnessed. She stated she also told the DON and Administrator that RN A was walking around making fun of it, like it was a big joke that she had been doing it and was not getting in any trouble. She stated she told all of this to management. CNA N stated Resident #1 did not seem upset because of his dementia but some of the staff was upset about it, including CNA E. She stated the residents do not understand because of their dementia. CNA N stated she had been trained to report abuse to the Administrator immediately. She stated she waited to report it because CNA E stated she had already reported it and at that point she had not seen it herself. She stated when RN A tried it, she was able to stop her. CNA N stated by Friday, 3/01/2024 she decided they needed to hear her side of the story. She stated she did not see any injuries to Resident #1. She stated management responded by saying there would be a state investigation. CNA N stated she was not asked to write a witness statement from facility management. She stated she would be willing to write out her version on a piece of paper in front of this surveyor for proof. During an interview on 4/17/2024 at 6:10 p.m., the ADON was presented as a witness by the DON. The ADON stated CNA D told her she did see RN A strap Resident #1 to a chair with a gait belt but because RN A was a registered nurse, she did not report it because Who are they going to believe a RN or a CNA? The ADON stated CNA D stated she actually witnessed it and told the ADON approximately one month ago. The ADON stated she was a charge nurse when this occurred and did not become the ADON until 3/01/2024. The ADON stated the first time she knew anything about the situation was when all the chatter started about it when the facility reported it to state (3/01/2024). She stated she heard NA H and CNA C talk about it, but this was after it was already reported. The ADON stated she never heard any residents complain and did not see any change in any resident behaviors. The ADON stated restraint was abuse. The ADON stated she has come to assist night shift before when they needed help but did not know where that was. She stated it was to do extra work. She stated she was new to the job and was still training. The ADON stated there had never been a discussion between management staff about monitoring night shift. The ADON stated she was not responsible for training any of the staff. During an observation/interview on 4/17/2024 at 6:35 p.m., the Maintenance Director measured the opening of the main living area to be 93 inches and the couch in the main living area was 74 inches. When placed in the middle of the doorway there was a 4.5 inch opening on each side of the couch which was too small for wither a wheelchair or a person to be able to walk through. The Maintenance Director stated there used to be two couches in the main living area, but one was thrown away on an unknown date. During an interview on 4/17/2024 at 6:45 p.m. CNA F stated she was regular full-time staff at the facility and worked many extra shifts. CNA F stated she saw Resident #1 restrained by RN A with her own eyes. CNA F stated RN A stated it was for his own protection. CNA F stated RN A stated she knew it was wrong and she knew she was going to take the blame for it. CNA F stated she saw RN A get a gait belt out of the closet because she kept having to get Resident #1 to sit down. CNA F stated RN A stated she could not keep watching him, so she strapped him down for his own safety. CNA F stated RN A used the gait belt across Resident #1's stomach and buckled in behind the resident in the back. CNA F stated Resident #1 responded by just sitting there. She stated he fiddled with it but did not cream or holler and did not try to get out. CNA F stated Resident #1 normally tried to stand up and his was off balance. CNA F denied participating in strapping Resident #1 to the chair or seeing any other staff member doing it. She stated she did witness RN A applying the straps. CNA F stated CNA E got in a heated exchange of words with RN A about strapping Resident #1 down. CNA F stated she could not remember when this occurred. She stated she could not remember what months this occurs. She stated she saw it maybe 2-3 times. She stated she thought the first time she saw it was before Christmas, but she could not be sure. CNA F stated she never reported it because RN A stated she was going to take the blame for it. CNA F stated she knows restraint was a form of abuse. She stated she did not report the abuse because she relied on RN A's word that she was going to take the blame. CNA F stated she knows she should have reported it. CNA F denied knowledge of any other resident abuse. CNA F stated RN A was a really good nurse. CNA F stated she did see RN move the couch and put in blocking the entrance/exit of the main living room to keep Resident #1 from getting out of the room. CNA F stated they normally work with one nurse and two aides at night. She stated they would all take turns watching the residents. She stated some of the residents do not sleep at night and there had been some chaotic nights. She stated on the chaotic nights they still made sure the residents needs were met. CAN F stated she did not complete the abuse training in-service after the incident and still had not completed it as of this interview. She