**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to ensure that Residents are free from abuse for 6 of 6 residents (Residents #3, #5, #13, #14, #26, #29) reviewed for abuse. 1. The facility failed to prevent Resident #29 from being verbally abused by a facility staff member. 2. The facility failed to keep Residents #3, #5, #13, #14, #26, #29 free from verbal abuse from a facility staff member for extended periods of time resulting in an unsafe and hostile environment. These failures place Residents at risk for psychosocial harm, fearful of retaliation, being uncomfortable, impaired quality of life and abuse as a result of the verbal abuse. An Immediate Jeopardy (IJ) was identified on 7/19/2023 at 5:08PM. While the immediate jeopardy was lifted on 7/21/2023 at 2:35PM, the facility remained out of compliance at a severity of actual harm with potential for more than minimal harm: and scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. Plan of removal of IJ will be included in findings. Findings included: Record review of Resident #3's face sheet revealed a [AGE] year old female with an admission date of 7/29/2019 with diagnoses including: chronic obstructive pulmonary disease, emphysema and acute kidney failure. Record review of Resident #3's MDS assessment dated [DATE] reflected a BIMS score of 13. Record review of Resident #5's face sheet reflected a [AGE] year old female with an admission date of 10/6/2022 and with diagnoses including chronic kidney disease, altered mental status, hyperparathyroidism, morbid (severe) obesity, unspecified dementia, moderate, with psychotic disturbance, delirium due to known physiological condition, schizophrenia, unspecified, delusional disorders, unspecified psychosis not due to a substance or known physiological condition, bipolar disorder, unspecified, major depressive disorder, recurrent, moderate anxiety disorder, unspecified, insomnia, unspecified, essential (primary) hypertension. Record review of Resident #5's MDS assessment dated [DATE] reflected a BIMS score of 15. Record review of Resident #13's face sheet reflected a [AGE] year old female with an admission date of 3/13/2023 and with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, alcohol use unspecified with alcohol-induced persisting dementia, essential (primary) hypertension, major depressive disorder, recurrent, unspecified, unspecified atrial fibrillation. Record review of Resident #13's MDS assessment dated [DATE] reflected a BIMS score of 8. Record review of Resident #14's face sheet reflected a [AGE] year old male with an admission date of 10/20/2016 and with diagnoses including acute upper respiratory infection, obesity, major depressive disorder, chronic obstructive pulmonary disease, dementia, unspecified severity, without behavioral, disturbance, psychotic disturbance, mood disturbance, and anxiety, schizoaffective disorder, bipolar type, unspecified psychosis not due to a substance or known physiological condition, bipolar disorder, current episode manic without psychotic features. Record review of Resident #14's MDS assessment dated [DATE] reflected a BIMS score of 15. Record review of Resident #26's face sheet reflected a [AGE] year old male with an admission date of 12/22/2021 and with diagnoses including chronic obstructive pulmonary disease, hypertensive chronic kidney disease with stage 1 through stage chronic kidney disease, or unspecified chronic kidney disease, other psychotic disorder not due to a substance or known physiological condition, bipolar disorder, unspecified, major depressive disorder, recurrent, moderate, anxiety disorder, unspecified, other seizures, essential (primary) hypertension, atherosclerosis of coronary artery bypass graft(s), unspecified with unstable angina pectoris, pneumonia due to coronavirus disease, gastro-esophageal reflux disease with esophagitis. Record review of Resident #26's MDS assessment dated [DATE] reflected a BIMS score of 15. Record review of Resident #29's face sheet revealed a [AGE] year old female with an admission date of 8/4/2016 with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, pressure ulcer of other site, stage 2, dysphagia, oral phase, diabetes mellitus, essential (primary) hypertension, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety bipolar disorder, unspecified, major depressive disorder, recurrent, unspecified, unspecified mood [affective] disorder, anxiety disorder. Record review of Resident #29's MDS assessment dated 6/9//2023 reflected a BIMS score of 14. During an interview on 7/19/2023 at 10:18AM with CNA F was asked when you see abuse and neglect who do you report it to and how soon do you report it and CNA F replied report it as soon as you see it, the abuse coordinator is Admin, if she isn't there you go up the chain of command. When asked if they have seen staff yell at residents before, CNA F stated yes, one in particular, she has a high-pitched voice, she doesn't yell at residents, but she talks loudly. When asked who, CNA F stated, Charge RN. CNA F was asked if they have any concerns about abuse and neglect in the facility at this time