**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure a safe environment free from physical and verbal abuse for Resident #1 when LVN D grabbed and pulled Resident #1 from behind the nurse's station, and Resident #1 was observed with redness on 07/13/25, and with bruises to both hands and wrists on 07/14/25. During this incident LVN D said to the resident three times that her daddy was dead. The noncompliance was identified as PNC. The IJ began on 07/13/25 and ended on 07/14/25. The facility had corrected the noncompliance before the survey began on 07/15/25. These failures could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotional distress, and serious harm. Findings include:Record review of Resident #1's face sheet, dated 07/17/25, revealed an [AGE] year-old-female who was originally admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia mild, with mood disturbance (cognitive decline with changes in behavior), insomnia (trouble sleeping), anxiety disorder ( excessive worry feelings of fear), disorientation (lost sense of direction), glaucoma (vision loss), schizoaffective disorder bipolar type (mental health condition episodes mania and depression), intermittent explosive disorder (physical and/or verbal outburst), lack of coordination (unsteadiness), muscle wasting (decrease in strength), muscle weakness (lack of movement), depression (sadness), difficulty in walking (abnormal walking pattern). Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE] revealed: Section C Brief Interview for Mental Status (BIMS) score revealed a score of 3 which indicated the resident's cognition was impaired. Section E Behavior indicated Resident 1 had potential behavior of psychosis that included hallucinations and delusions. And she exhibited physical behaviors directed towards others every 1 to 3 days, verbal behaviors directed towards others every 4 to 6 days, and wandering behavior that occurred every 4 to 6 days. Record review of Resident #1's care plan, dated 06/25/2025, revealed: Focus: Resident #1 had episodes of verbal/physical aggression. Date initiated 05/10/2024Intervention: Assist me to phone [family member] during episodes of agitation. Give me as many choices as possible about care and activities. Monitor for physical/verbally aggressive q shift. Document observed behavior and attempted interventions in behavior log. Focus: Resident #1 is an elopement risk/wanderer r/t disoriented to place, wander risk score 11. Date initiated 12/27/2024 date revised 06/25/2025. Intervention: Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, I prefer having snacks. Date initiated 12/27/2024 revised date 12/24/2025. Record review of Resident #1's progress notes, dated 07/14/2025 - 07/16/2025 revealed: On 07/14/2025 at 1:03 PM, the DON documented a Late Entry, because she was notified of Resident #1 having bruises to both wrists from an incident that occurred the on 07/13/25. The DON went to assess Resident #1 and found her to have bruising to both wrists. Resident #1 was asked if she was in pain from the bruising and she stated no. Notified the MD and emergency contact. The MD gave an order to get an x-ray to both wrists. Hospice was notified on 07/16/2025 at 3:29 PM, the DON documented spoke with Hospice staff about bruising on [Resident #1's] bilateral wrist. Per Hospice staff, the bruising to her wrists were not there Friday (07/11/2025). Per Hospice staff, she spent about 30 to 40 minutes talking with [Resident #1]. Monday (07-14-2025) Hospice staff did not know about bruising because [Resident #1] had her hands under her head and refused a shower. Noted resident is frequently wearing long sleeves. Record review of the x-ray report dated 07/14/2025 for Resident #1 revealed the right had wrist no acute abnormalities. The left wrist had osteopenia ( body doesn't make new bone as quickly as it reabsorbs old bone) and degenerative changes. Record review of Resident #1's physician's progress note dated 07/15/2025 revealed staff reported new onset bruising to bilateral ( having or relating to two sides; affecting both sides) FA (forearms). Record review of Resident #1's physician's orders dated 07/17/25 revealed Resident #1 was not prescribed blood thinners at the time of the incident. Observation on 07/15/25 at 7:30 AM indicated the nurses' cart was next to the display case that contained the reporting number for abuse and/or neglect and included the Administrator's phone number. Observation on 07/15/25 at 9:30 am of the facility's video recording dated 07/13/25 at 6:07 PM revealed LVN D was at the medication cart that was next to and in front of the nurse' station, when Resident #1 passed behind her and went into the nurses' station. LVN D said to Resident #1 You can't go back there. and Resident #1 replied I can too. LVN D said You cannot. and Resident #1 replied My daddy own's this place. LVN Dsaid Look lady as she grabbed Resident #1's left wrist, and Resident #1 responded by swinging her right hand at LVN D and stated, Leave me alone. LVN D said Stop. LVN D released Resident #1's right hand and placed something LVN D was holding in her hand on the nurses' desk. LVN D grabbed Resident #1's wrists with her hands and started pulling her out from behind the nurses' station. CNA C then approached LVN D and Resident #1 and said, [Resident #1] get out from back there; you can't be back there. LVN D continued to pull Resident #1 as Resident #1 resisted, kicked, and said to LVN D Turn loose my hands. LVN D pulled Resident #1 into the hallway and around the cabinet, which was out of camera view, and CNA C walked along side of them. LVN D could be heard saying I'm not going to fight with you. CNA B approached the nurses' station and said to Resident D Stop, and then CNA B used the medication cart to block the entry way into the nurses' station. Resident #1 could be heard saying My daddy's the one who owns this place. and LVN D responded He doesn't own it anymore because he's dead. Resident #1 replied He's not dead and LVN D said He is. LVN D, who was in front of the camera, walked into the hallway backwards holding Resident #1's wrist, and released her wrists as she passed in front of the nurses' station. Resident #1 followed her and said (Dad's name) is my daddy and he is not dead. Resident 1 kept saying to LVN D, Shut up and I don't want to hear it anymore. Resident #2 who was sitting approximately 3 feet away from LVN D, yelled out Leave her alone. Then CNAs B and C approached LVN D and Resident #1. Resident #1 lifted her arm as if to hit LVN D, walked one step away from LVN D, then walked back and grabbed LVN D's hand. LVN D said Stop, and grabbed Resident #1's wrists, and said Stop. I'm not gonna hit you. You're not strong enough. I'm not gonna let you hit me so you might as well keep walking. CNA A walked up to Resident #1, extended her hand to Resident #1, who jerked her hand back, and CNA A grabbed her by her right wrist and said come with me, as LVN D said You're not goanna win this fight. Resident #1 complied and walked off with CNA A. During an interview on 07/15/25 at 8:30 AM with the ADM indicated on 07/14/25 at 12 pm CNA A alleged LVN D had caused bruising to Resident #1's wrist on 07/13/25 at approximately 6:00 pm. ADM said on 07/14/25 at approximately 12 pm, she observed Resident #1 with bruising to her wrists, and turned in a self-reported incident on 07/14/25 at 1:55 pm per the Submission Report. The ADM said on 07/14/25 at approximately 12 pm, she observed the video recording dated 07/13/25 at approximately 6:08 pm that indicated Resident #1 entered the nurses' station and LVN D pulled her by her wrists out of the area. The ADM said LVN D told the resident her father was dead 2 or 3 times, which escalated Resident #1's behavior. ADM said she reported the incident as required per her policies and procedures, and she spoke to Resident #1, who could not recall how she sustained the bruising that was observed on Resident #1's wrists. ADM directed LVN F to assess Resident #1 obtain physician's order for an x-ray, and to document his findings. ADM notified LVN D's agency that LVN D could no longer work at the facility. ADM said she recognized that CNAs A, B, and C failed to report the incident of abuse to her or the DON. ADM said on 07/15/23 she conducted Safe Surveys with the facilities residents, including Resident #1, who did not recall being abused. ADM said she immediately in-serviced her staff on shift, and staff who were not at the facility would be in-service before working on the floor. These in-services provided on 05/17/25 included Coping with Agitation, Aggression, and Sundowning in Alzheimer and Disease, and Abuse, Neglect, Exploitation and Misappropriation Prevention Program. The ADM said the nurses and CNAs were receive disciplinary actions against them and she would continue her investigation. ADM said the Medical Director and Resident #1's responsible party were notified. ADM indicated the MD viewed the recording on 07/15/25 and directed her to terminate the contract with the agency that employs LVN D, and that he did not want any of their staff in the building. Prior to the incident on 07/13/25, ADM said she had in serviced the facility's staff and informed them that she was accessible to them twenty-four hours a day, seven days a week. In addition, ADM said prior to the incident she had a form posted next to the reporting guidelines in the hallway next to the nurses' station that included her phone number, and it was there when the incident occurred between LVN D and Resident #1. Record review of the facility's in-service provided 07/15/25 Coping with Agitation, Aggression, and Sundowning in Alzheimer and Disease indicated staff should be patient and try not to show frustration and to avoid arguing, gentle touching to calm down, and take deep breaths and count to 10. Staff should focus on an abject or activity to distract, and/or provide a snack and/or beverage. This in-service included protecting yourself and other if needed, and if the resident becomes aggressive, stay at a safe distance until the behavior stops. Talk to a doctor if aggressive behaviors worsen and consider medications that may help. Record review of the facility's in-service provided 07/15/25 and dated Revised 2021, Abuse, Neglect, Exploitation and Misappropriation Prevention Program indicated Resident have the right to be free from abuse and neglect. This included develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents. Establish and maintain a culture of compassion and caring for all resident and particularly those with behavioral, cognitive or emotional problems. Record Review of Resident Safety Survey provided on 07/15/25 indicated the facility's residents were asked the following. 1. Do you feel safe?2. Have you witnessed any abuse (physical or verbal)?3. Does staff knock and introduce themselves when entering your room?4. Do you know who o report alleged abuse to? There were no negative findings on these reports, including Resident #1. Observation on 07/15/25 at 9:50 AM of Resident #1 indicated she had three inches by three inches of bruising that wrapped around her right and left wrists.During an interview on 07/15/25 at 9:51 AM with Resident #1 indicated she could not recall how she sustained the bruising to her wrists. During an interview on 07/15/25 at 12:31 pm with HR indicated the agency is responsible for ensuring staff are trained to work for nursing homes before placing them on the agency portal. HR said if the facility needs a staff, she will apply the request on the porta. This allows the agency staff to accept the request through their portal. HR said the facility is not responsible for their training because the agency is responsible for their training. If the facility had known that LVN D had not been trained in Dementia, she would not have been allowed to work at the facility. Since this incident, HR said the Medical Director has requested the agency's contract terminated, and their staff not be allowed to care for the facility's residents. During an interview on 07/15/25 at 12:52 pm with CNA H, who works 6 am to 6 pm shift, indicated on 07/14/25 she was in-service on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. CNA H said before this incident on 07/13/25 involving LVN D and Resident #1, the ADM in-serviced her that she was available 24 hours a day seven days a week, and her phone number was posted on the bulletin board next to the A&N phone number. CNA H said when Resident #1 is upset, she will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. CNA H said she would not grab a resident by their wrist and force them to leave the area. CNA H said the nurse and CNAs are the ones that updates her with changes to a resident's care plan.Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA H had signed these in-services on 07/14/25. During an interview on 07/15/25 at 1:15 pm with CNA G, who works from 6 am to 4:30 pm, indicated he was in-service on 07/14/25 on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. CNA G said before 07/13/25 he was working but left before the incident occurred between LVN D and Resident #1. CNA G said he received an in-service from the ADM, who informed him her phone number was posted on the bulletin board next to the A&N phone number. CNA G said when Resident#1 is upset, he will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. CNA G said she would not grab a resident by their wrist and force them to leave the area. CNA G said if a resident's plan is changed, he will be informed by the nurse and CNAs. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA G had signed these in-services on 07/14/25. During an interview on 07/15/25 at 2:09 pm with LVN F, who works from 6 am to 6 pm, indicated on 07/14/25 the ADM asked him to assess Resident #1, obtain orders to X-ray her arms, inform the physician and family, and to document his findings. LVN F said he observed Resident #1 had two-to-three-inch bruising to her wrists but did not document this assessment until later in the day because he took his break and because a resident had a fall he was dealing with. LVN F said he was issued a disciplinary [NAME] for not document his assessment. LVN F said he obtained the order for Resident #1's X-rays, which were negative for fractures. LVN F said during shift report on 07/13/25 at approximately 6 am, LVN E did not inform him that Resident #1 had hit LVN D, and that she had assessed her. LVN F said Resident#1 can get aggressive; however, he will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. LVN F said these steps are in Resident #1's care plan. LVN F said he would not grab a resident by their wrist and force them to leave the area. LVN F said if a resident's plan is changed, he will be informed by the DON or outgoing nurse, and he will share this information with his CNAs. LVN F said in the future he will document his assessments on the resident's progress notes and skin assessment. indicated he was in-service on 07/14/25 on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. LVN F said before 07/13/25 he was in-service by the ADM that she could be reached 24 hours a day seven day a week, and her phone number was posted on the bulletin board next to the A&N phone number. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated LVN F had signed these in-services on 07/14/25. During an interview on 07/15/25 at 12:31 pm with HR indicated they use an agency, which is a third party, when they need a nurse or CNA to work at the facility due to a facility staff not being able to work. HR said the agency is responsible for ensuring their staff are trained to work at a nursing home, before placing them on the agency portal. HR said if she needs a staff, she will place her request on the portal, and the interested nurse or CNA will accept the request. HR said if she had known LVN D was not up to date on her training she never would have accepted her request to work at the facility. HR, said due to the incident with LVN D abusing Resident 1, the MD has terminated their contract with this agency. During an interview on 07/15/25 at 2:23 pm with CNA A, who works 6 am to 6 pm, indicated on 07/13/25 at approximately 6 pm, she witnessed LVN D direct Resident #1 to throw away cups the cups she had taken from the medication cart, and she complied. CNA A said she head LV D say to Resident #1 she did not belong there, and Resident #1 began yelling. CNA A said she approached Resident #1, who was in front of the nurses' station and tried to hit LVN D. LVN D grabbed resident #1's hands as Resident #1 yelled at LVN D that her daddy owned the facility. CNA A said LVN D said to resident #1 she could say what she wanted but she was protecting herself from Resident #1. Hitting her. CNA A said she intervened by extending her hand between LVN D and Resident #1, who swatted her hand but then allowed CNA A to hold her hand and follow her towards her room. CNA A said before getting into Resident #1's room, she stopped, pulled up her sleeves, and said look what that lady did to me. CNA A said she witnessed Resident #1's wrist were red. CNA A indicated on 07/14/25 Resident #1's hospice aide questions whey Resident #1 had bruises to her hands and wrists. CNA A replied that there was an incident between Resident #1 and LVN D, and the hospice aide question if this had been reported, and CNA A said yes to the ADM. CNA A said she on 07/14/25 she was in-service on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. CNA A said before this incident on 07/13/25 involving LVN D and Resident #1, the ADM in-serviced her that she was available 24 hours a day seven days a week, and her phone number was posted on the bulletin board next to the A&N phone number. CNA A said when Resident #1 is upset, she will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. CNA A said she would not grab a resident by their wrist and force them to leave the area. CNA A said the nurse and CNAs are the ones that updates her with changes to a resident's care plan. CNA A said she intervened to protect Resident #1; however, she failed to report to the ADM immediately. Instead, CNA A said she reported this incident to the ADM on 07/14/25 and was issued a disciplinary action against her. CNA A said on 07/13/25 she did not report the incident between LVN D and Resident #1 because she was distracted due to having a disagreement with a coworker over dividing the rooms which cause her to be distracted, it was shift change, and she was changing briefs and answering call lights. CNA A said when Resident #1 was upset and aggressive, LVN D should have asked one of the CNAs to assist her, because Resident #1 is familiar with the CNAs. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA A had signed these in-services on 07/14/25.Record Review of the Counseling Notice for CNA C signed and dated on 7/15/25 and signed by the DON revealed, CNA C received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of the Counseling Notice for CNA A signed and dated on 7/15/25 and signed by the DON revealed, CNA A received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of the Counseling Notice for LVN E signed and dated on 7/15/25 and signed by the DON revealed, LVN E received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of undated text messages at 4:17 PM from the facility ADM to the staffing agency revealed that the staffing agency acknowledged that dementia training was not mandatory unless the staffing agency was notified that it should be and moving forward the agency would document as a requirement. Record Review of an email dated 7/15/25 from the ADM to the staffing agency revealed that effective 7/15/25 the facility would no longer be using the staffing agency. During an interview on 07/17/25 at 7:33 am with LVN I, who worked 6 pm to 6 am indicated she was in-service on 07/14/25 on preventing A&N and how to address residents with Alzheimer and Dementia, per in-service forms. LVN I said the phones numbers for reporting A&N are posted next to the A&N poster by the nurses' station. LVN I said the ADM was accessible 24/7 for reporting A&N. LVN I said she is responsible for 2 CNAs during the night shift and for updating them with changes to a resident' care plan or significant changes. LVN I said Resident #1 likes to go into the nurses' station but can be redirected or given snacks so she can comply with leaving the nurses' station, which is part of her plan. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated LVN I had signed these in-services on 07/14/25.During an interview on 07/17/25 at 9:59 am with the DON indicated that what should have happened ( when LVN D abused Resident #1), staff involved should have reported the incident as soon as it happened. Staff should have intervened and then reported the incident. She stated staff are trained to intervene and stop the incident and then report the incident to the ADM, who is the abuse coordinator. The DON stated the staff should have reported immediately and not have waited for several hours to report. The DON stated staff did not follow the facility policy to report abuse immediately, which could have allowed injury, mental or physical abuse to continue. The DON stated to her knowledge Resident #1 is not on any blood thinners, but she is fragile and has thin skin and easy to bruise. The DON stated that the ADM should have been informed immediately because residents have the right to be protected. The DON stated that talking about Resident #1's dad will escalate her behaviors but offering her a snack will help to calm her behaviors. The DON stated that had staff notify her or the ADM when the incident happened, they would have gone to the facility and sent staff home and initiated the investigation. The DON stated Resident #1 doesn't know how the bruising happened and continues to say she doesn't know who did that to her. The DON stated staff reported the incident the next day (07/14/25) because that is when the bruises appeared. The ADM called LVN's agency and told them not to send the nurse back. She stated that they started in-servicing staff on abuse and reporting abuse and working with residents with behaviors. Review on 07/15/25 of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated DON had signed these in-services on 07/14/25.Record review on 07/17/25 of LVN D's timesheet dated 07/13/25 indicated she worked at the facility 10 hours and 43 minutes (07/13/25 at 7 am until 12:00 am). During an interview on 07/17/25 at 10:14 AM with LVN D indicated she started her shift on 07/13/25 at 7:00 AM and ended her shift at 12:00 AM. LVN D said at approximately 7 PM, Resident #1 went behind the nurses' station, and was rambling and grabbing stuff off the nurses' desk. LVN D said she told Resident #1 she could not be there, and walked towards Resident #1, who started fighting with her. LVN D said she caught Resident #1's wrist to keep her from hitting her and someone used a medication cart to prevent her from returning to the nurses' station. LVN D said she absolutely grabbed Resident #1's wrist; however, prior to that incident she had asked (unable to recall who she asked) why Resident #1 had bruises on her wrist. LVN D said she was positive she did not cause the bruises. LVN D said in the past Resident #1 would go into the nurses' station often; however, she did not do anything, unless Resident #1 took items from the nurses' desk. LVN D said she knew Resident #1 had a care plan; however, she never has nor did it cross her mind to review the care plan. LVN D said she did not know the care plan included interventions to address Resident #1's behaviors. LVN D said she did not call Resident #1's family member nor did she offer her a drink and/or snack when she became upset. LVN D said she did not document Resident #1's incident or her behaviors, and did not notify the physician, responsible party, Director of Nurses, (DON), and the Administrator, because Resident #1 did not have a change of condition and she did not see it as an escalated change. LVN D said that was Resident #1's normal behavior. LVN D said she was trained in addressing residents with Dementia and/or Alzheimer's but could not recall if it included holding residents by their hands or wrists. LVN D said in the moment of the incident she told Resident #1 You are not going to hit me, I'm stronger than you are. LVN D said she had not had training on elderly aggression. LVN D said when a resident is aggressive, she should offer the resident something to avert their attention, let them be if they are not hurting themselves or others, offer medications, and offer snacks. LVN D said she did not grab Resident 1's wrist, she caught her wrist, which was not appropriate but it depended on the situation. LVN D said the first time she put space between her and Resident #1 was when she was going by the medication cart, the second time was when the CNA directed her to leave, and the third time there was distance between her and Resident #1 until, Resident #1 lunged at me. LVN D said she recalled a resident (Resident #2) in the area but could not recall which one. LVN D said Resident #1 was not within reach of a resident. LVN D said Resident #1 has a history of talking about her deceased dad, and she (LVN D) told her he was dead because she was looking for her dad, and Resident #1 was saying she did not have to leave the nurses' station because her dad built the facility and he owns it. During an interview on 07/17/25 at 10:56 AM with Resident #2, who had been sitting approximately 5 feet from the nurses' station and per video yelled out leave her alone, indicated she could not recall the incident involving LVN D and Resident #1. Record review on 07/18/25 at 3 pm of CNA C's written witnesss statement indicate on 07/13/25 she witnessed LVN D holding Resident #1's by her wrists and attempting to redirect her. CNA C said LVN D was making verbal comments about Resident #1's dad being dead. Then Resident #1 became combative and that's when the CNAs took resident to her room. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA C had signed these in-services on 07/14/25.During an interview on 07/18/25 at 12:50 pm with CNA B, who works 6 pm to 6 am and 6 am to 6 pm shifts, indicated she was in-service but cannot recall the date, because she works for an agency, which requires her to be at numerous facilities. CNA B said prior to the incident on 07/13/25, between LVN D and Resident #1, she had been in-serviced on preventing A&N, and how to address residents with Alzheimer and Dementia through her required CNA training. CNA B said she knew she could call the ADM anytime of the day or night and that her number was posted on the bulletin board in the facility, and if not, she could ask for her number. CNA B said on 07/13/25 at approximately 6 PM, she heard LVN D say to Resident #1 she could not go there (behind the nurses' station). CNA B said when LVN D grabbed Resident #1's wrists and pulled her from behind the nurses' station. CNA B said intervened by using the medication cart to block the entrance to the nurses' station and asking Resident #1 two or three times to go with her to her room, because she could see that LVN D was holding her wrists. CNA B said Resident #1 pulled her right hand loose and swung at LVN D but missed hitting her. That was when LVN D grabbed her wrists and said If you hit me, I will hit you back. CNA B said she continued to direct Resident #1 to go with her to her room, but she refused. Then CNA A intervened by walking up to LVN D and Resident #1, extending her hand to Resident #1 and asking her to go with her, and Resident #1 complied. CNA B said she walked with CNA A, and Resident #1 towards Resident #1's room, until she stopped in the hallway, pulled her shirt sleeves above her wrists, and said Look what she did to me. CNA B said Resident #1 had redness and bruising (blueish blotches) to her wrists. Afterwards, CNA B left CNA A and Resident #1, who continued to walk to Resident #1's room while holding hands. CNA B said she reported the incident to LVN E, on the night of 07/13/25 at 12 am, because she was the nurse relieving LVN D. CNA B said she did not report the incident to the Administrator, because she was busy answering call lights. CNA B said she should have called the Administrator immediately, because she had been in-serviced and informed that the ADM's phone number was posted next to the bulletin board next to the number for reporting abuse and neglect. CNA B said during the incident she intervened to protect Resident #1 from LVN D by using the medication cart to block the entrance to the nurses' station, after she saw LVN D pulling Resident #1 by her hands out of the nurses' station. Then CNA B said she asked Resident #1 two or three times for her to go with her to her room, but she did not comply. Then CNA A reached her hand out to Resident #1 and asked her to go to her room, and Resident #1 complied because she is very familiar with CNA A. CNA B said since 07/13/25 she had not worked at the facility. CNA B said Resident #1 in the past has been redirected and offered snacks when she has been aggressive, and that works. CNA B said she in updated on residents' care plans by the nurses and CNAs. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA B had signed these in-services on 07/14/25.A phone call interview on 07/18/25 at 1:20 PM was attempted with LVN E via a voice mail and text message, but she did not return the message. Record review of LVN F's written statement(that was not dated) but prov[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement written policies and procedures that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of known source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Administrator for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure a safe environment free from physical and verbal abuse for Resident #1 when LVN D grabbed and pulled Resident #1 from behind the nurse's station, and Resident #1 was observed with redness on 07/13/25, and with bruises to both hands and wrists on 07/14/25. During this incident LVN D said to the resident three times that her daddy was dead. The noncompliance was identified as PNC. The IT began on 07/13/25 and ended on 07/14/25. The facility had corrected the noncompliance before the survey began on 07/15/25. These failures could affect all residents by placing them at risk of continued abuse, physical harm, pain, mental anguish, emotional distress, and serious harm. Findings include:Record review of Resident #1's face sheet, dated 07/17/25, revealed an [AGE] year-old-female who was originally admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia mild, with mood disturbance (cognitive decline with changes in behavior), insomnia (trouble sleeping), anxiety disorder ( excessive worry feelings of fear), disorientation (lost sense of direction), glaucoma (vision loss), schizoaffective disorder bipolar type (mental health condition episodes mania and depression), intermittent explosive disorder (physical and/or verbal outburst), lack of coordination (unsteadiness), muscle wasting (decrease in strength), muscle weakness (lack of movement), depression (sadness), difficulty in walking (abnormal walking pattern). Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE] revealed: Section C Brief Interview for Mental Status (BIMS) score revealed a score of 3 which indicated the resident's cognition was impaired. Section E Behavior indicated Resident 1 had potential behavior of psychosis that included hallucinations and delusions. And she exhibited physical behaviors directed towards others every 1 to 3 days, verbal behaviors directed towards others every 4 to 6 days, and wandering behavior that occurred every 4 to 6 days. Record review of Resident #1's care plan, dated 06/25/2025, revealed: Focus: Resident #1 had episodes of verbal/physical aggression. Date initiated 05/10/2024Intervention: Assist me to phone [family member] during episodes of agitation. Give me as many choices as possible about care and activities. Monitor for physical/verbally aggressive q shift. Document observed behavior and attempted interventions in behavior log. Focus: Resident #1 is an elopement risk/wanderer r/t disoriented to place, wander risk score 11. Date initiated 12/27/2024 date revised 06/25/2025. Intervention: Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, I prefer having snacks. Date initiated 12/27/2024 revised date 12/24/2025. Record review of Resident #1's progress notes, dated 07/14/2025 - 07/16/2025 revealed: On 07/14/2025 at 1:03 PM, the DON documented a Late Entry, because she was notified of Resident #1 having bruises to both wrists from an incident that occurred the on 07/13/25. The DON went to assess Resident #1 and found her to have bruising to both wrists. Resident #1 was asked if she was in pain from the bruising and she stated no. Notified the MD and emergency contact. The MD gave an order to get an x-ray to both wrists. Hospice was notified 07/16/2025 at 3:29 PM, the DON documented spoke with Hospice staff about bruising on [Resident #1's] bilateral wrist. Per Hospice staff, the bruising to her wrists were not there Friday (07/11/2025). Per Hospice staff, she spent about 30 to 40 minutes talking with [Resident #1]. Monday (07-14-2025) Hospice staff did not know about bruising because [Resident #1] had her hands under her head and refused a shower. Noted resident is frequently wearing long sleeves. Record review of the x-ray report dated 07/14/2025 for Resident #1 revealed the right had wrist no acute abnormalities. The left wrist had osteopenia ( body doesn't make new bone as quickly as it reabsorbs old bone) and degenerative changes. Record review of Resident #1's physician's progress note dated 07/15/2025 revealed staff reported new onset bruising to bilateral ( having or relating to two sides; affecting both sides) FA (forearms). Record review of Resident #1's physician's orders dated 07/17/25 revealed Resident #1 was not prescribed blood thinners at the time of the incident. Observation on 07/15/25 at 7:30 AM indicated the nurses' cart was next to the display case that contained the reporting number for abuse and/or neglect and included the Administrator's phone number. Observation on 07/15/25 at 9:30 am of the facility's video recording dated 07/13/25 at 6:07 PM revealed LVN D was at the medication cart that was next to and in front of the nurse' station, when Resident #1 passed behind her and went into the nurses' station. LVN D said to Resident #1 You can't go back there. and Resident #1 replied I can too. LVN D said You cannot. and Resident #1 replied My daddy own's this place. LVN D said Look lady as she grabbed Resident #1's left wrist, and Resident #1 responded by swinging her right hand at LVN D and stated, Leave me alone. LVN D said Stop. LVN D released Resident #1's right hand and placed something LVN D was holding in her hand on the nurses' desk. LVN D grabbed Resident #1's wrists with her hands and started pulling her out from behind the nurses' station. CNA C then approached LVN D and Resident #1 and said, [Resident #1] get out from back there; you can't be back there. LVN D continued to pull Resident #1 as Resident #1 resisted, kicked, and said to LVN D Turn loose my hands. LVN D pulled Resident #1 into the hallway and around the cabinet, which was out of camera view, and CNA C walked along side of them. LVN D could be heard saying I'm not going to fight with you. CNA B approached the nurses' station and said to Resident D Stop, and then CNA B used the medication cart to block the entry way into the nurses' station. Resident #1 could be heard saying My daddy's the one who owns this place. and LVN D responded He doesn't own it anymore because he's dead. Resident #1 replied He's not dead and LVN D said He is. LVN D, who was in front of the camera, walked into the hallway backwards holding Resident #1's wrist, and released her wrists as she passed in front of the nurses' station. Resident #1 followed her and said (Dad's name) is my daddy and he is not dead. Resident 1 kept saying to LVN D, Shut up and I don't want to hear it anymore. Resident #2 who was sitting approximately 3 feet away from LVN D, yelled out Leave her alone. Then CNAs B and C approached LVN D and Resident #1. Resident #1 lifted her arm as if to hit LVN D, walked one step away from LVN D, then walked back and grabbed LVN D's hand. LVN D said Stop, and grabbed Resident #1's wrists, and said Stop. I'm not gonna hit you. You're not strong enough. I'm not gonna let you hit me so you might as well keep walking. CNA A walked up to Resident #1, extended her hand to Resident #1, who jerked her hand back, and CNA A grabbed her by her right wrist and said come with me, as LVN D said You're not goanna win this fight. Resident #1 complied and walked off with CNA A. During an interview on 07/15/25 at 8:30 AM with the ADM indicated on 07/14/25 at 12 pm CNA A alleged LVN D had caused bruising to Resident #1's wrist on 07/13/25 at approximately 6:00 pm. ADM said on 07/14/25 at approximately 12 pm, she observed Resident #1 with bruising to her wrists, and turned in a self-reported incident on 07/14/25 at 1:55 pm per the Submission Report. The ADM said on 07/14/25 at approximately 12 pm, she observed the video recording dated 07/13/25 at approximately 6:08 pm that indicated Resident #1 entered the nurses' station and LVN D pulled her by her wrists out of the area. The ADM said LVN D told the resident her father was dead 2 or 3 times, which escalated Resident #1's behavior. ADM said she reported the incident as required per her policies and procedures, and she spoke to Resident #1, who could not recall how she sustained the bruising that was observed on Resident #1's wrists. ADM directed LVN F to assess Resident #1 obtain physician's order for an x-ray, and to document his findings. ADM notified LVN D's agency that LVN D could no longer work at the facility. ADM said she recognized that CNAs A, B, and C failed to report the incident of abuse to her or the DON. ADM said on 07/15/23 she conducted Safe Surveys with the facilities residents, including Resident #1, who did not recall being abused. ADM said she immediately in-serviced her staff on shift, and staff who were not at the facility would be in-service before working on the floor. These in-services provided on 05/17/25 included Coping with Agitation, Aggression, and Sundowning in Alzheimer and Disease, and Abuse, Neglect, Exploitation and Misappropriation Prevention Program. The ADM said the nurses and CNAs were receive disciplinary actions against them and she would continue her investigation. ADM said the Medical Director and Resident #1's responsible party were notified. ADM indicated the MD viewed the recording on 07/15/25 and directed her to terminate the contract with the agency that employs LVN D, and that he did not want any of their staff in the building. Prior to the incident on 07/13/25, ADM said she had in serviced the facility's staff and informed them that she was accessible to them twenty-four hours a day, seven days a week. In addition, ADM said prior to the incident she had a form posted next to the reporting guidelines in the hallway next to the nurses' station that included her phone number, and it was there when the incident occurred between LVN D and Resident #1. Record review of the facility's in-service provided 07/15/25 Coping with Agitation, Aggression, and Sundowning in Alzheimer and Disease indicated staff should be patient and try not to show frustration and to avoid arguing, gentle touching to calm down, and take deep breaths and count to 10. Staff should focus on an abject or activity to distract, and/or provide a snack and/or beverage. This in-service included protecting yourself and other if needed, and if the resident becomes aggressive, stay at a safe distance until the behavior stops. Talk to a doctor if aggressive behaviors worsen and consider medications that may help. Record review of the facility's in-service provided 07/15/25 and dated Revised 2021, Abuse, Neglect, Exploitation and Misappropriation Prevention Program indicated Resident have the right to be free from abuse and neglect. This included develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents. Establish and maintain a culture of compassion and caring for all resident and particularly those with behavioral, cognitive or emotional problems. Record Review of Resident Safety Survey provided on 07/15/25 indicated the facility's residents were asked the following. I1. Do you feel safe?2. Have you witnessed any abuse (physical or verbal)?3. Does staff knock and introduce themselves when entering your room?4. Do you know who o report alleged abuse to? There were no negative findings on these reports, including Resident #1. Observation on 07/15/25 at 9:50 AM of Resident #1 indicated she had three inches by three inches of bruising that wrapped around her right and left wrists.During an interview on 07/15/25 at 9:51 AM with Resident #1 indicated she could not recall how she sustained the bruising to her wrists. During an interview on 07/15/25 at 12:31 pm with HR indicated the agency is responsible for ensuring staff are trained to work for nursing homes before placing them on the agency portal. HR said if the facility needs a staff, she will apply the request on the porta. This allows the agency staff to accept the request through their portal. HR said the facility is not responsible for their training because the agency is responsible for their training. If the facility had known that LVN D had not been trained in Dementia, she would not have been allowed to work at the facility. Since this incident, HR said the Medical Director has requested the agency's contract terminated, and their staff not be allowed to care for the facility's residents. During an interview on 07/15/25 at 12:52 pm with CNA H, who works 6 am to 6 pm shift, indicated on 07/14/25 she was in-service on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. CNA H said before this incident on 07/13/25 involving LVN D and Resident #1, the ADM in-serviced her that she was available 24 hours a day seven days a week, and her phone number was posted on the bulletin board next to the A&N phone number. CNA H said when Resident #1 is upset, she will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. CNA H said she would not grab a resident by their wrist and force them to leave the area. CNA H said the nurse and CNAs are the ones that updates her with changes to a resident's care plan.Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA H had signed these in-services on 07/14/25. Record Review of the Counseling Notice for CNA C signed and dated on 7/15/25 and signed by the DON revealed, CNA C received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of the Counseling Notice for CNA A signed and dated on 7/15/25 and signed by the DON revealed, CNA A received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of the Counseling Notice for LVN E signed and dated on 7/15/25 and signed by the DON revealed, LVN E received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of undated text messages at 4:17 PM from the facility ADM to the staffing agency revealed that the staffing agency acknowledged that dementia training was not mandatory unless the staffing agency was notified that it should be and moving forward the agency would document as a requirement. Record Review of an email dated 7/15/25 from the ADM to the staffing agency revealed that effective 7/15/25 the facility would no longer be using the staffing agency. During an interview on 07/15/25 at 1:15 pm with CNA G, who works from 6 am to 4:30 pm, indicated he was in-service on 07/14/25 on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. CNA G said before 07/13/25 he was working but left before the incident occurred between LVN D and Resident #1. CNA G said he received an in-service from the ADM, who informed him her phone number was posted on the bulletin board next to the A&N phone number. CNA G said when Resident#1 is upset, he will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. CNA G said she would not grab a resident by their wrist and force them to leave the area. CNA G said if a resident's plan is changed, he will be informed by the nurse and CNAs. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA G had signed these in-services on 07/14/25. During an interview on 07/15/25 at 2:09 pm with LVN F, who works from 6 am to 6 pm, indicated on 07/14/25 the ADM asked him to assess Resident #1, obtain orders to X-ray her arms, inform the physician and family, and to document his findings. LVN F said he observed Resident #1 had two-to-three-inch bruising to her wrists but did not document this assessment until later in the day because he took his break and because a resident had a fall he was dealing with. LVN F said he was issued a disciplinary [NAME] for not document his assessment. LVN F said he obtained the order for Resident #1's X-rays, which were negative for fractures. LVN F said during shift report on 07/13/25 at approximately 6 am, LVN E did not inform him that Resident #1 had hit LVN D, and that she had assessed her. LVN F said Resident#1 can get aggressive; however, he will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. LVN F said these steps are in Resident #1's care plan. LVN F said he would not grab a resident by their wrist and force them to leave the area. LVN F said if a resident's plan is changed, he will be informed by the DON or outgoing nurse, and he will share this information with his CNAs. LVN F said in the future he will document his assessments on the resident's progress notes and skin assessment. indicated he was in-service on 07/14/25 on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. LVN F said before 07/13/25 he was in-service by the ADM that she could be reached 24 hours a day seven day a week, and her phone number was posted on the bulletin board next to the A&N phone number. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated LVN F had signed these in-services on 07/14/25.During an interview on 07/15/25 at 12:31 pm with HR indicated they use an agency, which is a third party, when they need a nurse or CNA to work at the facility due to a facility staff not being able to work. HR said the agency is responsible for ensuring their staff are trained to work at a nursing home, before placing them on the agency portal. HR said if she needs a staff, she will place her request on the portal, and the interested nurse or CNA will accept the request. HR said if she had known LVN D was not up to date on her training she never would have accepted her request to work at the facility. HR, said due to the incident with LVN D abusing Resident 1, the MD has terminated their contract with this agency. During an interview on 07/15/25 at 2:23 pm with CNA A, who works 6 am to 6 pm, indicated on 07/13/25 at approximately 6 pm, she witnessed LVN D direct Resident #1 to throw away cups the cups she had taken from the medication cart, and she complied. CNA A said she head LV D say to Resident #1 she did not belong there, and Resident #1 began yelling. CNA A said she approached Resident #1, who was in front of the nurses' station and tried to hit LVN D. LVN D grabbed resident #1's hands as Resident #1 yelled at LVN D that her daddy owned the facility. CNA A said LVN D said to resident #1 she could say what she wanted but she was protecting herself from Resident #1. Hitting her. CNA A said she intervened by extending her hand between LVN D and Resident #1, who swatted her hand but then allowed CNA A to hold her hand and follow her towards her room. CNA A said before getting into Resident #1's room, she stopped, pulled up her sleeves, and said look what that lady did to me. CNA A said she witnessed Resident #1's wrist were red. CNA A indicated on 07/14/25 Resident #1's hospice aide questions whey Resident #1 had bruises to her hands and wrists. CNA A replied that there was an incident between Resident #1 and LVN D, and the hospice aide question if this had been reported, and CNA A said yes to the ADM. CNA A said she on 07/14/25 she was in-service on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. CNA A said before this incident on 07/13/25 involving LVN D and Resident #1, the ADM in-serviced her that she was available 24 hours a day seven days a week, and her phone number was posted on the bulletin board next to the A&N phone number. CNA A said when Resident #1 is upset, she will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. CNA A said she would not grab a resident by their wrist and force them to leave the area. CNA A said the nurse and CNAs are the ones that updates her with changes to a resident's care plan. CNA A said she intervened to protect Resident #1; however, she failed to report to the ADM immediately. Instead, CNA A said she reported this incident to the ADM on 07/14/25 and was issued a disciplinary action against her. CNA A said on 07/13/25 she did not report the incident between LVN D and Resident #1 because she was distracted due to having a disagreement with a coworker over dividing the rooms which cause her to be distracted, it was shift change, and she was changing briefs and answering call lights. CNA A said when Resident #1 was upset and aggressive, LVN D should have asked one of the CNAs to assist her, because Resident #1 is familiar with the CNAs. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA A had signed these in-services on 07/14/25.Record Review of the Counseling Notice for CNA C signed and dated on 7/15/25 and signed by the DON revealed, CNA C received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of the Counseling Notice for CNA A signed and dated on 7/15/25 and signed by the DON revealed, CNA A received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of the Counseling Notice for LVN E signed and dated on 7/15/25 and signed by the DON revealed, LVN E received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of undated text messages at 4:17 PM from the facility ADM to the staffing agency revealed that the staffing agency acknowledged that dementia training was not mandatory unless the staffing agency was notified that it should be and moving forward the agency would document as a requirement. Record Review of an email dated 7/15/25 from the ADM to the staffing agency revealed that effective 7/15/25 the facility would no longer be using the staffing agency. During an interview on 07/17/25 at 7:33 am with LVN I, who worked 6 pm to 6 am indicated she was in-service on 07/14/25 on preventing A&N and how to address residents with Alzheimer and Dementia, per in-service forms. LVN I said the phones numbers for reporting A&N are posted next to the A&N poster by the nurses' station. LVN I said the ADM was accessible 24/7 for reporting A&N. LVN I said she is responsible for 2 CNAs during the night shift and for updating them with changes to a resident' care plan or significant changes. LVN I said Resident #1 likes to go into the nurses' station but can be redirected or given snacks so she can comply with leaving the nurses' station, which is part of her plan.Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated LVN I had signed these in-services on 07/14/25.During an interview on 07/17/25 at 9:59 am with the DON indicated that what should have happened ( when LVN D abused Resident #1), staff involved should have reported the incident as soon as it happened. Staff should have intervened and then reported the incident. She stated staff are trained to intervene and stop the incident and then report the incident to the ADM, who is the abuse coordinator. The DON stated the staff should have reported immediately and not have waited for several hours to report. The DON stated staff did not follow the facility policy to report abuse immediately, which could have allowed injury, mental or physical abuse to continue. The DON stated to her knowledge Resident #1 is not on any blood thinners, but she is fragile and has thin skin and easy to bruise. The DON stated that the ADM should have been informed immediately because residents have the right to be protected. The DON stated that talking about Resident #1's dad will escalate her behaviors but offering her a snack will help to calm her behaviors. The DON stated that had staff notify her or the ADM when the incident happened, they would have gone to the facility and sent staff home and initiated the investigation. The DON stated Resident #1 doesn't know how the bruising happened and continues to say she doesn't know who did that to her. The DON stated staff reported the incident the next day (07/14/25) because that is when the bruises appeared. The ADM called LVN's agency and told them not to send the nurse back. She stated that they started in-servicing staff on abuse and reporting abuse and working with residents with behaviors. Review on 07/15/25 of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated DON had signed these in-services on 07/14/25.Record review on 07/17/25 of LVN D's timesheet dated 07/13/25 indicated she worked at the facility 10 hours and 43 minutes (07/13/25 at 7 am until 12:00 am). During an interview on 07/17/25 at 10:14 AM with LVN D indicated she started her shift on 07/13/25 at 7:00 AM and ended her shift at 12:00 AM. LVN D said at approximately 7 PM, Resident #1 went behind the nurses' station, and was rambling and grabbing stuff off the nurses' desk. LVN D said she told Resident #1 she could not be there, and walked towards Resident #1, who started fighting with her. LVN D said she caught Resident #1's wrist to keep her from hitting her and someone used a medication cart to prevent her from returning to the nurses' station. LVN D said she absolutely grabbed Resident #1's wrist; however, prior to that incident she had asked (unable to recall who she asked) why Resident #1 had bruises on her wrist. LVN D said she was positive she did not cause the bruises. LVN D said in the past Resident #1 would go into the nurses' station often; however, she did not do anything, unless Resident #1 took items from the nurses' desk. LVN D said she knew Resident #1 had a care plan; however, she never has nor did it cross her mind to review the care plan. LVN D said she did not know the care plan included interventions to address Resident #1's behaviors. LVN D said she did not call Resident #1's family member nor did she offer her a drink and/or snack when she became upset. LVN D said she did not document Resident #1's incident or her behaviors, and did not notify the physician, responsible party, Director of Nurses, (DON), and the Administrator, because Resident #1 did not have a change of condition and she did not see it as an escalated change. LVN D said that was Resident #1's normal behavior. LVN D said she was trained in addressing residents with Dementia and/or Alzheimer's but could not recall if it included holding residents by their hands or wrists. LVN D said in the moment of the incident she told Resident #1 You are not going to hit me, I'm stronger than you are. LVN D said she had not had training on elderly aggression. LVN D said when a resident is aggressive, she should offer the resident something to avert their attention, let them be if they are not hurting themselves or others, offer medications, and offer snacks. LVN D said she did not grab Resident 1's wrist, she caught her wrist, which was not appropriate but it depended on the situation. LVN D said the first time she put space between her and Resident #1 was when she was going by the medication cart, the second time was when the CNA directed her to leave, and the third time there was distance between her and Resident #1 until, Resident #1 lunged at me. LVN D said she recalled a resident (Resident #2) in the area but could not recall which one. LVN D said Resident #1 was not within reach of a resident. LVN D said Resident #1 has a history of talking about her deceased dad, and she (LVN D) told her he was dead because she was looking for her dad, and Resident #1 was saying she did not have to leave the nurses' station because her dad built the facility and he owns it. During an interview on 07/17/25 at 10:56 AM with Resident #2, who had been sitting approximately 5 feet from the nurses' station and per video yelled out leave her alone, indicated she could not recall the incident involving LVN D and Resident #1. Record review on 07/18/25 at 3 pm of CNA C's written withes statement indicate on 07/13/25 she witnessed LVN D holding Resident #1's by her wrists and attempting to redirect her. CNA C said LVN D was making verbal comments about Resident #1's dad being dead. Then Resident #1 became combative and that's when the CNAs took resident to her room. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA C had signed these in-services on 07/14/25.During an interview on 07/18/25 at 12:50 pm with CNA B, who works 6 pm to 6 am and 6 am to 6 pm shifts, indicated she was in-service but cannot recall the date, because she works for an agency, which requires her to be at numerous facilities. CNA B said prior to the incident on 07/13/25, between LVN D and Resident #1, she had been in-serviced on preventing A&N, and how to address residents with Alzheimer and Dementia through her required CNA training. CNA B said she knew she could call the ADM anytime of the day or night and that her number was posted on the bulletin board in the facility, and if not, she could ask for her number. CNA B said on 07/13/25 at approximately 6 PM, she heard LVN D say to Resident #1 she could not go there (behind the nurses' station). CNA B said when LVN D grabbed Resident #1's wrists and pulled her from behind the nurses' station. CNA B said intervened by using the medication cart to block the entrance to the nurses' station and asking Resident #1 two or three times to go with her to her room, because she could see that LVN D was holding her wrists. CNA B said Resident #1 pulled her right hand loose and swung at LVN D but missed hitting her. That was when LVN D grabbed her wrists and said If you hit me, I will hit you back. CNA B said she continued to direct Resident #1 to go with her to her room, but she refused. Then CNA A intervened by walking up to LVN D and Resident #1, extending her hand to Resident #1 and asking her to go with her, and Resident #1 complied. CNA B said she walked with CNA A, and Resident #1 towards Resident #1's room, until she stopped in the hallway, pulled her shirt sleeves above her wrists, and said Look what she did to me. CNA B said Resident #1 had redness and bruising (blueish blotches) to her wrists. Afterwards, CNA B left CNA A and Resident #1, who continued to walk to Resident #1's room while holding hands. CNA B s[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to the abuse coordinator, the facility Administrator for 2 of 5 residents (Resident #1) reviewed for abuse.The facility failed to ensure a safe environment free from physical and verbal abuse for Resident #1 on 7/13/25 at 6:07 PM when LVN D grabbed and pulled Resident #1 from behind the nurse's station, and Resident #1 was observed with redness on 07/13/25, and with bruises to both hands and wrists on 07/14/25. During this incident LVN D said to the resident three times that her daddy was dead. LVN D remained working at the facility for 6 hours the remainder shift on 7/13/25 after the incident and had direct contact with Resident #1.The noncompliance was identified as PNC. The IJ began on 07/13/25 and ended on 07/14/25. The facility had corrected the noncompliance before the survey began on 07/15/25. These failures could affect all residents by placing them at risk of continued abuse, physical harm, pain, mental anguish, emotional distress, and serious harm.Findings include: Record review of Resident #1's face sheet, dated 07/17/25, revealed an [AGE] year-old-female who was originally admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia mild, with mood disturbance (cognitive decline with changes in behavior), insomnia (trouble sleeping), anxiety disorder ( excessive worry feelings of fear), disorientation (lost sense of direction), glaucoma (vision loss), schizoaffective disorder bipolar type (mental health condition episodes mania and depression), intermittent explosive disorder (physical and/or verbal outburst), lack of coordination (unsteadiness), muscle wasting (decrease in strength), muscle weakness (lack of movement), depression (sadness), difficulty in walking (abnormal walking pattern). Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE] revealed: Section C Brief Interview for Mental Status (BIMS) score revealed a score of 3 which indicated the resident's cognition was impaired. Section E Behavior indicated Resident 1 had potential behavior of psychosis that included hallucinations and delusions. And she exhibited physical behaviors directed towards others every 1 to 3 days, verbal behaviors directed towards others every 4 to 6 days, and wandering behavior that occurred every 4 to 6 days.Record review of Resident #1's care plan, dated 06/25/2025, revealed:Focus: Resident #1 had episodes of verbal/physical aggression. Date initiated 05/10/2024Intervention: Assist me to phone [family member] during episodes of agitation. Give me as many choices as possible about care and activities. Monitor for physical/verbally aggressive q shift. Document observed behavior and attempted interventions in behavior log.Focus: Resident #1 is an elopement risk/wanderer r/t disoriented to place, wander risk score 11. Date initiated 12/27/2024 date revised 06/25/2025.Intervention: Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, I prefer having snacks. Date initiated 12/27/2024 revised date 12/24/2025.Record review of Resident #1's progress notes, dated 07/14/2025 - 07/16/2025 revealed: On 07/14/2025 at 1:03 PM, the DON documented a Late Entry, they were notified of Resident #1 having bruises to both wrists from an incident that occurred the day before. The DON went to assess Resident #1 and found her to have bruising to both wrists. Resident #1 was asked if she was in pain from the bruising and she stated no. Notified the MD and emergency contact. The MD gave an order to get an x-ray to both wrists. Hospice was notified 07/16/2025 at 3:29 PM, the DON documented spoke with Hospice staff about bruising on [Resident #1's] bilateral wrist. Per Hospice staff, the bruising to her wrists were not there Friday (07/11/2025). Per Hospice staff, she spent about 30 to 40 minutes talking with [Resident #1]. Monday (07-14-2025) Hospice staff did not know about bruising because [Resident #1] had her hands under her head and refused a shower. Noted resident is frequently wearing long sleeves.Record review of the x-ray report dated 07/14/2025 for Resident #1 revealed the right had wrist no acute abnormalities. The left wrist had osteopenia ( body doesn't make new bone as quickly as it reabsorbs old bone) and degenerative changes. Record review of Resident #1's physician's progress note dated 07/15/2025 revealed staff reported new onset bruising to bilateral ( having or relating to two sides; affecting both sides) FA (forearms). Record review of Resident #1's physician's orders dated 07/17/25 revealed Resident #1 was not prescribed blood thinners at the time of the incident.Observation on 07/15/25 at 7:30 AM indicated the nurses' cart was next to the display case that contained the reporting number for abuse and/or neglect and included the Administrator's phone number. Observation on 07/15/25 at 9:30 am of the facility's video recording dated 07/13/25 at 6:07 PM revealed LVN D was at the medication cart that was next to and in front of the nurse' station, when Resident #1 passed behind her and went into the nurses' station. LVN D said to Resident #1 You can't go back there. and Resident #1 replied I can too. LVN D said You cannot. and Resident #1 replied My daddy own's this place. LVN D said Look lady as she grabbed Resident #1's left wrist, and Resident #1 responded by swinging her right hand at LVN D and stated, Leave me alone. LVN D said Stop. LVN D released Resident #1's right hand and placed something LVN D was holding in her hand on the nurses' desk. LVN D grabbed Resident #1's wrists with her hands and started pulling her out from behind the nurses' station. CNA C then approached LVN D and Resident #1 and said, [Resident #1] get out from back there; you can't be back there. LVN D continued to pull Resident #1 as Resident #1 resisted, kicked, and said to LVN D Turn lose my hands. LVN D pulled Resident #1 into the hallway and around the cabinet, which was out of camera view, and CNA C walked along side of them. LVN D could be heard saying I'm not going to fight with you. CNA B approached the nurses' station and said to Resident D Stop, and then CNA B used the medication cart to block the entry way into the nurses' station. Resident #1 could be heard saying My daddy's the one who owns this place. and LVN D responded He doesn't own it anymore because he's dead. Resident #1 replied He's not dead and LVN D said He is. LVN D, who was in front of the camera, walked into the hallway backwards holding Resident #1's wrist, and released her wrists as she passed in front of the nurses' station. Resident #1 followed her and said (Dad's name) is my daddy and he is not dead. Resident 1 kept saying to LVN D, Shut up and I don't want to hear it anymore. Resident #2 who was sitting approximately 3 feet away from LVN D, yelled out Leave her alone. Then CNAs B and C approached LVN D and Resident #1. Resident #1 lifted her arm as if to hit LVN D, walked one step away from LVN D, then walked back and grabbed LVN D's hand. LVN D said Stop, and grabbed Resident #1's wrists, and said Stop. I'm not gonna hit you. You're not strong enough. I'm not gonna let you hit me so you might as well keep walking. CNA A walked up to Resident #1, extended her hand to Resident #1, who jerked her hand back, and CNA A grabbed her by her right wrist and said come with me, as LVN D said You're not goanna win this fight. Resident #1 complied and walked off with CNA A. During an interview on 07/15/25 at 8:30 AM with the ADM indicated on 07/14/25 at 12 pm CNA A alleged LVN D had caused bruising to Resident #1's wrist on 07/13/25 at approximately 6:00 pm. ADM said on 07/14/25 at approximately 12 pm, she observed Resident #1 with bruising to her wrists, and turned in a self-reported incident on 07/14/25 at 1:55 pm per the Submission Report. The ADM said on 07/14/25 at approximately 12 pm, she observed the video recording dated 07/13/25 at approximately 6:08 pm that indicated Resident #1 entered the nurses' station and LVN D pulled her by her wrists out of the area. The ADM said LVN D told the resident her father was dead 2 or 3 times, which escalated Resident #1's behavior. ADM said she reported the incident as required per her policies and procedures, and she spoke to Resident #1, who could not recall how she sustained the bruising that was observed on Resident #1's wrists. ADM directed LVN F to assess Resident #1 obtain physician's order for an x-ray, and to document his findings. ADM notified LVN D's agency that LVN D could no longer work at the facility. ADM