stated worked to help the DON out by working an extra shift and the DON gave her permission to be excluded from the abuse class. CNA F stated she had taken abuse training in the past and she had been trained to report restraint, abuse including physical, verbal and sexual abuse immediately to the Administrator. During an interview on 4/17/2024 at 7:10 p.m. LVN J stated there were two-night shift nurses. She was one of them and RN A was the other one. She stated they did not work on the same nights. LVN J stated she had no knowledge of the restraint of Resident #1 or any other resident. She stated she learned about it when RN A was fired. She stated she knows RN A worked a lot of hours and did not have full time aides and was given agency staff to work with. LVN J stated it was not RN A's fault. She stated RN A did they best she could. LVN J stated the facility was a restraint free facility. She stated they could not use restraints because it was a dignity issue, and the residents could hurt themselves if restrained. She stated she was trained to report abuse, including restraint to the Administrator immediately. During an interview on 4/17/2024 at 7:19 p.m., CNA K stated she worked for an agency. She stated she had worked with RN A. CNA K stated RN A was a little rude and did not move much. She stated RN A passed meds and then would just sit at the desk. CNA K stated RN A never asked her to put a restraint or use a gait belt on a resident. She stated she never saw one put on a resident but did hear RN A state she was going to have to put a gait belt on Resident #1 to keep him in his wheelchair so he would not fall. CNA K stated she tried to just keep to herself and not pay attention. She stated she really did not have any knowledge and for the most part RN A was alright with her. She stated she could not really remember working at the facility when asked if she had reported it. She replied I don't remember to all further questions about details and training and declined further interview. During an interview on 4/17/2024 at 7:24 p.m., CNA G stated she was full time staff at the facility. She stated the very first time she worked nights at the facility, a Saturday night (2/10/2024-2/11/2024), RN A asked NA H to put a gait belt around Resident #1. CNA G stated NA H physically put the gait belt around the resident clasping it in the back. CNA G stated she asked NA H what she was doing it and NA H stated she was restraining Resident #1. CNA G stated had asked RN A if there were doctor's order and she said no, it was just the way she did it so he would not have any falls. CNA G stated she told NA H she had to take it off Resident #1 because there were no doctor's orders and NA H said no. CNA G stated she knew it was against the law to restrain residents in the state of Texas. She stated CNA E and RN A got in an argument over it. CNA G stated it just did not sit right with her and felt like the DON would have told her if they were supposed to restrain Resident #1. CNA G stated CNA E said it had happened before and that she had reported it to her agency. CNA G stated RN A got really upset with her when she told her to take it off. CNA G stated she asked CNA E to help her take it off Resident #1. She stated RN A told her and CNA E if we touched Resident #1, we would get in trouble. CNA G stated CNA E and RN A got in a screaming match and a lot of abuse things were said by both parties. She stated both CNA E and RN A were calling the DON trying to resolve it. CNA G stated she told the DON about the gait belt. She stated she was not able to hear the DON's response. She stated while CNA E was talking to the DON on the phone RN A continued yelling at CNA E. CNA G stated she did hear CNA E tell the DON that RN A placed a gait belt around Resident #1 and that she told NA H to do it to. CNA G stated she heard CNA E tell the DON that she (CNA G) had taken it off. CNA G stated she does not know what was said after that point because CNA E had to go outside to continue the conversation because RN A was yelling. CNA G stated after this happened everything calmed down and she took Resident #1 to bed. CNA G stated when she came back to work on Sunday (date unknown) RN A tried to do it again. She stated RN A told NA H to do it and this time NA H refused. CNA G stated RN A said if ya'll are not going to do it then she was going to do it. CNA G stated she told RN A no and told her she was just going to lay Resident #1 down in bed. CNA G stated RN A stated if he stays in bed then that is perfect. CNA G stated she never witnessed RN A physically put the gait belt on Resident #1 but she did witness her tell NA H to do it. She stated those were the only two days she worked with RN A. She stated she told the DON she was not going to work with RN A anymore because of it and moved to working day shift. CNA G stated this occurred on Super Bowl weekend 2/11/2024. She stated she worked both 2/10/2024 and 2/11/2024. CNA G stated after CNA E reported the restraint to the DON, RN A stayed at the facility and worked the whole shift. She stated no one went home. She stated the DON never came to the facility that night. CNA G stated she was new to the facility at the time and did not have anyone's phone numbers to report it but she knew CNA E reported it. She stated CNA E showed her where she had reported it (to her