said she recognized that CNAs A, B, and C failed to report the incident of abuse to her or the DON. ADM said on 07/15/23 she conducted Safe Surveys with the facilities residents, including Resident #1, who did not recall being abused. ADM said she immediately in-serviced her staff on shift, and staff who were not at the facility would be in-service before working on the floor. These in-services provided on 05/17/25 included Coping with Agitation, Aggression, and Sundowning in Alzheimer and Disease, and Abuse, Neglect, Exploitation and Misappropriation Prevention Program. The ADM said the nurses and CNAs were to receive disciplinary actions against them and she would continue her investigation. ADM said the Medical Director and Resident #1's responsible party were notified. ADM indicated the MD viewed the recording on 07/15/25 and directed her to terminate the contract with the agency that employs LVN D, and that he did not want any of their staff in the building. Prior to the incident on 07/13/25, ADM said she had in serviced the facility's staff and informed them that she was accessible to them twenty-four hours a day, seven days a week. In addition, ADM said prior to the incident she had a form posted next to the reporting guidelines in the hallway next to the nurses' station that included her phone number, and it was there when the incident occurred between LVN D and Resident #1. Record review of the facility's in-service provided 07/15/25 Coping with Agitation, Aggression, and Sundowning in Alzheimer and Disease indicated staff should be patient and try not to show frustration and to avoid arguing, gentle touching to calm down, and take deep breaths and count to 10. Staff should focus on an object or activity to distract, and/or provide a snack and/or beverage. This in-service included protecting yourself and other if needed, and if the resident becomes aggressive, stay at a safe distance until the behavior stops. Talk to a doctor if aggressive behaviors worsen and consider medications that may help. Record review of the facility's in-service provided 07/15/25 and dated Revised 2021, Abuse, Neglect, Exploitation and Misappropriation Prevention Program indicated Resident have the right to be free from abuse and neglect. This included develop and implement policies and protocols to prevent and identify abuse or mistreatment of residents. Establish and maintain a culture of compassion and caring for all resident and particularly those with behavioral, cognitive or emotional problems. Record Review of Resident Safety Survey provided on 07/15/25 indicated the facility's residents were asked the following.I1. Do you feel safe?2. Have you witnessed any abuse (physical or verbal)?3. Does staff knock and introduce themselves when entering your room?4. Do you know who to report alleged abuse to?There were no negative findings on these reports, including Resident #1.Observation on 07/15/25 at 9:50 AM of Resident #1 indicated she had three inches by three inches of bruising that wrapped around her right and left wrists. During an interview on 07/15/25 at 9:51 AM with Resident #1 indicated she could not recall how she sustained the bruising to her wrists.During an interview on 07/15/25 at 12:31 pm with HR indicated the agency is responsible for ensuring staff are trained to work for nursing homes before placing them on the agency portal. HR said if the facility needs a staff, she will apply the request on the porta. This allows the agency staff to accept the request through their portal. HR said the facility is not responsible for their training because the agency is responsible for their training. If the facility had known that LVN D had not been trained in Dementia, she would not have been allowed to work at the facility. Since this incident, HR said the Medical Director has requested the agency's contract terminated, and their staff not be allowed to care for the facility's residents.During an interview on 07/15/25 at 12:52 pm with CNA H, who works 6 am to 6 pm shift, indicated on 07/14/25 she was in-service on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. CNA H said before this incident on 07/13/25 involving LVN D and Resident #1, the ADM in-serviced her that she was available 24 hours a day seven days a week, and her phone number was posted on the bulletin board next to the A&N phone number. CNA H said when Resident #1 is upset, she will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. CNA H said she would not grab a resident by their wrist and force them to leave the area. CNA H said the nurse and CNAs are the ones that updates her with changes to a resident's care plan.Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA H had signed these in-services on 07/14/25. During an interview on 07/15/25 at 1:15 pm with CNA G, who works from 6 am to 4:30 pm, indicated he was in-service on 07/14/25 on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. CNA G said before 07/13/25 he was working but left before the incident occurred between LVN D and Resident #1. CNA G said he received an in-service from the ADM, who informed him her phone number was posted on the bulletin board next to the A&N phone number. CNA G said when Resident#1 is upset, he will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. CNA G said she would not grab a resident by their wrist and force them to leave the area. CNA G said if a resident's plan is changed, he will be informed by the nurse and CNAs.Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA G had signed these in-services on 07/14/25. During an interview on 07/15/25 at 2:09 pm with LVN F, who works from 6 am to 6 pm, indicated on 07/14/25 the ADM asked him to assess Resident #1, obtain orders to X-ray her arms, inform the physician and family, and to document his findings. LVN F said he observed Resident #1 had two-to-three-inch bruising to her wrists but did not document this assessment until later in the day because he took his break and because a resident had a fall he was dealing with. LVN F said he was issued a disciplinary [NAME] for not document his assessment. LVN F said he obtained the order for Resident #1's X-rays, which were negative for fractures. LVN F said during shift report on 07/13/25 at approximately 6 am, LVN E did not inform him that Resident #1 had hit LVN D, and that she had assessed her. LVN F said Resident#1 can get aggressive; however, he will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. LVN F said these steps are in Resident #1's care plan. LVN F said he would not grab a resident by their wrist and force them to leave the area. LVN F said if a resident's plan is changed, he will be informed by the DON or outgoing nurse, and he will share this information with his CNAs. LVN F said in the future he will document his assessments on the resident's progress notes and skin assessment. indicated he was in-service on 07/14/25 on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. LVN F said before 07/13/25 he was in-service by the ADM that she could be reached 24 hours a day seven day a week, and her phone number was posted on the bulletin board next to the A&N phone number.Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated LVN F had signed these in-services on 07/14/25. During an interview on 07/15/25 at 12:31 pm with HR indicated they use an agency, which is a third party, when they need a nurse or CNA to work at the facility due to a facility staff not being able to work. HR said the agency is responsible for ensuring their staff are trained to work at a nursing home, before placing them on the agency portal. HR said if she needs a staff, she will place her request on the portal, and the interested nurse or CNA will accept the request. HR said if she had known LVN D was not up to date on her training she never would have accepted her request to work at the facility. HR, said due to the incident with LVN D abusing Resident 1, the MD has terminated their contract with this agency. During an interview on 07/15/25 at 2:23 pm with CNA A, who works 6 am to 6 pm, indicated on 07/13/25 at approximately 6 pm, she witnessed LVN D direct Resident #1 to throw away cups the cups she had taken from the medication cart, and she complied. CNA A said she head LV D say to Resident #1 she did not belong there, and Resident #1 began yelling. CNA A said she approached Resident #1, who was in front of the nurses' station and tried to hit LVN D. LVN D grabbed resident #1's hands as Resident #1 yelled at LVN D that her daddy owned the facility. CNA A said LVN D said to resident #1 she could say what she wanted but she was protecting herself from Resident #1. Hitting her. CNA A said she intervened by extending her hand between LVN D and Resident #1, who swatted her hand but then allowed CNA A to hold her hand and follow her towards her room. CNA A said before getting into Resident #1's room, she stopped, pulled up her sleeves, and said look what that lady did to me. CNA A said she witnessed Resident #1's wrist was red. CNA A indicated on 07/14/25 Resident #1's hospice aide questions whey Resident #1 had bruises to her hands and wrists. CNA A replied that there was an incident between Resident #1 and LVN D, and the hospice aide question if this had been reported, and CNA A said yes to the ADM. CNA A said she on 07/14/25 she was in-service on preventing A&N and how to address residents with Alzheimer and Dementia, per the in-service forms. CNA A said before this incident on 07/13/25 involving LVN D and Resident #1, the ADM in-serviced her that she was available 24 hours a day seven days a week, and her phone number was posted on the bulletin board next to the A&N phone number. CNA A said when Resident #1 is upset, she will talk to her, offer her a snack and/or drink, and guide her away from the area, which usually works. CNA A said she would not grab a resident by their wrist and force them to leave the area. CNA A said the nurse and CNAs are the ones that updates her with changes to a resident's care plan. CNA A said she intervened to protect Resident #1; however, she failed to report to the ADM immediately. Instead, CNA A said she reported this incident to the ADM on 07/14/25 and was issued a disciplinary action against her. CNA A said on 07/13/25 she did not report the incident between LVN D and Resident #1 because she was distracted due to having a disagreement with a coworker over dividing the rooms which cause her to be distracted, it was shift change, and she was changing briefs and answering call lights. CNA A said when Resident #1 was upset and aggressive, LVN D should have asked one of the CNAs to assist her, because Resident #1 is familiar with the CNAs. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA A had signed these in-services on 07/14/25.During an interview on 07/17/25 at 9:59 am with the DON indicated that what should have happened ( when LVN D abused Resident #1), staff involved should have reported the incident as soon as it happened. Staff should have intervened and then reported the incident. She stated staff are trained to intervene and stop the incident and then report the incident to the ADM, who is the abuse coordinator. The DON stated the staff should have reported immediately and not have waited for several hours to report. The DON stated staff did not follow the facility policy to report abuse immediately, which could have allowed injury, mental or physical abuse to continue. The DON stated to her knowledge Resident #1 is not on any blood thinners, but she is fragile and has thin skin and easy to bruise. The DON stated that the ADM should have been informed immediately because residents have the right to be protected. The DON stated that talking about Resident #1's dad will escalate her behaviors but offering her a snack will help to calm her behaviors. The DON stated that had staff notify her or the ADM when the incident happened, they would have gone to the facility and sent staff home and initiated the investigation. The DON stated Resident #1 doesn't know how the bruising happened and continues to say she doesn't know who did that to her. The DON stated staff reported the incident the next day (07/14/25) because that is when the bruises appeared. The ADM called LVN's agency and told them not to send the nurse back. She stated that they started in-servicing staff on abuse and reporting abuse and working with residents with behaviors.Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated DON had signed these in-services on 07/14/25.Record review on 07/17/25 of LVN D's timesheet dated 07/13/25 indicated she worked at the facility 10 hours and 43 minutes (07/13/25 at 7 am until 12:00 am). During an interview on 07/17/25 at 10:14 AM with LVN D indicated she started her shift on 07/13/25 at 7:00 AM and ended her shift at 12:00 AM. LVN D said at approximately 7 PM, Resident #1 went behind the nurses' station, and was rambling and grabbing stuff off the nurses' desk. LVN D said she told Resident #1 she could not be there, and walked towards Resident #1, who started fighting with her. LVN D said she caught Resident #1's wrist to keep her from hitting her and someone used a medication cart to prevent her from returning to the nurses' station. LVN D said she absolutely grabbed Resident #1's wrist; however, prior to that incident she had asked (unable to recall who she asked) why Resident #1 had bruises on her wrist. LVN D said she was positive she did not cause the bruises. LVN D said in the past Resident #1 would go into the nurses' station often; however, she did not do anything, unless Resident #1 took items from the nurses' desk. LVN D said she knew Resident #1 had a care plan; however, she never has, nor did it cross her mind to review the care plan. LVN D said she did not know the care plan included interventions to address Resident #1's behaviors. LVN D said she did not call Resident #1's family member nor did she offer her a drink and/or snack when she became upset. LVN D said she did not document Resident #1's incident or her behaviors, and did not notify the physician, responsible party, Director of Nurses, (DON), and the Administrator, because Resident #1 did not have a change of condition, and she did not see it as an escalated change. LVN D said that was Resident #1's normal behavior. LVN D said she was trained in addressing residents with Dementia and/or Alzheimer's but could not recall if it included holding residents by their hands or wrists. LVN D said in the moment of the incident she told Resident #1 You are not going to hit me, I'm stronger than you are. LVN D said she had not had training on elderly aggression. LVN D said when a resident is aggressive, she should offer the resident something to avert their attention, let them be if they are not hurting themselves or others, offer medications, and offer snacks. LVN D said she did not grab Resident 1's wrist, she caught her wrist, which was not appropriate, but it depended on the situation. LVN D said the first time she put space between her and Resident #1 was when she was going by the medication cart, the second time was when the CNA directed her to leave, and the third time there was distance between her and Resident #1 until, Resident #1 lunged at me. LVN D said she recalled a resident (Resident #2) in the area but could not recall which one. LVN D said Resident #1 was not within reach of a resident. LVN D said Resident #1 has a history of talking about her deceased dad, and she (LVN D) told her he was dead because she was looking for her dad, and Resident #1 was saying she did not have to leave the nurses' station because her dad built the facility, and he owns it. During an interview on 07/17/25 at 10:56 AM with Resident #2, who had been sitting approximately 5 feet from the nurses' station and per video yelled out leave her alone, indicated she could not recall the incident involving LVN D and Resident #1. Record review on 07/18/25 at 3 pm of CNA C's written withes statement indicate on 07/13/25 she witnessed LVN D holding Resident #1's by her wrists and attempting to redirect her. CNA C said LVN D was making verbal comments about Resident #1's dad being dead. Then Resident #1 became combative and that's when the CNAs took resident to her room. Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA C had signed these in-services on 07/14/25.During an interview on 07/18/25 at 12:50 pm with CNA B, who works 6 pm to 6 am and 6 am to 6 pm shifts, indicated she was in-service but cannot recall the date, because she works for an agency, which requires her to be at numerous facilities. CNA B said prior to the incident on 07/13/25, between LVN D and Resident #1, she had been in-serviced on preventing A&N, and how to address residents with Alzheimer and Dementia through her required CNA training. CNA B said she knew she could call the ADM anytime of the day or night and that her number was posted on the bulletin board in the facility, and if not, she could ask for her number. CNA B said on 07/13/25 at approximately 6 PM, she heard LVN D say to Resident #1 she could not go there (behind the nurses' station). CNA B said when LVN D grabbed Resident #1's wrists and pulled her from behind the nurses' station. CNA B said intervened by using the medication cart to block the entrance to the nurses' station and asking Resident #1 two or three times to go with her to her room, because she could see that LVN D was holding her wrists. CNA B said Resident #1 pulled her right hand loose and swung at LVN D but missed hitting her. That was when LVN D grabbed her wrists and said, If you hit me, I will hit you back. CNA B said she continued to direct Resident #1 to go with her to her room, but she refused. Then CNA A intervened by walking up to LVN D and Resident #1, extending her hand to Resident #1 and asking her to go with her, and Resident #1 complied. CNA B said she walked with CNA A, and Resident #1 towards Resident #1's room, until she stopped in the hallway, pulled her shirt sleeves above her wrists, and said Look what she did to me. CNA B said Resident #1 had redness and bruising (blueish blotches) to her wrists. Afterwards, CNA B left CNA A and Resident #1, who continued to walk to Resident #1's room while holding hands. CNA B said she reported the incident to LVN E, on the night of 07/13/25 at 12 am, because she was the nurse relieving LVN D. CNA B said she did not report the incident to the Administrator, because she was busy answering call lights. CNA B said she should have called the Administrator immediately, because she had been in-serviced and informed that the ADM's phone number was posted next to the bulletin board next to the number for reporting abuse and neglect. CNA B said during the incident she intervened to protect Resident #1 from LVN D by using the medication cart to block the entrance to the nurses' station, after she saw LVN D pulling Resident #1 by her hands out of the nurses' station. Then CNA B said she asked Resident #1 two or three times for her to go with her to her room, but she did not comply. Then CNA A reached her hand out to Resident #1 and asked her to go to her room, and Resident #1 complied because she is very familiar with CNA A. CNA B said since 07/13/25 she had not worked at the facility. CNA B said Resident #1 in the past has been redirected and offered snacks when she has been aggressive, and that works. CNA B said she in updated on residents' care plans by the nurses and CNAs.Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 07/14/25, indicated CNA B had signed these in-services on 07/14/25.Record Review of the Counseling Notice for CNA C signed and dated on 7/15/25 and signed by the DON revealed, CNA C received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of the Counseling Notice for CNA A signed and dated on 7/15/25 and signed by the DON revealed, CNA A received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of the Counseling Notice for LVN E signed and dated on 7/15/25 and signed by the DON revealed, LVN E received a Final written warning for failure to report abuse and neglect per policy and procedure. Further Infractions will result in disciplinary action up to and including termination. Record Review of undated text messages at 4:17 PM from the facility ADM to the staffing agency revealed that the staffing agency acknowledged that dementia training was not mandatory unless the staffing agency was notified that it should be and moving forward the agency would document as a requirement. Record Review of an email dated 7/15/25 from the ADM to the staffing agency revealed that effective 7/15/25 the facility would no longer be using the staffing agency. IA phone call interview on 07/18/25 at 1:20 PM was attempted with LVN E via a voice mail and text message, but she did not return the message. Record review of LVN E's written statement(that was not dated) but provided 07/18/25 indicated Was told in report from nurse (LVN D) that resident (Resident #1) became combative and aggressive while being redirected from nurses' station. CNA stated that nurse was holding resident by the wrist to stop her from hitting. Went and checked for new bruising but none noted at that time, only scattered bruising to BUE (Bilateral Upper Extremities). Was not told that abuse was suspected and did not know of all details until ADM watched camera footage.Review of the facility's Inservice Training Report dated 07/14/25 for Alzheimer's Disease, Coping with Agitation , Aggression, and Sundowning in Alzheimer's Disease, and Abuse, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program da[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents had the right to be free from sexual abuse for 3 (Resident #3, Resident #4 and Resident #6) of 9 residents reviewed for abuse. 1. The facility failed to put protective measures in place on 05/11/24 to protect Resident #4 from sexual abuse after knowing Resident #2 had displayed inappropriate sexual behavior with Resident #3. 2. The facility failed to put protective measures in place on 06/02/24 to protect Resident #3 in place from sexual abuse after knowing Resident #5 had a history of inappropriate sexual behavior. 