agency) multiple times, 3 times in total on the portal. She stated after this occurred the facility eventually put phone numbers up to report abuse. CNA G stated RN A continued to work in at the facility until sometimes in March (date unknown). CNA G denied knowledge of abuse or restraint of any other resident. She stated it was just Resident #1. She stated Resident #1 looked really confused by the restraint and he was trying to fight it. She stated he did not know why he could not get up. She stated it was tied around him like a seat belt. She stated he was trying to get up and stand up which was causing the wheelchair to move forward with him. She stated it was almost making the wheelchair fall over while he was trying to stand up. CNA G stated it looked really weird. She stated RN A then[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation for 1 of 8 residents (Resident #1) reviewed for restraint and abuse, in that; The facility failed to develop and implement and abuse policy that clearly defines restraint as abuse and ensure staff had the knowledge of how and where to report allegations of restraint and abuse. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 4/18/2023 at 5:27 p.m. The IJ template was provided to the facility on 4/18/2024 at 5:31 p.m. While the IJ was removed on 4/21/2024 the facility remained out of compliance at a level of potential harm with a scope identified as isolated until interventions were put in place to ensure staff members were in compliance with identifying and reporting abuse. This failure could place all residents at risk for potential abuse due to restraint due to unreported restraint and abuse and result in continued abuse, physical harm, psychosocial harm and a decline in health and potential for injury. The findings included: Record review of a facility policy titled Abuse and Neglect-Clinical Protocol dated 2022 revealed: 1. Abuse is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enable through the use of technology. 2. The nurse will report findings to the physician. As needed, the physician will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear. The policy did not identify or define restraint as a form of abuse. Record review of a facility policy titled Recognizing Signs and Symptoms of Abuse/Neglect undated revealed To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing Services Immediately. This policy contradicts other evidence including an interview with the Administrator who identified herself as the abuse coordinator. Record review of Form 3613-A Provider Investigative Report dated 3/08/2024 and signed by the Administrator revealed an allegation of abuse was confirmed. The report indicated on 3/01/2024 a CNA alleged RN A used a gait belt to keep a resident in the wheelchair and used profanity when she spoke to a resident. The report indicated Resident #1 was the victim. Record review of Resident #1's face sheet dated 4/15/2024 revealed an admission date of 1/21/2021 with readmission date of 4/15/2024 with diagnoses which included: dementia moderate with behavioral disturbance, unsteadiness on feet and generalized muscle weakness. Record review of Resident #1's significant change MDS assessment dated [DATE] revealed a BIMS score of could not be assessed because the resident was rarely or never understood. The assessment indicated Resident #1 required moderate assistance to go from sitting to standing, moderate assistance to walk and was totally dependent on staff for ADL care. The assessment indicated Resident #1 had two or more falls since admission to the facility and no restraints were being used. Record review of Resident #1's Care Plan for falls dated 9/28/2023 revealed a revision 2/21/2024 for an intervention which included that Resident #1 would be seated in the front dining room within eyesight when not in his bed. Also, on 2/21/2024 an intervention was added that read Resident #1 will have seat belt attached to wheelchair and must be locked when in wheelchair and seatbelt must be released every 2 hours, it was revised on 2/26/2024 and removed from the active care plan. Record review of Resident #1's Care Plan for elopement dated 8/11/2021 revealed the resident liked to wander and was disoriented to place, had impaired safety awareness and a cognitive impairment, and had verbalized wanting to leave the facility with a history of wandering which included: distract Resident #1 by offering pleasant diversions, structured activities, food, conversation, television, book. Resident #1 prefers to socialize with peers in common area. Record review of the Resident #1's consents revealed there were no consents for physical restraints. Record review of Resident #1's physician orders history from admission to current revealed no orders for restraints. During an interview on 4/16/2024 at 10:04 a.m., the DON stated she had terminated RN A on night shift for restraining Resident #1 in his wheelchair with a gait belt. The DON stated Resident #1 was more active on night shift. She stated he was so unsteady on his feet that by the time the staff saw him stand up it was too late. The DON stated she did not know how often or how many days Resident #1 was restrained. The DON stated when she asked staff about it, she could not get a good answer. The DON stated the staff said they did not report the restraint earlier because they were scared of retaliation. The DON stated the facility did discuss restraining Resident #1 because a family member brought it up. The family member wanted Resident #1 restrained. The DON stated she briefly added restraint to Resident #1's care plan, but he never had an order for restraint. She stated they presented it to their legal team and it did not pass through. She stated legal said, absolutely not. The DON stated she never got as far as assessing Resident #1 to see if he could undo a seatbelt in the wheelchair because it never got that far. She stated RN A was not using a seatbelt she was using a gait belt as a restraint, and he could not undo it. The DON stated the facility did not have cameras in the facility. The DON stated RN A admitted to doing it but would not give a time frame, or an exact date. The DON stated RN A admitted to restraining Resident #1 two to three times, but she was very vague. During an interview on 4/17/2024 at 3:17 p.m., the DON stated RN A worked night shift from 6 pm to 6 am. She stated she had two witnesses who worked from 6 pm to 10 pm who confirmed the allegations of abuse against RN A were CNA C and CNA D. The DON stated she initially suspended RN A when the allegation surfaces (date unknown) but right away she thought she was going to have to let RN A go. The DON stated since RN A admitted the allegation, they let her go. The DON stated RN A told her she was the only person who restrained a resident, but she was really vague. The DON stated she asked RN A about the times and dates, but RN A did not know how long it had occurred. During an interview on 4/17/2024 at 3:46 p.m., CNA B stated on 3/01/2024 (unknown time) she notified the DON via text that she needed to talk to her. CNA B stated CNA E notified the DON by talking to her and text that RN A was doing stuff to the residents on the same night. CNA B stated she did not talk to the DON about what was occurring until the next morning which was 3/01/2024 when the DON came to the facility. CNA B stated Resident #1 wandered and would go into rooms. She stated RN A did not want him to wander so he started to get aggressive. She stated he was pulling on the handrails and kicking. CNA B stated RN A told the CNAs to go get a gait belt and tie Resident #1 down. CNA B stated we (CNA B and CNA E) told her they were not going to do it. She stated CNA E took RN A a gait belt and gave it to her, but CNA E did not use it. CNA B stated RN A stated fine, it was going to be on her anyways (meaning she was the one who would get in trouble), like she did not care and tied him down anyway. CNA B stated the DON asked her the dates and it was two shifts prior so it would have been on 2/28/2024 around med pass time which was approximately 8:00 p.m. CNA B stated she also told the DON; it really bothered her that RN A wanted to restrain Resident #1. She stated she also let the DON know it was not the first time. CNA B stated she did not tell the DON because she forgot about it until now, but RN A would also get the big couch in the main living area and block the entrance to prevent Resident #1 from coming out of the room. CNA B stated she knew that was also a restraint. She stated Resident #1 knew he could not get out of the room, so he just sat there in his wheelchair. She stated RN A stated she wanted to keep him there because he was wandering and trying to get into rooms, and she did not want him to move while she was sitting down, and the CNAs were down the halls working. CNA B stated she had not spoken to the Administrator and did not even know who the Administrator was. She stated she was trained to report abuse which is what she did (to the DON). During an interview on 4/17/2024 at 4:11 p.m., CNA D stated she did not think using a gait belt to restrain Resident #1 was abuse. She stated she did not understand. She stated RN A did ask her to put a gait belt on as a restraint on Resident #1 but she did not understand what the meant. CNA D stated she responded to RN A by telling her she was going to lay him down in bed. She stated she did lay him down and he stayed in bed. CNA D stated RN A told her to get the gait belt because Resident #1 was trying to walk. She stated this occurred before 9:30 p.m. because she did her last rounds at 9:30 p.m. and left by 10:00 p.m. She stated this occurs sometimes before Christmas. She stated she thought it was somewhere between October and November 2023. She stated it was hard to remember the dates She stated it was not until the DON told her what was going on (unknown date) and there were other reports of abuse and the use of restraint by RN A that she told the DON what she knew about RN A. CNA D stated she never saw any other resident with a gait belt on or a restraint. CNA D stated after the events they had a meeting where they talked about restraint, abuse, and neglect but she could not remember what was taught. She stated they had to watch some videos and take a quiz. She stated she was trained to report abuse immediately to the Administrator. During an interview on 4/17/2024 at 4:31 p.m., agency CNA E stated she was trained to report abuse to her agency. CNA E stated RN A told her Resident #1 was problematic and aggressive. CNA E stated RN A told her the facility used a gait belt restrain on him because he was a fall risk and did not sit still. CNA E stated she asked