3. The facility failed to put protective measures in place on 06/02/24 to protect Resident #6 in place from sexual abuse after knowing Resident #5 had a history of inappropriate sexual behavior. On 06/07/24 at 5:00 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 06/09/24 at 3:30 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure caused additional residents to be sexually abused and potentially placed other residents at risk for sexual abuse. Findings Include: 1. Findings for the facility's failure to put protective measures in place on 05/11/24 to protect Resident #4 from sexual abuse after knowing Resident #2 had displayed inappropriate sexual behavior included: Record review of Resident #2's face sheet, dated 06/05/24, revealed a [AGE] year-old-male that was readmitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember), depressive disorder (constant feelings of sadness), mood disorder (emotional deficit), and blindness to the right eye. Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. Section B Hearing, Speech, and Vision revealed that Resident #2 had clear speech, makes himself understood, and understands others. His vision is impaired, and he does not wear corrective lenses. Section E Behavior revealed that he had not had any incidents of physical or verbal behavior. Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a blank BIMS score. Section E Behavior revealed that he had had delusions, physical behaviors such as hitting, kicking, pushing, scratching, grabbing, and abusing others. Resident # 2 had exhibited verbal behaviors such as threatening others, screaming, and cursing at others. Resident #2 had other behavioral symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, smearing food or bodily wastes, or verbal/vocal symptoms like screaming and disruptive sounds. Resident #1 exhibited wandering behavior 1-3 days. Record review of Resident #2 care plan, dated 05/01/24 revealed the following: Resident #2 wanders in other residents' rooms and gets into their beds at times and had the following interventions: Resident #2 required assistance out of rooms that were not his and staff could use snacks if needed. Resident #2 was an elopement risk/wanderer and had the following interventions: Distract Resident #2 from wandering by offering pleasant diversions. Resident #2 prefer having snacks. Followed by [name of psych care]. Notify their MD/NP of any escalation in wandering behaviors, ineffectiveness, or side effects of psychiatric medications. Monitor the resident's location throughout shifts. Document wandering behavior and attempted diversional interventions in behavior log. Resident #2 had episodes of verbal and physical aggression r/t dementia with the following interventions: Give me as many choices as possible about care and activities. Monitor for physically/verbally aggressive behavior q shift. Document observed behavior and attempted interventions in behavior log. Monitor/document/report PRN any s/sx of Resident #2 posing danger to self and others. Resident #2 had impaired visual function r/t cataracts and glaucoma. Resident #2 was blind in his right eye with the following interventions: Arrange consultation with eye care practitioner as required. Monitor/document/report PRN any s/sx of acute eye problems: Change in ability to perform ADLs, decline in mobility, sudden visual loss, pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. Place frequently used items on my left side so I may see them. Record review of Resident #2's progress notes revealed the following: Record review of on 05/11/24 at 12:12 AM LVN G documented: Data: Resident observed by CNA H reported to this nurse observed resident with pants unzipped and PENIS in Resident #3's hand. Action: Resident removed from Resident #3's room w/o incident. Resident #3 appears to have been asleep during entire incident. No physical injuries noted at this time. Response: Resident in his room and placed on 1-1 monitoring per DON instructions. Roommate moved to different room as this nurse considers this a HIGH RISK INCIDENT. DON & Administrator notified. Record review of on 05/11/24 at 03:23 PM The DON documented: Received orders from NP may administer Lorazepam 1ml now and then every 8 hours as needed. DON gave orders to charge nurse may use emergency restraint for safety of resident and others. Record review of on 05/11/24 at 05:27 PM the DON documented: Spoke with Family Member L about incident and orders to give Lorazepam 2mg/ml injection every 8 hours as needed x 14 days. Voiced understanding and gives verbal consent at this time for medication. Also discussed that he would be going back to the behavior support center on Monday and facility would be actively looking for alternate long-term placement for resident. Voiced understanding and consents for referrals to be sent to other facilities. Record review of on 05/11/24 at 05:27 PM LVN B documented: Staff alerted this nurse that this male resident was found in female resident's bed with his hands in the female's pants. Upon entering room male resident is found in bed with female resident with his hand on resident's waist. Told resident he needed to get out of bed. RT refused and put his arm around female resident. Male resident immediately removed from female's bed and taken to his own room. Resident became aggressive with staff refusing to leave bed causing CNAs to fall. Administration notified. Physician A, the DON notified. New order for Ativan 2mg/ml injection. Injection administered. Resident continues to try to go into other female rooms. Record review on 05/31/24 at 01:07 PM The DON documented: Resident returned from behavioral center via their facility van. Notified Physician A of return and medications. Notified the NP of return and reconciled psychotropic medications. Notified family Member L of return and went over psych medications and no issues or concerns at this time. Record review of on 06/02/24 at 03:26 AM LVN M documented: Follow-up on readmission, resident continues to urinate on floor. Reminded resident to use urinal. Resident voiced understanding. Resident also continues to wander. Resident breathing even and unlabored. No complaints voiced. Record review of on 06/02/24 at 07:35 PM The DON documented: Notified by charge nurse that resident was wandering in rooms and becoming aggressive when staff was trying to redirect. Contacted the NP and new orders received to increase Seroquel to 50mg 3 times daily, Xanax 0.25mg every 6 hours as needed x 14 days, and Zyprexa 10mg IM every 12 hours as needed x 14days. Notified Family Member L of resident behavior and new orders. Voiced understanding and no issues or concerns at this time. Record review of Resident #2's monitoring sheets revealed the following: Resident #2 was monitored every 30 minutes starting 05/08/24 at 11:30 AM until 5/10/24 at 6:00 PM. (No abnormal behavior reported during this monitoring time.) No time monitoring accounted for 05/10/24 at 11:00 PM- 12:00 AM. Resident #2 was monitored on 05/11/24 from 1:00 AM-5:45 AM. (No abnormal behavior notated during this time. No time monitoring accounted for 12:00 AM-1:00 AM.) Resident #2 was monitored on 05/11/24 from 6:30 AM-4:00 PM. (No abnormal behavior notated during this time. No time monitoring accounted for 4:30 PM-6:00 PM) Record review of Resident #3's face sheet, dated 06/05/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (memory loss), cognitive communication deficit (difficulty communicating), fracture to neck and left femur, anxiety disorder (increased worry), and major depressive disorder (increased sadness). Record review of Resident #3's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 01, which indicated the resident's cognition was severely impaired. Section B. Ability to understand others revealed that she had clear speech, sometimes could make herself understood, and sometimes could understand others. Record review of Resident #3's care plan dated 6/5/24 revealed the following: Resident #3 was dependent on staff for emotional, intellectual, physical, and social needs related to cognitive deficits. Resident #3 required assistance to ADLs related to Alzheimer's disease, had impaired cognitive function/impaired thought processes related to Alzheimer's, had a mood problem related to depression, and had potential for psychosocial well-being related to trauma. Record review of Resident #3's progress notes revealed the following: 05/11/24 at 01:27 AM LVN G documented: Resident #2 observed in resident's room with Penis in her hand attempting what appears to ejaculate himself. Resident Immediately stopped by staff and removed to his room. Placed on 1-1 monitoring with instructions by DON NOT to be left out of staff sight at any time. No apparent injuries not upon physical inspection with female CNA present. DON to notify PCP & family. Record review of Resident #4's face sheet, dated 06/05/24, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis that included Alzheimer's disease (memory loss). Record review of Resident #4's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section B. Ability to understand others revealed that she had clear speech, could make herself understood, and could understand others. Record review of Resident #4's care plan dated 4/29/24 revealed the following: Resident #4 was dependent on staff for emotional, intellectual, physical, and social needs related to cognitive deficits. Resident 41 had impaired cognitive function related to Alzheimer's disease. Record review of Resident #4's progress notes revealed the following: 05/11/24 at 05:32 PM LVN B documented: Staff alerted this nurse that Resident #2 was found in female resident's bed with his hands in female's pants. Upon entering room male resident is found in bed with female resident with his hand on resident's waist. Male resident immediately removed from female's bed and taken to his own room. Female resident assessed for injury, no visible injury noted. Administration notified. DON to speak with family regarding incident. During an interview on 06/05/24 at 1:49 PM, CNA E stated that one night, when he worked the night shift (unsure of the date and exact time), Resident #2 exposed himself to Resident #3. He said he did not see it but was told by CNA H that Resident #2 had his penis in Resident #3's hand and was jerking off. He said because of that incident, Resident #2 was placed on 1:1 and was checked every 15 minutes by the night staff. He said Resident #3 was not in her right mind and would have been unable to consent. He said Resident #3 may have a BIMs score of 0. He said prior to the incident involving Resident #3, Resident #2 was not on any close monitoring. He said that when Resident #3 was in the dining room and wanted to return to his room, they would assist him, but after he was in his room, they did not do additional monitoring. During an interview on 06/05/24 at 2:57 PM, LVN G stated that on 05/11/24, he was working the night shift. He said he heard a young lady yell out. He said it was the female CNA but did not know her name. He said he was on break. He said the female CNA reported that Resident #2 had a particular part of his anatomy in Resident #3's hand. LVN G stated they assisted in getting Resident #2 out of Resident #3's room. He stated when he walked in, he did not see Resident #2's penis in Resident #3's hand but did see his penis out. He said he had not seen Resident #2 do the sexual act in the past, but that Resident #2 would expose himself and urinate on the floor. He stated that, because of the incident, he reported it to the DON and was instructed to place Resident #2 on 1:1 monitoring. He stated he would sit in the hall and ensure Resident #2 did not go into other rooms. LVN G said that Resident #3 was catatonic (immobile) and could not defend herself. LVN G did not confirm that the DON or the ADM provided specifics to what was expected regarding placing Resident #2 on 1:1 monitoring. During an interview on 06/05/24 at 4:04 PM, the ADM stated she was told but could not remember who told her that Resident #2 was standing over Resident #3 with his penis out and Resident #3's hand was on Resident #2's. The ADM stated she was not told that Resident #2 was masturbating. She said in addition to being notified about Resident #3, she was informed later that day (05/11/24) by LVN B that Resident #2 had gotten into bed with Resident #4 and had his hand near her privates. She said she had read the progress notes since the state surveyor exited on 05/09/24. She said she did not report or investigate both incidents of inappropriate sexual behavior because, in both incidents, all residents involved had dementia. The ADM stated that Resident #2 was placed on 1:1 during the second incident involving Resident #4 because Resident #2 became aggressive. The ADM stated that Resident #2 was not put on 1:1 during the first incident involving Resident #3 because he was not aggressive, and this was the first time he displayed this behavior. During an interview on 06/05/24 at 4:24 PM, the DON stated when the inappropriate sexual incidents were reported to her, she reported it to the ADM as she was the abuse coordinator. She said she had not completed any specific training with staff regarding Resident #2's behavior after the first incident. During an interview on 06/05/24 at 5:14 PM, the NP stated she was aware of and had been notified about the inappropriate sexual touching between Resident #2 and #4. She said that she had charted in her notes that the DON was concerned about the behavior of Resident #2. The NP reported that the DON reported to her that Resident #2 was found in the room of a defenseless resident (Resident #3), and he placed his penis in her hand, and was stroking his penis. The NP then said it was reported to her that Resident #2 was found in the room of another female resident on a separate incident and became combative with staff. The NP stated that she permitted the nursing staff to administer Ativan to Resident #2 during the first incident with Resident #3. During an interview on 06/06/24 at 5:04 AM, CNA N stated she had observed Resident #2 go into a female resident's room but always redirected him when she was on shift. She stated that when he would attempt to go into residents' rooms (male and female), she would report it to her charge nurse. She said she could not tell exact dates and times but that it had happened more than once that she had to redirect Resident #2 out of other rooms. CNA N said his behavior for wandering was constant when he was awake. During an interview on 06/06/24 at 9:47 AM, CNA H stated the incident between Resident #2 and #3 occurred on 05/10/24 around 11:00 PM. She said she was told to go and check on another resident by LVN G. While doing so, she observed Resident #2 in Resident #3's room. When she got closer, she was able to see that he had his penis out, and Resident #3's hand was cuffed under Resident #2's penis. She said Resident #2 had his hand under hers and was masturbating (rubbing it up and down). CNA H said she yelled for help, and LVN G and CNA E assisted her. CNA H said the two male staff could get Resident #2 out of Resident #3's room without any issues. CNA H stated that administration instructed them to watch Resident #2. CNA H said all staff took turns watching Resident #2 every two hours and sat outside his door. CNA H said they told the oncoming shift what happened, and that Resident #2 was on 1:1 supervision. Before the incident on her shift, CNA H said she had not been given any specific instructions regarding Resident #2. She stated that they did pass the information the following shift. CNA H said LVN G had reported the incident between Resident #2 and Resident #4. During an interview on 06/06/24 at 11:47 AM, the Dietary [NAME] stated she assisted in 1:1 monitoring with Resident #2 before the incident on 05/11/24 with Resident #3. The Dietary [NAME] stated that when she watched Resident #2, he continued to display wandering and had to be redirected. She said during her monitoring, she did observe him pull out his penis and urinate on the floor. She said this occurred while he was in his room during the night shift. The Dietary [NAME] said she suggested during the morning meeting (before the incidents on 05/11/24) that Resident #2 be moved closer to the nurses' station for better observation. The Dietary [NAME] said the ADM looked at her, looked at the whiteboard that had the room assignments, and continued the meeting. The Dietary [NAME] said she does not have the ability to change rooms for residents and that this was the duty and responsibility of the ADM and the DON. The dietary [NAME] said outside of monitoring no additional efforts were made to supervise Resident #2's behaviors. During an interview on 06/06/24 at 12:25 PM, the DON stated she did not see the discrepancy in the monitoring sheet that showed that Resident #2 was not monitored from the alleged time of the incident on 05/10/24 from 11:00 AM until 05/11/24 1:00 AM. She said the person in charge of staying with Resident #2 during the first incident would have been LVN G. During the second incident that involved Resident #2 and #4; she was unaware of why there was a gap in the monitoring sheet from 4:00-6:00 PM. The DON said she did not see the gap and, since she had seen it, had not followed up or questioned why there was a gap. The DON said there should have been a staff assigned 1:1 with Resident #2 on 05/11/24 and this could have prevented the incident with Resident #4. She said that once she was notified about the incident between Resident#2 and #4, she realized that there was not a 1:1 staff with Resident #2. The DON stated that normally, staff call administration when staff do not show up, and that she was unaware of why the staff did not call on 05/11/24 when the monitor tech did not show up. The DON said the only interventions that have been put in place for Resident #2 were medication adjustments and redirection from staff. She said those interventions had not been successful. The DON said no specific interventions were put in place for the night shift even though it had been identified previously that Resident #2 tended to have increased behaviors at night. The DON said it had been discussed at morning meetings that they would like to hire more staff. The DON stated that Resident #2 did exhibit wandering during the days before his inappropriate sexual behavior. The DON said inappropriate sexual behavior was new, and this was why she told LVN G to watch him. The DON said she was unsure if the oncoming shift after the first incident was notified of the 1:1 monitoring expectation and that she did not follow up to see if this was done. The DON stated she did not come up to the facility after the instructions for 1:1 was given. She said that usually, in special supervision circumstances, the ADM would come to the facility because she lives in town, and the DON does not. She said that she did not remember discussing with the ADM about the ADM coming to implement formal training for Resident #2's inappropriate sexual behavior. The DON said that regarding the incident with Resident #2, the potential negative outcome was that other incidents could also occur if this was another resident. The DON said she never expected the sexual incident because he never displayed that type of behavior. The DON said she was unaware that he had sexual tendencies. She said the system the facility had in place for monitoring was the 1:1 for the 72 hours when he returned from any behavior support. The DON said she had never observed any sexual behavior or his continued wandering behavior in person. She said all staff were responsible for keeping abuse from happening. The DON said the staff handled everything correctly regarding Resident #2 and his inappropriate sexual behavior with Resident #3 and #4. The DON said the purpose addressing resident behaviors was to protect the residents and to follow policy. During an interview on 06/06/24 at 1:16 PM, The ADM stated no one ever relayed to her that they considered the inappropriate sexual contact a high-risk situation. The ADM said she vaguely remembered talking about moving Resident #2's room but that the way the facility was set up had all of the females and the males together. The ADM stated moving Resident #2 would have placed him among the female residents. The ADM stated she was unaware of who monitored Resident #2 from 05/10/24 at 11:00 PM until 05/11/24 at 1:00 AM. The ADM stated she did not have the monitoring sheets and that the DON had those sheets. The ADM stated the DON was responsible for reviewing those sheets. The ADM said she sometimes reviewed them to ensure they were completed, but not regularly. The ADM said Resident #2 was not supervised because there was supposed to be a monitor tech at the facility, but they did not show up. The ADM stated that staff were trained on what to do if someone does not show up for their shift but were unaware that the staff on 05/11/24 during the day shift was aware that there was supposed to be someone for 1:1 with Resident #2. The ADM said they usually do 1:1 monitoring with any resident for 72 hours after being released from a behavior support center. She said Resident #2 was released on 05/10/24 from 1:1 supervision after being admitted back to the facility on [DATE]. The ADM stated that Resident #2 had no issues during his monitoring period. The ADM said if he had problems, staff would have reported them to her. She stated that staff had been trained to report concerns but that she did not have any written documentation to show that staff had been trained to report incidents while observing 1:1 with Resident #2. The ADM said that it was a verbal instruction given when Resident #2 was placed under 1:1 supervision on 05/11/24 after the incident with Resident #4. The ADM said no formal training was conducted. The ADM stated regarding Resident #2, the inappropriate sexual behavior was new. She said that before, Resident #2 had aggression toward staff and other residents. The ADM said she was unaware of Resident #2's tendency for sexual behavior. The ADM stated she was unaware that Resident #2 was not under 1:1 supervision when he acted inappropriately sexually against Resident #4. The system to monitor behaviors and prevent abuse specifically involved close monitoring and monitoring tech assistance. The ADM said that not addressing a resident's inappropriate sexual behavior and supervising the residents correctly could result in harm to other residents. During an interview on 06/06/24 at 2:30 PM, Resident #4 stated she kind of remembered being touched by a man. She was unable to specify a date, time, or person. During an interview on 06/06/24 at 7:26 PM, the Regional Director stated the ADM was responsible for all activities in the facility He said he would expect for the ADM and the DON to follow facility policies. During an interview on 06/07/24 at 9:00 AM, Resident #2 stated he did not touch anyone. He stated that the staff treated him well at the facility, and he was able to move around the facility without staff. He said that all the residents liked him and celebrated him. He was unable to clarify what he meant by celebrate. During an interview on 06/07/24 at 12:00 PM, LVN B stated that she did not observe what happened. She stated what she noted in the resident's progress notes was what she saw. She said that the medication aide notified her but that he no longer worked at the facility. LVN B said she assessed the situation and observed Resident #2's hands in Resident #4's pants. LVN B said they told Resident #2 that he needed to stop and get out. LVN B stated that when she tried to redirect Resident #2 out of the room, which was when Resident #2 became aggressive. LVN B said Resident #2 was kicking, and it was difficult because Resident #4's bed was low and on the ground. LVN B said Resident #2 was trying to kick and fight the Medication Aide. LVN B said she was upset about the incident. She said it was not passed on that he needed to be 1:1 the night before. LVN B was made aware of the incident with Resident #3, and she was told that she had to do close monitoring. She said she would set her timer and check on him every 30 minutes. She said it would have been impossible for her to sit with him 1:1, and she was the only charge nurse. LVN B said she does not know why she did not completely sign off on the monitoring form between 4:00 PM and 6:00 PM. LVN B confirmed that the initials by the 4:00-6:00 PM blank hours were hers. LVN B said on 05/11/24 during her shift (day 6:00 AM-6:00 PM), she or her staff did not sit 1:1 with Resident #2. LVN B said she would peek in on Resident #2 when she could, but she was the only nurse for all of the residents at the facility. During an interview on 06/07/24 at 12:11 PM, CNA K stated that she did physically see Resident #2's hand in Resident #4's pants. She said Resident #2's right hand was in Resident #4's brief. CNA K said Resident #2's nails were extremely long and gross. CNA K said Resident #4 was not doing anything during this incident. CNA K said Resident #4 had no emotion on her face, but her eyes were open. She said that 05/11/24 Resident #2 was all over the facility and not on special 1:1 supervision. CNA K said no monitor techs were on duty that day (05/11/24). During an interview on 06/07/24 at 12:17 PM, CNA J stated that she does not know much about the incident that occurred on 05/11/24 with Resident #2 and Resident #4. She said that the Medication Aide was the one who observed Resident #2 touching Resident #4. CNA J said they had not been notified that Resident #2 was on 1:1 and were not trained to do anything different with Resident #2. 