RN A if there was a doctor's order for the restraint and she said no. CNA E stated once she learned there was no doctors order she no longer assisted. CNA E stated RN A stated it was okay to use it because she was going to take the fall for it (she was the one who would get in trouble). CNA E stated she took pictures and sent them to her agency and also told the DON about it. CNA E stated she did not want to work at the facility anymore because of it. CNA E stated it was just Resident #1 that she was witness to. She stated she did not have knowledge of any other residents. CNA E stated there were other aides who assisted in strapping Resident #1 down, including NA H. She stated she could not remember the names of the other aides. She stated Resident #1 would not cooperate with RN A. He would try to go from sitting to standing. She stated it was the way RN A spoke to Resident #1, he would regularly hit RN A and be aggressive with her. CNA E stated RN A would tie Resident #1 down by putting him either in his wheelchair or a regular chair and she would loop the gait belt around his abdomen and then loop the buckle in the back where he would not reach it or untie it. CNA E stated RN A would put the gait belt on pretty tight. CNA E stated LVN L, a morning nurse asked about the redness on Resident #1's abdomen, and she told the nurse RN A straps Resident #1 down. She stated LVN L asked me additional information and then asked if she had informed the DON. CNA E stated LVN L said there were no orders for restraint. CNA E stated she told the DON the third time she saw it. She stated this started in January 2023. She stated she told the DON; RN A makes her do things she was not supposed to do. She stated she told the DON on the week of 2/23/2024-2/27/2024 but was not sure the exact day. She stated she also talked on the phone with the DON on 2/11/2024-2/12/2024 about it. She stated the DON was surprised and listened to her side of the story. She stated after she initially told the DON on 2/11/2024-2/12/2024, RN A called the DON and complained about her. CNA E stated she specifically told the DON she (RN A) strapped Resident #1 down with a gait belt word for word. CNA E stated the DON stated she would talk to RN A. CNA E stated RN A was not sent home and continued to work at the facility. She stated multiple other staff also reported it to the DON (unknown staff, unknown dates). She stated she thought she reported it to her agency in January 2023. During an interview on 4/17/2024 at 5:11 p.m., CNA N stated she reported the restraint of Resident #1 on Friday 3/01/2024 to the DON and Administrator together after having knowledge of it for several days. She stated on a Monday in February 2024 she stayed over from day shift to work until 10 p.m. with RN A and agency CNA E. She stated on that Monday, CNA E told her RN A was making the aides put Resident #1 in a chair with a gait belt. She stated they strapped him to the chair like a restraint and then was mean to the residents telling them to shut up and called them stupid. CNA N stated CNA E told her RN A and CNA E got into and she called the DON. CNA N stated on Tuesday, the next day she again stayed until 10 p.m. with RN A. She stated Resident #1 was in the front main living/dining room area trying to stand up. CNA N stated RN A was passing meds and could see Resident #1 from where she was standing. CNA N stated RN A yelled at her to grab Resident #1 and then get a gait belt and put it around him. CNA N stated she told RN A no. CNA N stated RN A yanked the gait belt out of her hand and stated she was doing it herself. CNA N stated she again told RN A no and told her she would sit with Resident #1 so he would not need a restraint. CNA N stated RN A tried to put the gait belt around Resident #1, but she (CNA N) put her hand out and stopped RN A from wrapping it around him. CNA N demonstrated how RN A took the gait belt and reached around the front of the resident with the gait belt with intentions to strap it around his abdomen and secure it in the back. CNA N stated she believes if she had not been there to stop her RN A would have strapped Resident #1 down with the gait belt. CNA A stated RN A walked off. CNA N stated she asked CNA E and CNA G what had happened with RN A. She stated they told her RN A had asked them to put a gait belt restraint on Resident #1 and they did because RN A told them to. CNA N stated on Friday, RN A was still working at the facility, and said she guessed it was not a big deal and she was not in trouble because someone had told on her and she was still working. CNA N stated she let the DON and the Administrator know what RN A said about not getting in trouble. She stated that was on a Friday (3/01/2024). CNA N stated it then became a big deal and she has not seen RN A since. CNA N stated to her knowledge no other residents were not involved. CNA N stated RN A was not verbally the nicest, but more like she was inconvenienced by the residents rather than abusive towards them. CNA N stated she never heard name called. She stated RN A did use profanity but not directed towards the residents. CNA N stated the first time she told anyone about it was that Friday 3/01/2024. She stated CNA E was very upset about the way RN A was treating the residents. CNA N stated she told the DON and the Administrator together what she had