2. Findings for the facility's failure to put protective measures in place on 06/02/24 to protect Resident #3 from sexual abuse after knowing Resident #5 had a history of inappropriate sexual behavior included: Record review of Resident #3's progress notes revealed the following: 05/11/24 at 01:27 AM LVN G documented: Resident #2 observed in resident's room with Penis in her hand attempting what appears to ejaculate himself. Resident Immediately stopped by staff and removed to his room. Placed on 1-1 monitoring with instructions by DON NOT to be left out of staff sight at any time. No apparent injuries not upon physical inspection with female CNA present. DON to notify PCP & family. Record review of Resident #5's face sheet, dated 06/09/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses that included other sexual dysfunction (difficulty with sexual response), intermittent explosive disorder (impulsive and aggressive outbursts), insomnia (difficulty sleeping), age related cognitive decline, and cognitive communication deficit (difficulty communicating). Record review of Resident #5's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 07, which indicated the resident's cognition was severely impaired. Section B. Ability to understand others revealed that she had clear speech, could usually make herself understood, and usually understood others. Section E Behavior revealed that he had no documented behavior outside of wandering that occurred 1-3 days. Record review of Resident #5's care plan dated 6/02/24 revealed the following: Resident #5 occasionally attempted to be sexually inappropriate with staff and other residents. Resident #5 occasionally stated he was a killer and a rapist. Resident #5 had impaired cognitive function. Record review of Resident #5's progress notes revealed the following: On 06/02/24 at 02:20 PM LVN Q documented: LATE ENTRY Data: Resident #5 was kissing another resident (unidentified) on the lips. Action: Stopped the resident and sent him to his room and informed him not to be kissing other female residents. Response: WCTM this shift. 06/02/24 at 08:50 PM LVN Q documented: LATE ENTRY Data: Resident #5 was seen by a staff member touching and kissing on another resident (unidentified) in the dining room. Action: Removed the resident away from the other resident and informed him to keep his hands to himself. Response: WCTM this shift. On 06/09/24 at 02:56 PM the DON documented: Family members x 3 here to see [Resident #5]. Family would like facility to attempt referrals closer to their area. They would like referrals sent to multiple facilities. Informed Family that we would start referral process on Monday. Record review of Resident #5's monitoring sheets revealed the following: No time monitoring accounted for the following dates: 06/02/2024. Resident #5 was monitored every 15 minutes starting 06/09/24 at 12:00 AM until 11:45 PM (No abnormal behavior reported during this monitoring time). Resident #5 was monitored every 15 minutes starting 06/10/24 at 12:00 AM until 12:45 PM (No abnormal behavior reported during this monitoring time). During an interview on 06/09/24 at 11:23 AM, the DON stated as a result of the IJ, they were able to identify two other incidents that involved inappropriate sexual touching that was not investigated or reported. This occurred with Residents #5, and #3. She stated they identified the incident when they were following their removal plan and reviewing progress notes for potential residents that could be affected. The DON stated they immediately placed Resident #5 on Red supervision, notified Physician A, assessed all residents involved (Resident # 5 and #3), notified the family of both residents, and trained staff. The DON stated that she did not have details of what happened but that they had started the process of investigating. During an interview on 06/09/24 at 12:46 PM, the Dietary [NAME] stated she was present for the incident with Resident #5 and #4. The Dietary [NAME] said she was unsure of the date but that it happened a week before the interview. The Dietary [NAME] said the incident with Resident #4 involved Resident #5 touching and rubbing Resident #4's breast in the dining room. She said she reported this to LVN B and the ADM. She said she was u[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse and neglect for 4 (Resident #1, Resident #3, Resident #4, and Resident #6) of 9 residents reviewed for abuse and neglect. The facility failed to implement their abuse and neglect policy when: 1. The facility failed to investigate the fall incident that occurred with Resident #1 while in the care of CNA E on 05/30/24. CNA E failed to notify the nurse of the fall. Resident #1 sustained a hip fracture. 2. The facility failed to report to the state agency and investigate a sexual incident that occurred on 05/10/24 between Resident #2 and Resident #3. 3. The facility failed to report to the state agency and investigate a sexual incident that occurred on 05/11/24 between Resident #2 and Resident #4. 4. The facility failed to notify Family Member C of the inappropriate sexual incident that involved Resident #3. 5. The facility failed to report to the state agency and investigate a sexual incident that occurred on 06/02/24 between Resident #5 and Resident #3. 6. The facility failed to report to the state agency and investigate a sexual incident that occurred on 06/02/24 between Resident #5 and Resident #6. On 06/07/24 at 5:00 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 06/09/24 at 3:30 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The failures placed resident at risk for continued abuse and neglect and a decline in quality of life, harm and mental anguish. Findings included: 1. Findings for fall incident that occurred on 05/30/24 with Resident #1 and CNA E included: Record review of Resident #1's face sheet, dated 06/05/24, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), major depressive disorder, anxiety (increased feelings of fear, dread, and uneasiness), and cognitive communication deficit (difficulty understanding and communicating). Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 04, which indicated the resident's cognition was severely impaired. Section B Hearing, Speech, and Vision revealed that Resident #1 had slurred speech, could make himself understood, and usually understood others. Section GG Functional Abilities and Goals indicated the Resident #1 was dependent and this could mean that the resident did all the effort or that he required the assistance of 2 or more helpers to complete the activity of tub or shower transfer. Record review of Resident #1 Care Plan, dated 05/29/24, revealed the following: Resident #1 had an ADL self-care performance deficit r/t to limited range of motion due to CVA. Resident #1's self-performance fluctuated r/t confusion, but he usually requires assistance with ADLs. Resident #1 required 1-2 staff for showering/bath and shower/tub transfer Resident #1 required two+ person physical assists. Resident #1 used a mechanical lift for transfers with a minimum of two staff present unless transferring with therapy/ restorative. Resident #1 was at risk for falls r/t balance problem. Ensuring Resident #1 frequently used items were within reach. Resident #1 had osteoporosis and was at risk for fractures. Record review of Resident #1's progress notes revealed the following: 05/30/24 at 1:10 AM LVN F documented: Xray results show positive intertrochanteric hip fracture (upper thigh hip fracture) to left hip. Physician A notified and received orders to send [Resident #1] to ER to evaluate. Notified [Family Member A] POA. EMS here to transport resident to local hospital. Report called in to ER. ADM and DON notified as well. 05/30/24 at 1:43 AM the DON documented: 5:38 PM was notified by charge nurse that resident was c/o left hip pain. Instructed charge nurse to notify [Physician A]. Nurse received orders to obtain x-rays to left hip. Notified administrator of resident c/o left hip pain. Then instructed night nurse to notify as soon as x-ray results received. Received notification at 10:25 pm from night charge nurse that x-ray showed a left acute intertrochanteric hip fracture (upper thigh hip fracture). Immediately notified administrator of findings. 06/03/24 at 9:29 PM the LVN F documented: Resident readmitted to facility following hospitalization following fall on 5/30 resulting in intertrochanteric hip fracture (upper thigh hip fracture) to left hip. Dynamic hip screw surgery to left hip. Resident weight bearing as tolerated. During an interview on 06/05/24 at 12:07 PM, Family Member D stated on 05/30/24 she visited with Resident #1. She stated that he had received a shower that morning from CNA E. She said during the day, around the time they played Bingo, Resident #1 started complaining that his butt hurt. She said she thought maybe he was constipated. She said that when the CNAs (CNA J and CNA K) went to put him in bed, he started complaining of pain. She said Resident #1 pointed to his left side and said, Hurt hurt. She said she waited until the CNAs left to notify RN I to ask Resident #1 what happened because he was complaining more than earlier. Resident #1 told me that he fell in the shower that morning with CNA E. She said Resident #1 said he fell and hit his head. She said CNA E was in the room when Resident #1 fell but he did not see Resident #1 fall because his back was to Resident #1. CNA E was shutting the bathroom door when Resident #1 fell. Family Member D said she asked if Resident #1 had reported to anyone that he had fallen and if the nurse knew. She said Resident #1 said no. She said Resident #1 explained that it was an accident, that he did not want to get CNA E in trouble, and that he liked him. She said she spoke with CNA E after Resident #1's fall (unknown date and time), and he said he was sorry and acknowledged the fall. She said CNA E told her that he told the ADM and therapy. She stated she was not notified of the fall and was at the facility when CNA E showered Resident #1. She said she would have liked to have been told so that she could have had Resident #1 checked out immediately. During an interview on 06/09/24 at 12:22 PM, Resident #1 stated that he fell in the shower while showering. Resident #1 said CNA E was in the restroom, but his back was to him. Resident #1 said he fell to the floor and hit his head. Resident #1 said CNA E picked him up and put him in the wheelchair. Resident #1 said no other staff helped CNA E pick him up. Resident #1 said that a nurse did not check him. Resident #1 said no one from the administration came and talked to him about the incident. Resident #1 said he was in pain when he left the shower room but did not report it because he did not want to get CNA E in trouble. During an interview on 06/05/24 at 1:49 PM, CNA E stated the incident with Resident #1 occurred on Thursday (05/30/24). CNA E stated he had just completed Resident #1's shower. He stated Resident #1 appeared to be standing fine. He said Resident #1's leg buckled, and as Resident #1 was holding on to the grab bar, he swiveled and hit the wall. He said Resident #1 never completely hit the ground. CNA E stated he called for assistance with Resident #1. CNA E stated he called CNA J and CNA K. CNA E stated he and CNA J and CNA K finished getting Resident #1 dressed and placed Resident #1 in his wheelchair. CNA E stated he asked Resident #1 how he was doing and was told by Resident #1 that he was ok. CNA E stated he had reported what happened to the ADM and the PTA directly after the incident. CNA E stated that he reported to the ADM that the fall was not a complete fall to the ground. CNA E could not recall if he told the ADM that Resident #1 had hit the wall. He stated Resident #1 did not complain of pain or show any signs of discomfort. When he demonstrated to Family Member D what happened, CNA E stated that his head hit the wall. CNA E stated he did not have the nurse look at Resident #1 because he felt he did the correct thing when he reported the incident to the ADM. CNA E stated the ADM told him that the incident was not reportable, so he did not tell anyone else. He said although Resident #1's care plan says to use the mechanical lift, he was a physical transfer. He said the fall might have happened around 11:30 AM on 05/30/24. During an interview on 06/05/24 at 2:08 PM, RN I stated that he was unsure when the fall incident happened with Resident #1 but was in the middle of the week. RN I said he did not know anything about it until the end of his shift. He said CNA K came to him and alerted him that Resident #1 was in pain the same day Resident #1 fell. He said he was told by Resident #1 that he had a fall in the shower earlier that day, and he had hit his head and his hip. RN I said Resident #1 said he did not want to get CNA E in trouble. RN I said while Resident #1 was telling him, he was crying. RN I stated he notified the DON, and the DON was surprised that CNA E had not told the nursing staff anything about the incident. RN I said he was frustrated because although the incident was communicated to the PTA and the ADM, it was not communicated to him as the charge nurse, and a delay in treatment occurred. He stated that once he became aware of this, he assessed and notified Physician A. RN. I stated that x-rays were ordered, but he did not receive the results on his shift. RN I said he spoke with CNA E and inquired why he was not notified. RN I said CNA E said he could not find RN I and apologized for not reporting the incident to RN I. RN I explained that his license could be on the line and treatment for Resident #1 could be delayed. RN I said that CNA E stated he was doing therapy in the shower to promote movement, and Resident #1 gave out. RN I said that CNA E told him that Resident #1 never hit the ground, but that differed from what Resident #1 told him. He stated he was told by Resident #1 that he fell to the ground. RN I said it was vital that he was notified when fall incidents occurred so that the residents were assessed at the time of injury. RN I said during his assessment of Resident #1, he saw issues with his range of motion and the apparent pain that Resident #1 was expressing. RN I said failure to report the incident to him could compromise resident safety, and with Resident #1 hitting his head, it could have been a more significant issue. RN I said during his assessment he did not see any problems with Resident #1's mental status. RN I stated he did not talk to the PTA or the ADM about the incident as they were already gone for the day and not in the facility. During an interview on 06/05/24 at 3:10 PM, CNA J stated she was not assisting Resident #1 the day he fell. She said she and her partner (CNA K) heard the call light go off in the shower room. She said that when they saw what was happening, CNA E requested that they bring Resident #1's wheelchair. CNA J stated she did observe Resident #1, and CNA E. CNA J stated that CNA E was holding Resident #1 up. She said CNA E did not appear to need assistance. CNA J said she and her partner provided the wheelchair and walked away. She said she nor her partner provided any assistance then. CNA J stated that around 4:30-4:45 PM that same day, the call light in Resident #1's room went off, and they were told by Resident #1 and Family Member D to place Resident #1 in bed. CNA J said they (her and CNA K) transferred Resident #1, and he complained that his leg was hurting. After the transfer, CNA J said they reported the leg pain to RN I. During an interview on 06/05/24 at 3:41 PM, CNA K stated that when Resident #1 fell, she and her partner, CNA J, were not working directly with Resident #1. CNA K said she was working the floor with other residents. She said she and her partner heard the lights go off in the shower room. CNA K said CNA E asked for Resident #1's wheelchair. CNA K stated they provided him with the wheelchair and walked back out of the shower room. She said no additional assistance was provided. She said Resident #1 was being held up by CNA E. She said when she and her partner were in the restroom, CNA E did not look like he needed help. She said that the encounter was before lunch. She said that at around 4:40 PM, Resident #1's call light went off, and she and CNA J went to see what he needed. She said Resident #1 wanted to be transferred to bed, and during the transfer with her and CNA J, Resident #1 expressed that he was in pain. She stated they completed the transfer and got him comfortable. She said she and her partner immediately notified RN I. CNA K stated that RN I went to Resident #1's room, which was all she knew happened. During an interview on 06/05/24 at 4:04 PM, the ADM stated she did not consider Resident #1's incident a fall because CNA E told her that Resident #1 did not fall to the ground. The ADM said CNA E told her that during a transfer, CNA E held Resident #1 up, straightened Resident #1 up, and was able to place him in his wheelchair. The ADM stated she did not talk to Resident #1 about the incident. She stated that she did not because when she was told about the incident, Resident #1 was present in the dining room. The ADM said she was unaware if the presence of CNA E could have influenced Resident #1 to speak up. She said she did not investigate the incident further after CNA E reported it. She said she later heard that CNA J and CNA K were transferring Resident #1, and Resident #1 complained of pain. She stated she was confused that Resident #1 would have been in any pain because earlier that day, he never voiced any pain concerns. The ADM said she did not know if he was in pain because she did not know how he could sit 6-7 hours in pain. She said she would have thought if he was in pain, he would have said something. She also said she did not consider it a fall because the DOR told her that if a fall occurred during restorative or therapy, it was not considered a fall. During an interview on 06/05/24 at 4:24 PM, the DON stated she received a call on 05/30/24 from RN I around 5:28 PM or 5:30 PM. RN I said Resident #1 was complaining of pain and stated he had fallen. The DON said she called CNA E, and CNA E told her Resident #1 did not fall. She said CNA E said he reported it to the ADM and the PTA directly after the incident. The DON said she was told by CNA E that Resident #1's legs buckled, and that CNA E held Resident #1 up. The DON said that she was told CNAs J and K helped CNA E with Resident #1. The DON said she interviewed CNA J and CNA K and confirmed that they observed CNA E holding Resident #1 up and that they got the wheelchair. The DON said she did not confirm if they helped with the transfer. The DON said she did not speak with Resident #1 because he had already gone to the hospital. The DON stated she had not spoken with Resident #1 since he returned from the hospital. The DON stated that she understood that since CNA E had been trained, he could transfer Resident #1 alone. During an interview on 06/06/24 at 4:56 AM, LVN F stated she worked the night shift when Resident #1 fell. She stated it was passed to her during the report that Resident #1 fell while in the shower room. LVN F said that x-rays had been ordered, and she received the report around 10:00 PM on 05/30/24 that Resident #1 had a positive fracture. LVN F stated RN I told