witnessed. She stated she also told the DON and Administrator that RN A was walking around making fun of it, like it was a big joke that she had been doing it and was not getting in any trouble. She stated RN A was slamming drawers on the med carts around the residents. She stated she told all of this to management. CNA N stated Resident #1 did not seem upset because of his dementia but some of the staff was upset about it, including CNA E. She stated the residents do not understand because of their dementia. CNA N stated she had been trained to report abuse to the Administrator immediately. She stated she waited to report it because CNA E stated she had already reported it and at that point she had not seen it herself. She stated when RN A tried it, she was able to stop her. CNA N stated by Friday, 3/01/2024 she decided they needed to hear her side of the story. She stated management responded by saying there would be a state investigation. During an interview on 4/17/2024 at 6:45 p.m. CNA F stated she had taken abuse training in the past and she had been trained to report restraint, abuse including physical, verbal, and sexual abuse immediately to the Administrator. CNA F stated she saw Resident #1 restrained by RN A with her own eyes. CNA F stated RN A stated it was for his own protection. CNA F stated RN A stated she knew it was wrong and she knew she was going to take the blame for it. CNA F stated she saw RN A get a gait belt out of the closet because she kept having to get Resident #1 to sit down. CNA F stated RN A stated she could not keep watching him, so she strapped him down for his own safety. CNA F stated RN A used the gait belt across Resident #1's stomach and buckled in behind the resident in the back. CNA F stated Resident #1 responded by just sitting there. She stated he fiddled with it but did not cream or holler and did not try to get out. CNA F stated Resident #1 normally tried to stand up and his was off balance. CNA F denied participating in strapping Resident #1 to the chair or seeing any other staff member doing it. She stated she did witness RN A applying the straps. CNA F stated CNA E got in a heated exchange of words with RN A about strapping Resident #1 down. CNA F stated she could not remember when this occurred. She stated she could not remember what months this occurs. She stated she saw it maybe 2-3 times. She stated she thought the first time she saw it was before Christmas, but she could not be sure. CNA F stated she never reported it because RN A stated she was going to take the blame for it. CNA F stated she knows restraint was a form of abuse. She stated she did not report the abuse because she relied on RN A's word that she was going to take the blame. CNA F stated she knows she should have reported it. CNA F stated she did see RN move the couch and put in blocking the entrance/exit of the main living room to keep Resident #1 from getting out of the room. CNA F stated she knows she should have reported it. During an interview on 4/17/2024 at 7:10 p.m. LVN J stated she was trained to report abuse, including restraint to the Administrator immediately. She stated was one of them and RN A was the other one. She stated they did not work on the same nights. LVN J stated she had no knowledge of the restraint of Resident #1 or any other resident. She stated she learned about it when RN A was fired. She stated she knows RN A worked a lot of hours and did not have full time aides and was given agency staff to work with. LVN J stated it was not RN A's fault. She stated RN A did they best she could. LVN J stated the facility was a restraint free facility. She stated they could not use restraints because it was a dignity issue, and the residents could hurt themselves if restrained. During an interview on 4/17/2024 at 7:19 p.m., CNA K stated RN A never asked her to put a restraint or use a gait belt on a resident. She stated she never saw one put on a resident but did hear RN A state she was going to have to put a gait belt on Resident #1 to keep him in his wheelchair so he would not fall. CNA K stated she tried to just keep to herself and not pay attention. She stated she could not really remember working at the facility when asked if she had reported it. She replied I don't remember to all further questions about details and training and declined further interview. During an interview on 4/17/2024 at 7:24 p.m., CNA G stated restraint was considered abuse and was supposed to be reported to the Administrator immediately. She stated the very first time she worked nights at the facility, a Saturday night (2/10/2024-2/11/2024), RN A asked NA H to put a gait belt around Resident #1. CNA G stated NA H physically put the gait belt around the resident clasping it in the back. CNA G stated she asked NA H what she was doing it and NA H stated she was restraining Resident #1. CNA G stated had asked RN A if there were doctor's order and she said no, it was just the way she did it so he would not have any falls. CNA G stated she told NA H she had to take it off Resident #1 because there were no doctor's orders and NA H said no. CNA G stated she knew it was against the law to restrain residents in the state of Texas. She stated CNA E and RN A got in an argument over it. CNA G stated it just did not sit right with her and felt like the DON would have told her if they were supposed to restrain Resident #1. CNA G stated CNA E said it had happened before and that she had reported it to her agency. CNA G stated RN A got really upset with her when she told her to take it off. CNA G stated she asked CNA E to help her take it off Resident #1. She stated RN A told her and CNA E if we touched Resident #1, we would get in trouble. CNA G stated CNA E and RN A got in a screaming match and a lot of abuse things were said by both parties. She stated both CNA E and RN A were calling the DON trying to resolve it. CNA G stated she told the DON about the gait belt. She stated she was not able to hear the DON's response. She stated while CNA E was talking to the DON on the phone RN A continued yelling at CNA E. CNA G stated she did hear CNA E tell the DON that RN A placed a gait belt around Resident #1 and that she told NA H to do it to. CNA G stated she heard CNA E tell the DON that she (CNA G) had taken it off. CNA G stated she does not know what was said after that point because CNA E had to go outside to continue the conversation because RN A was yelling. CNA G stated after this happened everything calmed down and she took Resident #1 to bed. CNA G stated when she came back to work on Sunday (date unknown) RN A tried to do it again. She stated RN A told NA H to do it and this time NA H refused. CNA G stated RN A said if ya'll are not going to do it then she was going to do it. CNA G stated she told RN A no and told her she was just going to lay Resident #1 down in bed. CNA G stated RN A stated if he stays in bed then that is perfect. CNA G stated she never witnessed RN A physically put the gait belt on Resident #1 but she did witness her tell NA H to do it. She stated those were the only two days she worked with RN A. She stated she told the DON she was not going to work with RN A anymore because of it and moved to working day shift. CNA G stated this occurred on Super Bowl weekend 2/11/2024. She stated she worked both 2/10/2024 and 2/11/2024. CNA G stated after CNA E reported the restraint to the DON, RN A stayed at the facility and worked the whole shift. She stated no one went home. She stated the DON never came to the facility that night. CNA G stated she was new to the facility at the time and did not have anyone's phone numbers to report it but she knew CNA E reported it. She stated CNA E showed her where she had reported it (to her agency) multiple times, 3 times in total on the portal. She stated after this occurred the facility eventually put phone numbers up to report abuse. CNA G stated RN A continued to work in at the facility until sometimes in March (date unknown). CNA G denied knowledge of abuse or restraint of any other resident. She stated it was just Resident #1. She stated Resident #1 looked really confused by the restraint and he was trying to fight it. She stated he did not know why he could not get up. She stated it was tied around him like a seat belt. She stated he was trying to get up and stand up which was causing the wheelchair to move forward with him. She stated it was almost making the wheelchair fall over while he was trying to stand up. CNA G stated it looked really weird. She stated RN A then placed Resident #1 in the corner of the main living room area with a table in front of him blocking his wheelchair with furniture so he could not move. She stated he still had the gait belt around his abdomen at the time. She stated the gait belt was on tight and she was not able to get her fingers under the belt. CNA G stated she could not tell if Resident #1 was in any pain. She stated he just looked frustrated and confused. She stated Resident #1 could not really express his feelings because of the dementia. She stated he was unable to talk. CNA G stated on one of the days she was unsure how long Resident #1 had been in the restraint. She stated he was already in it when she saw it around 8:00 p.m. She stated she heard RN A tell NA H to put it on his but she did not see it occur. She stated she just heard RN A yell at NA H. She stated the words she heard were get the gait belt and NA H went and did it. CNA G stated she had always been taught they could not prevent a resident from moving by placement of furniture because that in of itself was considered restraint. She stated she was also told that the facility does not use restraints except by doctor order and we could not use objects as restraint. CNA G stated it was important that the residents have the right to be free and they don't deserve to be restrained or abused. During an interview on 4/17/2024 at 7:51 p.m., agency CNA M stated she was trained to notify the DON for any problems at the facility. She stated she only worked one night at the facility with RN A. She stated she had problems with RN A and did have to call the DON for interventions. She stated she refused to return to work at the facility after that one night due to issues with RN A. CNA M stated she had no knowledge of restraint or abuse. During an interview on 4/17/2024 at 7:53 p.m., agency CNA P stated she was trained to report abuse to her agency and to the Administrator. She stated she was trained they were not supposed to restrain people and she would report as abuse. She stated she had no knowledge of abuse or neglect at the facility. During an interview on 4/17/2024 at 8:09 p.m., the DON stated she first learned issues