her he was not informed about the incident when it happened. LVN F stated she spoke with Resident #1, and he was able to say to her that he had fallen in the shower, but he did not provide any additional information. During an interview on 06/06/24 at 11:00 AM, the PTA stated that on 05/30/24, CNA E approached him. The PTA said CNA E was doing restorative on Resident #1, and he slipped. The PTA said CNA E stated that he had already reported the incident to the ADM. The PTA stated that CNA E had not given him any additional information. The PTA said that when he was told about the incident, he was not told it was in the shower. The PTA stated that he had not seen Resident #1's care plan and could not verify what it entailed, but two people to transfer was for safety especially when using the mechanical lift. He stated that if the care plan stated that there needed to be two people, then there should be two people, and staff should not deviate from that. The PTA stated that therapists could transfer with one person, and sometimes, it depended on if a female or male was doing the transfer. He did not specify why gender would make a difference. The PTA said he spoke with Resident #1, and all Resident #1 kept saying was fall, fall. During an interview on 06/06/24 at 12:25 PM, the DON stated she was unaware that Resident #1 had fallen in the shower. The DON said she was made aware when the nurse called about Resident #1's pain. The DON stated that the restorative aide had been trained to report the incident to therapy and the nurse (that included the DON). The DON confirmed that CNA E was a restorative aide. She said Resident #1 had improved in his health and strength. The DON said it was her understanding that Resident #1 could be transferred with one person if it was a restorative aide. The DON said that regarding the incident with Resident #1, the potential negative outcome was that similar incidents could also occur with other residents. The DON said the potential negative outcome of not reporting Resident #1's fall to the nurse staff, not following their policy, and not investigating the incident was the charge nurse would not be made aware of the incident, and there could be a negative outcome for the resident if something internally would have been wrong with the resident. The DON said she was responsible for incident/accident prevention, but the ADM was responsible for investigations and reporting. The DON said the purpose of reporting incidents and investigating incidents of alleged abuse and neglect was to protect the residents and to follow policy. The DON said the facility system to monitor was to follow their policy. The DON said she was unaware of why they did not follow the policy. During an interview on 06/06/24 at 1:16 PM, the ADM stated that not reporting falls to the nurse, investigating incidents, and/or following their facility abuse policy could cause continued harm to the residents. The ADM said she was made aware of the incident regarding Resident #1 after CNA E told her about it. The ADM said she was unaware that Resident #1 was in pain and did not interview Resident #1. She said the system was implemented to monitor that falls were reported to the appropriate people, incidents were investigated, and ANE policies were followed by training staff on the facility policy. The ADM said she did not investigate the incident because she did not consider the incident a fall since it happened with therapy. The ADM stated she expected all staff to follow the care plan. The ADM said she did not look at the care plan to confirm that CNA E's transfer was correct. During an interview on 06/06/24 at 4:00 PM, the DOR stated that she had been notified during a morning meeting that Resident #1 had a fall. The DOR said she could not remember in particular the details. The DOR said she did not remember the date of the morning meeting. The DOR said she believed it was the day after the fall incident because they typically screened every fall. The DOR said all she knew was that it had something to do with the shower and that Resident #2's knee buckled. The DOR said doing restorative in the shower was normal and that CNA E had been specifically trained to do restorative with Resident #1. The DOR said Resident #1 required two people for transfer, but a restorative could transfer Resident #2's with one person. The DOR said that because CNA E was a male, he was allowed to transfer Resident #1 with one person, but if the staff were smaller, they would recommend that the staff use two people. The DOR said nursing would ultimately make the decision. 2. Findings for sexual incident that occurred on 05/10/24 between Resident #2 and Resident #3 include: Record review of Resident #2's face sheet, dated 06/05/24, revealed a [AGE] year-old-male that was readmitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember), depressive disorder (constant feelings of sadness), mood disorder (emotional deficit), and blindness to the right eye. Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 05, which indicated the resident's cognition was severely impaired. Section B Hearing, Speech, and Vision revealed that Resident #2 had clear speech, made himself understood, and understands others. His vision was impaired, and he did not wear corrective lenses. Section E Behavior revealed that he had not had any incidents of physical or verbal behaviors. Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a blank BIMS score. Section E Behavior revealed that he had had delusions, physical behaviors such as hitting, kicking, pushing, scratching, grabbing, and abusing others. Resident #2 had exhibited verbal behaviors such as threatening others, screaming, and cursing at others. Resident #2 had other behavioral symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, smearing food or bodily wastes, or verbal/vocal symptoms like screaming and disruptive sounds. Resident #1 exhibited wandering behavior 1-3 days. Record review of Resident #2 care plan, dated 05/01/24 revealed the following: [Resident #2] wanders in other residents' rooms and gets into their beds at times and had the following interventions: [Resident #2] required assistance out of rooms that were not his and staff could use snacks if needed. [Resident #2] was an elopement risk/wanderer and had the following interventions: Distract [Resident #2] from wandering by offering pleasant diversions. [Resident #2] prefer having snacks. Followed by [name of psych care]. Notify their MD/NP of any escalation in wandering behaviors, ineffectiveness, or side effects of psychiatric medications. Monitor the resident's location throughout shifts. Document wandering behavior and attempted diversional interventions in behavior log. [Resident #2] had episodes of verbal and physical aggression r/t dementia with the following interventions: Give me as many choices as possible about care and activities. Monitor for physically/verbally aggressive behavior q shift. Document observed behavior and attempted interventions in behavior log. Monitor/document/report PRN any s/sx of [Resident #2] posing danger to self and others. [Resident #2] had impaired visual function r/t cataracts and glaucoma. Resident #2 was blind in his right eye with the following interventions: Arrange consultation with eye care practitioner as required. Monitor/document/report PRN any s/sx of acute eye problems: Change in ability to perform ADLs, decline in mobility, sudden visual loss, pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. Place frequently used items on my left side so I may see them. Record review of Resident #2's progress notes revealed the following: Record review on 05/11/24 at 12:12 AM LVN G documented: Data: Resident observed by CNA H reported to this nurse observed resident with pants unzipped and PENIS in Resident #3's hand. Action: Resident removed from Resident #3's room w/o incident. Resident #3 appears to have been asleep during entire incident. No physical injuries noted at this time. Response: Resident in his room and placed on 1-1 monitoring per DON instructions. Roommate moved to different room as this nurse considers this a HIGH RISK INCIDENT. DON & Administrator notified. Record review on 05/11/24 at 03:23 PM The DON documented: Received orders from NP may administer Lorazepam 1ml now and then every 8 hours as needed. DON gave orders to charge nurse may use emergency restraint for safety of resident and others. Record review on 05/11/24 at 05:27 PM the DON documented: Spoke with Family Member L about incident and orders to give Lorazepam 2mg/ml injection every 8 hours as needed x 14 days. Voiced understanding and gives verbal consent at this time for medication. Also discussed that he would be going back to the behavior support center on Monday and facility would be actively looking for alternate long-term placement for resident. Voiced understanding and consents for referrals to be sent to other facilities. Record review on 05/11/24 at 05:27 PM LVN B documented: Staff alerted this nurse that this male resident was found in female resident's bed with his hands in the female's pants. Upon entering room male resident is found in bed with female resident with his hand on resident's waist. Told resident he needed to get out of bed. RT refused and put his arm around female resident. Male resident immediately removed from female's bed and taken to his own room. Resident became aggressive with staff refusing to leave bed causing CNAs to fall. Administration notified. Physician A, the DON notified. New order for Ativan 2mg/ml injection. Injection administered. Resident continues to try to go into other female rooms. Record review on 05/31/24 at 01:07 PM The DON documented: Resident returned from behavioral center via their facility van. Notified Physician A of return and medications. Notified the NP of return and reconciled psychotropic medications. Notified family Member L of return and went over psych medications and no issues or concerns at this time. Record review on 06/02/24 at 03:26 AM LVN M documented: Follow-up on readmission, resident continues to urinate on floor. Reminded resident to use urinal. Resident voiced understanding. Resident also continues to wander. Resident breathing even and unlabored. No complaints voiced. Record review of on 06/02/24 at 07:35 PM The DON documented: Notified by charge nurse that resident was wandering in rooms and becoming aggressive when staff was trying to redirect. Contacted the NP and new orders received to increase Seroquel to 50mg 3 times daily, Xanax 0.25mg every 6 hours as needed x 14 days, and Zyprexa 10mg IM every 12 hours as needed x 14days. Notified Family Member L of resident behavior and new orders. Voiced understanding and no issues or concerns at this time. Record review of Resident #2's monitoring sheets revealed the following: Resident #2 was monitored every 30 minutes starting 05/08/24 at 11:30 AM until 5/10/24 at 6:00 PM. (No abnormal behavior reported during this monitoring time.) No time monitoring accounted for 05/10/24 at 11:00 PM- 12:00 AM. Resident #2 was monitored on 05/11/24 from 1:00 AM-5:45 AM. (No abnormal behavior notated during this time. No time monitoring accounted for 12:00 AM-1:00 AM.) Resident #2 was monitored on 05/11/24 from 6:30 AM-4:00 PM. (No abnormal behavior notated during this time. No time monitoring accounted for 4:30 PM-6:00 PM) Record review of Resident #3's face sheet, dated 06/05/24, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (memory loss), cognitive communication deficit (difficulty communicating), fracture to neck and left femur, anxiety disorder (increased worry), and major depressive disorder (increased sadness). Record review of Resident #3's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 01, which indicated the resident's cognition was severely impaired. Section B. Ability to understand others revealed that she had clear speech, sometimes could make herself understood, and sometimes could understand others. Record review of Resident #3's care plan dated 6/5/24 revealed the following: Resident #3 was dependent on staff for emotional, intellectual, physical, and social needs related to cognitive deficits. Resident #3 required assistance to ADLs related to Alzheimer's disease, had impaired cognitive function/impaired thought processes related to Alzheimer's, had a mood problem related to depression, and had potential for psychosocial well-being related to trauma. Record review of Resident #3's progress notes revealed the following: On 05/11/24 at 01:27 AM LVN G documented: [Resident #2] observed in resident's room with Penis in her hand attempting what appears to ejaculate himself. Resident Immediately stopped by staff and removed to his room. Placed on 1-1 monitoring with instructions by DON NOT to be left out of staff sight at any time. No apparent injuries not upon physical inspection with female CNA present. DON to notify PCP & family. During an interview on 06/05/24 at 1:49 PM, CNA E stated that one night, when he worked the night shift (unsure of the date and exact time), Resident #2 exposed himself to Resident #3. He said he did not see it but was told by CNA H that Resident #2 had his penis in Resident #3's hand and was jerking off. He said as a result of that incident, Resident #2 was placed on 1:1 and was checked every 15 minutes by the night staff. He said Resident #3 was not in her right mind and would have been unable to consent. He said Resident #3 may have a BIMs of 0 (severe cognitive impairment). He said prior to the incident involving Resident #3, Resident #2 was not on any close monitoring. He said that when Resident #3 was in the dining room and wanted to return to his room, they would assist him, but after he was in his room, they did not do additional monitoring. During an interview on 06/05/24 at 2:57 PM, LVN G stated that on 05/11/24, he was working the night shift. He said he heard a young lady yell out. He said it was the female CNA but did not know her name. He said he was on break. He said the female CNA reported that Resident #2 had a particular part of his anatomy in Resident #3's hand. LVN G stated they assisted in getting Resident #2 out of Resident #3's room. He stated when he walked in, he did not see Resident #2's penis in Resident #3's hand but did see his penis out. He said he had not seen Resident #2 do the sexual act in the past, but that Resident #2 would expose himself and urinate on the floor. He stated that, because of the incident, he reported it to the DON and was instructed to place Resident #2 on 1:1 monitoring. He stated he would sit in the hall and ensure Resident #2 did not go into other rooms. LVN G said that Resident #3 was catatonic (immobile) and could not defend herself. During an interview on 06/05/24 at 4:04 PM, the ADM stated she did not report the incident that involved inappropriate sexual contact that occurred with Residents #2 and #3 because all parties had dementia. She said she focused on if the act was willful. She said Resident #3 was asleep and did not know what was happening. She said she was told but could not remember who told her that Resident #2 was standing over Resident #3 with his penis out and Resident #3's hand was on Resident #2's penis. The ADM stated she was not told that Resident #2 was masturbating. The ADM stated that Resident #2 was not put on 1:1 during the first incident involving Resident #3 because he was not aggressive, and that was the first time he displayed this behavior. During an interview on 06/05/24 at 4:24 PM, the DON stated when the inappropriate sexual incident between Residents #2 and #3 were reported to her, she reported it to the ADM as she was the abuse coordinator.[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident had the right to be free from abuse for 8 of 10 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #10), reviewed for abuse. The facility failed to ensure a safe environment free from abuse for Resident #1 when can D was suspected to have used unnecessary force causing a spiral fracture to Resident #1 on night shift on 04/12/2023. The facility failed to ensure Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10 resided in a safe environment after making allegations of abuse toward CNA D and CNA D was continued to allow to work with all resident's even after prior allegations of abuse. This failure was determined to be an Immediate Jeopardy situation that was identified on 04/14/2023 at 5:51 p.m. While the IJ was removed on 04/17/2023 , the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could affect all residents by placing them at risk of abuse, physical harm, pain, mental anguish, emotion distress, serious harm, and death. Findings include: Resident #1: Record Review of Resident #1's face sheet documented he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 was admitted with a diagnosis which includes: dementia without behavioral disturbance, muscle wasting and atrophy (loss or thinning of muscle tissue), difficulty in walking, Record review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] documented that Resident #1's BIMS (Brief Interview for Mental Status) was a 3/15, meaning severe cognitive impairment. Under Section B under Hearing, Speech, and Vision indicated that Resident #1, for ability to hear listed him at a 0, meaning no difficulty in normal conversation, social interaction, or watching tv. Under Section B in B0600 labeled Speech Clarity indicated listed at a 1 meaning that Resident #1 has unclear speech such as slurred or mumbled words. Under B0700 labeled Makes Self Understood Lists Resident #1 at a 1 meaning that Resident #1 is usually understood with difficulty communicating some words or finishing thoughts but is able if prompted or given time. Under B0800 labeled Ability to Understand documents that Resident #1 usually understands meaning misses some part/intent of message but comprehends most conversation. Under B0700 labeled Makes Self Understood is documented at a 1 meaning usually understands: difficulty communication some words or finishing thoughts but is able if prompted or given time. Under Section C for cognitive patterns for C0700 labeled short-term memory is left blank and not completed. Under C0700 labeled long-term memory is left blank and not completed. Under C0800 labeled Memory/Recall Ability is left blank and not completed. Under C01000 labeled Cognitive Skills for Daily Decision Making is left blank and not completed. Under C01300 for Delirium for the question, Is there evidence of an acute change in mental status, labeled as a) meaning no there is not a change in mental status, for inattention is listed as a 0 meaning no behavior is present, for disorganized thinking is listed as a 0 meaning there is no behavior present, for altered level of consciousness is listed as a 0 meaning behavior is not present. Under Section D for Resident Mood Interview under D0200 Resident #1 shows little interest or pleasure doing things displayed at a frequency of 7-11 days, feeling down, depressed, or hopeless at a frequency of 2-6 days, feeling tired or having little energy at a frequency of 2-6 days. Under Section E for E0200 under Behavioral Symptom-Presence and Frequency is documented at a 0 meaning Resident #1 did not exhibit behaviors for physical behavioral symptom directed towards others such as for example (hitting, scratching, pushing, kicking, grabbing, abusing others sexually) , verbal behavioral symptoms directed toward others such as, for example (threatening others, screaming at others, cursing at others), other behavioral symptoms not directed towards others such as, for example (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal such as screaming or disruptive sounds). Under B0300 under Overall Presence of Behavioral Symptoms listed at a 0 meaning Resident #1 did not exhibit these behaviors. Under B0500 under Impact on Resident for the questions: put the resident at significant risk for physical illness or injury, significantly interfere with resident care, significantly interfere with the resident's participation in activities or social interactions was blank and incomplete. Under B0600 under Impact on Others for the questions: put others at significant risk for physical injury, significantly intrude on the privacy or activity of others, significantly disrupt care or living environment was left blank and incomplete. Under B0800 under rejection of care is listed as a 0 meaning that Resident #1 did not exhibit this behavior. Under Section E for Wandering labeled has the resident wandered list a 0 indicating that Resident #1 has not displayed this behavior. Under Section G for Functional Status for G0100 labeled a), bed mobility (how resident moves to and from lying positions, turns side to side, and positions body while in bed or alternate sleep furniture) is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) listed as a 2 person assist, b). transfer (how the resident moves between surfaces including to and from bed, wheelchair, and standing position) is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) with a 2 person assist, c). Walk in room is listed as a 1 meaning Resident #1 needs supervision (oversight, encouragement, or cueing) with a 1 person assist, e). Locomotion on unit (how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair) is listed as a 0 indicating Resident #1 does not need assistance. Under G0300 for Balance during Transitions and Walking for a). Moving from seated to standing position is listed as a 1 meaning (not steady, but able to stabilize without staff assistance), b). Walking is listed as a 1 meaning (not steady, but able to stabilize without staff assistance), e). Surface to Surface transfer (transfer between bed and wheelchair) is listed as a 1 meaning (not steady, but able to stabilize without staff assistance). Under G0400 labeled Functional Limitation of Range of Motion for a). Upper extremities is listed as a 0 meaning no impairment. Under G0600 labeled Mobility Devices indicates that Resident #1 uses a wheelchair. Under G0900 labeled Functional Rehabilitation Potential indicates for Direct care staff believe resident is capable of increased independence in at least some ADLs is listed as a 1 meaning yes, they do believe Resident #1 is capable of increased independence. Under Section J for Health Conditions for J0300 for Pain Assessment indicates that Resident #1 has not had any pain or hurting in the past 5 day. Under J1700 for, a). Did the resident have a fall any time in the last month prior to admission/entry or reentry, indicates that Resident #1 was listed as a 1 meaning that he did have a fall prior to admission in the past month, b). Did the resident have a fall any time in the past 2-6 months prior to admission/entry or reentry, is documented as a 1 indicating that Resident #1 has experienced a fall in the past 2-6 months prior to admission in the facility. C). Did the resident have any fracture related to a fall in the past 6 months prior to admission/entry or reentry is listed as a 0 meaning the resident has not experienced a fracture in the past 6 months prior to admission into the facility. Under J1800 labeled Any falls since admission/entry or re-entry prior to assessment indicates a 1 meaning that Resident #1 has experienced a fall prior to admission into the facility. A). No Injuries is listed as a 1 meaning (no evidence of any injury on physical assessment by the nurse or primary care clinician, no complaints of pain or injury by the resident; no change in the resident's behavior is noted after the fall). Record review of Resident #1s Care Plan dated 4/12/2023 revealed Resident #1 had a fracture of the left humerus with the interventions of: non weight bearing to LUE-nursing was to remove from sling 3 times a day to perform elbow extension only PROM. Nursing only to perform. In-service was given on 4/12/2023 to CN from PT on how to perform PROM correctly to prevent further injury. LPN, RN, DON, apply sling and encourage to leave it on assisting as needed for proper placement. Record review of Resident #1s Care Plan dated 04/14/2023 indicated Resident #1 had limited mobility r/t fx of left humerus that limits ADL self-performance. AEB unable to use left arm and requires a restorative nursing program to maintain current level of function with the interventions of: Nursing rehab/restorative: Passive ROM Program #1 extend lower arm flexing elbow 3 sets of 15 with 5 second pause. Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is dependent on staff for meeting emotional, intellectual, physical, and social needs due to cognitive deficits with the interventions of: All staff to converse while providing care, establish and record level of activity and interests by talking with Resident, caregivers, and family on admission and as necessary, needs assistance/escort to activity function. Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is deficit with dementia with the interventions with ADLs as follows: bed mobility: self-performance supervision, bed mobility: support provided with 2 person physical assist, transfer: self-performance supervision, support provided with 2 person physical assist, walk in room: self-performance supervision, support provided with one person assist, locomotion on unit: self-performance independent, support provided no setup or physical help from staff, nurse aides to document most dependent self-performance per shift. Monitor signs and symptoms of ADL decline and notify family, MD, identify causes and solutions. Record review of Resident #1s Care Plan dated on 02/28/2023 indicated Resident #1 is an elopement risk/wanderer with disoriented to place, wander risk is 9, with the interventions of distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, snacks, monitor location throughout shifts. Document wandering behavior and attempted diversional intervention in behavior log. Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 had a cognitive impairment due to dementia with the interventions of ask yes/no questions in order to determine the resident's needs. Cue, reorient and supervise as needed. Need assistance with all decision making. Keep routine consistent and try to provide care givers as much as possible in order to decrease confusion. Present just one thought, idea, question or command at a time. Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 had a communication problem with difficulty making self-understood and difficulty understanding others with the interventions of monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed. Monitor/document frustration level, wait 30 seconds before providing with a word. Speak on an adult level, speaking clearly and slower than normal. Validate message by repeating aloud. Record review of Resident #1s Care Plan dated on 02/28/2023 indicated that Resident #1 is at risk for falls with gait/balance problems with the interventions of: provide with a chair to sit in when wondering in halls, be sure my call light is within reach and remind to use it for assistance as needed. Record Review of Resident #1's Progress notes dated 04/12/2023 at 5:38 am, signed by LVN A revealed: Note Text: Resident #1 woke up and came to nursing station stating he fell asleep on hand, and it was hurting/tingling. Assessed and hand was red with minimal puffiness. Resident #1 walks off and was later found in another Resident's room asleep in an empty bed. Male Aide (CNA D) was notified, and he assisted Resident #1 and he assisted Resident #1 out of room and down hall to his assigned room. LVN A (Nurse) hears Resident #1 yelling really loud and complaining of shoulder pain. LVN A (Nurse) asked Nurse Aide (CNA D) what did he do and he replied nothing, I just lifted him up under his arms and took him to his room. Nurse (LVN A) and Aide went into room to see what was wrong and Resident #1 attempts to hit aide yelled, get away from me in anger. Assessed arm and noticed bruising to lower forearm but Resident #1 had on a long sleeve shirt that would only go up so far. Resident #1 lays down. A few minutes later LVN A hears Resident #1 still moaning in pain. By this time aide (CNA D) reports that he just vomited and needed to leave and go home because he wasn't feeling well. Nurse (LVN A) and only aide (CNA C) present, goes in to check on Resident #1. This time I (LVN A) attempted to take off Resident #1 shirt and he's yelling in pain. I (LVN A) was able to get it off and assessed shoulder. I (LVN A) noticed a crease in arm in-between shoulder and elbow. Softly palpating down arm, Resident #1 guards' arm and a knot is felt and arms appears to be disformed. I (LVN A) had the aide (CNA C) to ask Resident #1 what happened in the room in Spanish, and he replied, He hit me two times. BOM, MD, wife, and Regional Operations Director notified. 911 called and Resident #1 transferred to UMC. During an observation on 04/13/2023 at 12:01 p.m., Resident #1 was sleeping and did not awaken to name being called. Resident #1 had a sling on the left arm. Resident #1 did not appear to be in any distress at this time. During an interview on 04/15/2023 at 12:48 p.m., with Family member 13 stated that the morning that Resident #1 was sent out to the hospital she received a call from LVN A and told her that Resident #1 had a hurt arm and was being sent out to the hospital. Family member 13 stated that LVN A told her that Resident #1 had stated that CNA D had hurt his arm. Family member 13 stated that she immediately felt sick to her stomach because she had been told by Resident #1 on a couple of different occasions that CNA D was mean to him. Family member 13 stated that she had told the staff and Administrator about Resident #1 stating that CNA D was being mean. Family member 13 stated she didn't know if anything had been done about the other times that Resident #1 had complained because she never heard anything from the staff or Administrator about the situations. Family member 13 stated that she would hope that now that something would get done about CNA D hurting Resident #1. Family member 13 stated that it's bad enough that something like this had to happen before something would get done about CNA D hurting Resident #1. Family member 13 stated that BOM had called her later that morning after she had already talked to LVN A and BOM told her that CNA D was transferring Resident #1 to bed and accidentally hurt him. Family member 13 stated that on one of the other times that Resident #1 was saying he was being treated mean, Resident #1 had told her and her brother, He beat me, Resident #1 had told family member 13, That big guy was in a boxing match with me, he beat me. Family member 13 stated that she took her concerns to the Administrator and never heard anything else about it. *Resident #2: Record Review of Resident #2 face sheet documented he is a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 was admitted with a diagnosis which includes: stroke, seizures, difficulty swallowing, facial weakness, major depressive disorder, anxiety disorder, type 2 diabetes, muscle wasting, cognitive communication deficit, lack of coordination, hyperlipidemia (a condition which there are high levels of fat particles (lipids) in the blood). Record review of Resident #2's admission MDS dated [DATE] documented that Resident #2's BIMS was listed as 00 meaning zero points are assigned if the resident didn't repeat words correctly Under B0600 for Speech Clarity indicated that Resident #2 scored 1 meaning Unclear Speech-slurred or mumbled words. Under B0700 for Makes Self Understood indicated that Resident #2 scored 2 for ability to express ideas and wants. meaning sometimes understood ability is limited to making concrete requests. Under B0800 for Ability to Understand Others-understanding verbal content scoring a 2 meaning responds adequately to simple and direct communication only. Under G0110 for Activities of Daily Living Assistance indicates: A). Bed Mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) Resident #2 scored a 3 meaning extensive assistance (resident involved in activity, staff providing weight bearing support) with 2 persons assist. B). Transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), Resident #2 scored a 4 indicating total dependence (full staff performance every time during entire 7-day period). G). Dressing how resident puts on, fastens and takes off all items of clothing, including donning/removing a prosthesis or TED hose. Dressing includes putting on and changing pajamas, Resident scored a 3 indicating extensive assistance (resident involved in activity, staff providing weight bearing support) with 2 persons assist). Resident #2 scored a 3 indicating extensive assistance (resident involved in activity, staff providing weight bearing support) with one person assist. Toilet Use: how resident uses the toilet room, commode, bedpan, or urinal Record review of Resident #2s Care Plan dated on 07/01/2022 indicated the following: Resident #2 has an ADL self-care performance deficit with interventions of: ADL self-performance fluctuates with confusion but usually requires assistance as follows: Bed mobility-self-performance (Total Dependence), Bed mobility: support provided with 2-person physical assist, Transfer: self-performance (total dependence), Transfer-support provided with 2 person physical assist, walk in room- self-performance (activity did not occur), walk in room- support provided ADL activity did not occur, Walk in corridor- self-performance (Activity did not occur), walk in corridor-support provided ADL activity itself did not occur, Locomotion on unit-self performance (total dependence), Locomotion on unit- support provided one person physical assist, Locomotion off unit- self-performance (total dependence), locomotion off unit- support provided with one person physical assist, Dressing: self-performance (Extensive assistance), Dressing: support provided with two person physical assist, Eating: self-performance (Supervision), Eating: support provided with one person physical assist, Toilet use: self-performance (Total dependence), Toilet use: support provided with two person physical assist, Personal hygiene: self-performance (Total dependence), Personal hygiene: support provided with two-person physical assist, Nurse aides to document Resident #2s most dependence self-performance per shift. Monitor for signs and symptoms of ADL decline and notify family, MD, identifying causes and solutions. Monitor/document/report to MD as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Record Review of Resident #2's Progress notes dated 04/15/2023 at 10:57 am, signed by Social Worker revealed: Social worker spoke with Family Member #12 to let her know about the new reporting guidelines for abuse and neglect. She (Family Member #12) asked that it be mailed. She (Family Member #12) may also pick it up today when she is here. The form is also placed in Resident #2's room. During an Observation on 04/13/2023 at 12:08 pm with Sampled Resident #2 revealed: Observed Resident #2 laying in his bed visiting with family member. Observed Resident #2 free from distress. During an Interview with Resident #2 on 04/13/2023 at 12:07 pm. Resident #2 was able to slowly reveal the complaint that he had against CNA D with the help of family member. Resident #2 stated that during care he went to grab side bars and CNA D pushed him hard and motioned to Surveyor where his head was hit on the side bars. Resident #2 stated, He hits me, hard. (CNA D). Resident #2 put his fingers on top of his head and stated, Devil. Surveyor stated who is the Devil, Resident #2 called CNA D by name. Observed Resident #2 began to show signs of anxiety just talking about it and began to tear up in his eyes. Family member #11 had to console Resident #2 to get him to calm down. During an interview on 04/13/2023 at 12:17 p.m., with Family member 12 via telephone for Resident #2, Family Member #11 used her own personal cell phone to reach out to Family member #12 and was happy to share some concerns. Family Member #12 stated that she does have some concerns with CNA D and that she did not have a lot of time because she had to get back to work but would like the opportunity to write down all the concerns and get back with Surveyor in a couple of days. Family Member #12 stated that she was told by Resident #2's old roommate (Resident #9) that he witnessed CNA D tell Resident #2 to stop using the call light so much or the next time he puts him in the Hoyer lift he (CNA D) will leave him there. Family Member #12 stated that the Administrator and BOM both knew that these things were going on and did nothing about it. Family Member #12 stated that she had stressed out so much from worrying about Resident #2 being in the facility when CNA D is working. Family Member #12 stated that she would like to make a written statement to provide to Surveyor about all the things that CNA D did to Resident #2. Record Review of a written Statement provided on 04/15/2023 at 8:00 am, from Family member #12, revealed: To Whom it May Concern: I (Family Member #12) just want to say thank you, my name is (Family Member #12), stated it is unfortunate that they are in the situation that they are in with the facility. Family Member #12 stated that she is willing to share Resident #2 journey at the facility in hopes that something or someone will finally do something to help these residents. Family Member #12 stated that everything had gone fine until the facility had hired CNA D (nights). Family Member #12 stated that she finally became concerned when CNA D had acted in a manner in front of another family member like he didn't like Resident #2 (talking rude to him). Family Member #12 stated that CNA D had a demeanor that he did not have a very caring personality and acted like he didn't want to be there most times. Family Member #12 stated that she had witnessed one of the times that CNA D had been rough with Resident #2 when she walked in when he was providing care and she told CNA D, Hey be easy with him. Family Member #12 stated that it seemed to upset CNA D when she told him because he got an upset look on his face. Family Member #12 stated that as time passed by it got to a point when Resident #2 didn't want family to leave him there alone when CNA D was working. Family Member #12 stated that she finally reported her concerns to the DON and Administrator at the time on October 2022 and she was told that the facility was investigating the situation but nothing ever changed. Family Member #12 stated that she asked weeks later and was still told that it was being investigated and still nothing changed. Family Member #12 stated that she got so frustrated because the facility is supposed to protect the resident's and did nothing to protect. Family Member #12 stated that about the second week of November 2022 she was approached by the DON and stated that the DON told her that there was an incident that the CNA D had Resident #2 up in the Hoyer and CNA D told Resident #2 that if he didn't stop, bitching, and pushing the call light that he (CNA D) would leave him up there. Family Member #12 stated that she was told by DON at the time that CNA D had left Resident #2 in midair in his brief that was soiled and wet for a good period of time. Family member #12 stated that she was told that the situation is being investigated, and again nothing happened. Family Member #12 stated that she went to the DON after days of hearing nothing and asked what was going to be done and DON stated that other residents had to be questioned. Family Member #12 stated that she asked at this time for CNA D not to be allowed to go into the room or care for Resident #2. Family Member #12 stated that she was told by the administrator that the facility could not do that and that is when she knew that there was going to be a problem with this place. Family Member #12 stated that it got to a point that family members would try to go as much as possible in hopes that the situation would stop. Family Member #12 stated that most times she was there that Resident #2 would show anxiety anytime CNA D would work. Family Member #12 stated that another incident happened in December 2022 with CNA D and Resident #2. Family Member #12 stated she was there at the facility with Resident #2, and she pushed the call light because Resident #2 was soaking wet and had, poop in his brief. Family Member #12 stated that Resident #2 started getting really anxious and scared. Family Member #12 stated that CNA D came in the room and told Family Member #12 that she had to leave the room for the privacy of Resident #2. Family Member #12 told CNA D that she would not leave the room. Family Member #12 stated that CNA D then told her that he would not change Resident #2 then. Family Member #12 stated that she told CNA D that she was going to report him to the administrator. Family Member #12 stated when she threatened to report CNA D, he then changed Resident #2, but CNA D was very rough and when he pushed Resident #2 to the side CNA D pushed him so hard that Resident #2 hit his head on the side pull bars. Family Member #12 stated that Resident #2 would cry sometimes and say that he was scared to go to sleep because of CNA D. Family member #12 stated that she did report this to the administrator and again, nothing, just investigating. Family Member #12 stated that she finally got to the point with the administrator that she said, What is it going to take, CNA D seriously hurting someone or killing them? Family Member #12 stated that she was scared daily, and this stressed her out because she was constantly worried about Resident #2. Family member #12 stated that things got worse with CNA D and Resident #2 began telling her that CNA D would twist his arm really hard and yell at him. Family Member #12 stated that she had went to the facility on March 10th, 2023, and already had Resident #2 up and in the wheelchair. Family Member #12 stated that Resident #2 was crying and very scared with his fists clenched. Family Member #12 stated, What's wrong, what happened, to Resident #2. Family Member #12 stated that Resident #2 had told her that CNA D was pulling and hitting him in his bad arm and leg. Family Member #12 stated that she had never been so scared before for Resident #2 because it was getting worse. Family Member #12 stated that she would have to go out of town that day due to her daughter having cancer. Family Member #12 stated that she told the current Administrator and was told by the Administrator that she would have to report this to Human Services, and she would question CNA D to see what happened. Family member #12 stated that when she came back from out of town that the Administrator told her that CNA D was on a 30-probation and was suspended. Family Member #12 stated that she told the Administrator not put CNA D to care for Resident #2 and she was told that this could not happen due to lack of staff that the facility had. Resident #3: Record Review of Resident #3's face sheet documented she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 was admitted with diagnoses which included: stroke, anorexia, muscle wasting and atrophy (decrease in size of a body part), dementia, lack of coordination, atherosclerotic heart disease (buildup of fats, cholesterol, and other substances on the artery walls), unsteadiness on feet, schizoaffective disorder, depression, anxiety, seizures, insomnia, high blood pressure, abnormalities of gait and mobility. Record review of Resident #3 admission MDS dated [DATE] documented that Resident #2's BIMS was listed as 12 meaning cognitively moderately impaired. Under B0200-Hearing: Resident #3 was listed as 0 meaning: Adequate- no difficulty in normal conversation, social interaction, listening to tv. Under B0600-Speech Clarity: Resident #3 was listed as 0 meaning: distinct intelligible words. Under B0700-Makes Self Understood: Resident #3 was listed as 1 meaning: Usually Understood-difficulty communicating some words or finishing thoughts but is able if prompted or given time. Under B0800-Understands Verbal Content however able: Resident #3 is listed as a 1 meaning: Usually understands-misses some part/intent of message but comprehends most conversation. Under C1310-Delirium- Resident #3 was listed as a 0 meaning there is no delirium. Under G0110-Functional Status: Bed mobility-Resident #3 was listed as extensive assistance with 2 person assist, Transfer-Resident #3 is listed as total dependence with 2 person assist, walk in room- Resident #3 was listed as activity did not occur, Walk in corridor- Resident #3 was listed as activity occurred only once or twice with 1 person assist, Locomotion on Unit- Resident #3 was listed as extensive assistance with one person assist, Locomotion off Unit- Resident #3 w[TRUNCATED]