involving abuse/restraint regarding on evening/night shift when CNA B called her on 3/01/2024. She stated after she talked to CNA B, she also spoke with CNA E. The DON stated she did not obtain a statement of what happened from CNA E because her and RN A had argued on the shift, and she knew they were not getting along. The DON stated she wanted to only consider facts. The DON stated the argument between RN A and CNA E occurred sometime in February. She estimated it to be 2/27/2024 or 2/28/2024. She stated it was shortly before CNA B told her about the gait belt. The DON stated she did not bring CNA E back to work for approximately two weeks because she thought she was the problem. The DON stated what was reported to her in February was that RN A was rude and disrespectful. There was nothing about a gait belt. The DON stated after she talked to CNA E on the phone in February, RN A called her and told her CNA E was lazy and did not want to work with her. The DON stated she asked what she meant by that, and RN A wanted CNA E to do vital signs, but CNA E was giving showers. The DON stated she told RN A that the nurse typically obtains vital signs, but RN A did not like that answer. The DON stated she did not come to the facility during that shift to assess the situation. She stated they both agreed to get along and she (DON) felt the situation was okay. The DON stated she also talked to other staff but could not remember who she talked to. She stated the other staff told her RN A was rude. DON stated both RN A and CNA E were shouting but both agreed they could finish the shift. She stated no one told her about a gait belt restraint and she did not know how it impacted the residents. The DON stated she did not believe she received any notification about restraint or abuse or the use of a gait belt on 2/11/2024. She stated night shift nurse should report abuse to her. She stated she was certain no one told her about a gait belt as a restraint. She stated the staff only told her about it when she specifically asked questions about it. The DON stated RN A told her the gait belt restraint was to keep Resident #1 from falling. The DON stated no one had told her anyone was using furniture to block Resident #1. She stated that would be violating the rights of the resident and they could be injured. She stated their resident population, due to dementia just do not understand. She stated the resident's do not even understand something you do not want them to do. The DON stated the charge nurse was responsible for ensuring the safety of residents, for ensuring they were free from abuse and restraint on night shift. The DON stated she was responsible for monitoring the charge nurses. She stated she monitored the charge nurses by having a ton of in-services. She stated she had periodically dropped in at night to deliver supplies, to start an IV or just to peek in a window. She stated both the charge nurses and her were responsible for monitoring agency staff. The DON stated the agency was responsible for ensuring their staff had their own training. The DON stated the facility ensured residents were safe and free from harm by constant in-services and weekly skin assessments and observations. The DON stated does and does not consider restraint abuse, depending on the circumstances. The DON stated for Resident #1 his own family member wanted him to have a seat belt on his wheelchair. She stated she does not think in this case it would be considered abuse because he would not even realize he had one on. The DON stated she knows they are not supposed to use a gait belt as a restraint, but it was a hard one to consider and she didn't know if she would consider it abuse. The DON stated a restraint for Resident #1 did not pass legal because they are a restraint free facility. The DON stated her only question was if RN A was at that point of needing to use a gait belt as a restraint, why did she not call and tell anyone. The DON stated she does consider furniture placement as abuse because it prevents movement. She stated Resident #1 had to have some way to burn his energy and if he cannot stand, he wants to move. She stated he used his feet to self-propel in the wheelchair around the facility. The DON stated their policy indicated the facility was restraint free. She stated they could not block their vision or impede residents from getting out of bed. She stated the abuse policy did indicate restraint was abuse to her knowledge. During an interview on 4/18/2024 at 9:16 a.m., the Medical Director (MD) stated he had not been made aware of abuse/restraints in the facility. He stated he thought restraints were wrong. The MD stated he typically communicated with the facility and heard about situations like this from a call from the DON, the Administrator, or the NP. He stated he would tell them he did not agree with the restraint, but that had not happened, no one had communicated with him. He stated he communicated with the DON when he came to the facility and during QAPI meetings to discuss incidents to try to make things better. The MD stated the last QAPI was a few weeks ago and restrains was not part of the discussion. During an interview on 4/18/2024 at 10:56 a.m., the Administrator stated she was the abuse coordinator. She stated she expected the staff to notify her regardless of time imme[TRUNCATED]