and CNA F replied, not right now. Interview with Resident #13 on 7/19/2023 at 10:32AM: Resident #13 was asked what occurred before, during and immediately after the incident and Resident #13 stated Charge RN was in there yelling at Resident #29 like always. All of the employees know. Charge RN told her to quit her damn yelling. Charge RN looks mean, she's intimidating. Very stern. When she goes past the line, I can recognize it. When asked what the tone of the perpetrator was Resident #13 replied she was ugly and horrible. When asked if they think retaliation has occurred, Resident #13 stated not that I know of. They take Resident #29 to her room to eat now. Its better now because of that. As for me, I've been getting some looks from some nurses. Nurse glares at me all the time. One of them ignored me when I tried to speak to her. Resident #13 was asked if this was reported to who and when, and Resident #13 stated to Admin, the administrator. I've gone to her before about issues that have happened, she just says that she knows, and she'll take care of it. When asked how the resident and the perpetrator interacted before and after the incident, Resident #13 stated just yelling like always since she got here and always at Resident #29. After- she's just a weekend nurse so she's only here 2 days a week. She doesn't interact with me at all now. Not everyone is Charge RN's favorite. On the weekend we all stay in our rooms, so we don't make her mad. Resident #13 was asked if the perpetrator exhibited inappropriate behaviors to the resident or other residents in the past such as derogatory language, rough handling or ignoring residents while giving care and Resident #13 stated no, no one else, just Resident #29. In an Interview on 7/19/2023 at 10:42AM with family member of Resident #13: Family member was asked while here have they seen any concerns about abuse and neglect and the family member of Resident #13 stated Resident #13 has had issues with Charge RN because of how she talks to the residents. She (Charge RN) just rubs people the wrong way. In an Interview on 7/19/2023 at 10:58AM with Charge LVN was asked when they see abuse and neglect who do they report it to and how soon do they report it and Charge LVN replied Admin and immediately. Charge LVN was asked how they watch the staff to ensure they are caring for residents and Charge LVN stated I watch them providing care at times. When asked if they seen staff yell at residents before, Charge LVN stated Charge RN, but she's just loud, I wouldn't consider it abuse, it's almost like she's hard of hearing. When asked if they have any concerns about abuse and neglect in the facility at this time, Charge LVN replied no. Interview with Resident #26 on 7/19/2023 at 11:05AM: Resident #26 was asked if they like it here and Resident #26 replied it's alright. When asked if staff treat them with dignity and respect, Resident #26 stated mostly. Resident #26 was asked if they ever see staff yell at residents and Resident #26 replied they yell at Resident #29, it happens all the time, Resident #29 yells at people and staff yells back. When asked what the tone of the staff when they yell, Resident #26 stated I don't think it's in a mean or rude way. When asked if they have a problem or concern, who would they talk to, Resident #26 stated well the staff I would guess. Resident #26 asked if they feel comfortable going to staff to talk to them about your concerns and Resident #26 replied not extremely and said, well I don't want to get yelled at. Resident stated that they are familiar with Charge RN and when asked if they see her yell at residents Resident #26 responded sure, she yells at people. Staff and residents, mostly Resident #29. When asked if they are afraid of her, Resident #26 replied it's impossible not to be, she has a voice that says I'm right. Interview with Resident #5 on 7/19/2023 at 12:13PM: Resident #5 was asked if they see interactions between their roommate Resident #29 and staff and Resident #5 stated all the time. When asked how staff treat Resident #29, Resident #5 replied Charge RN yells at her and gets tough with her, but Resident #29 just takes it. Resident #5 stated it makes me feel bad for her. When asked if they have seen staff yell at any other residents, Resident #5 stated no. Interview with Resident #3 on 7/19/2023 at 12:20PM: Resident #3 was asked how they like living there and Resident #3 replied I like it here. When asked if the staff treat them with dignity and respect, Resident #3 stated yes they treat me good, but not everyone is treated well and it only happens on the weekends with Charge RN. When asked if they have seen it happen, Resident #3 replied yes, I've seen her yell at Resident #29, I've seen her yell at staff and stated, sometimes I'm afraid of Charge RN. When asked if they are afraid of retaliation Resident #3 stated yes I am. Resident #3 stated she's verbally abusive and it goes on all the time. When asked if this has been reported to staff, Resident #3 replied lots of people have, everyone knows about it, I don't think they'll ever do anything about it. When asked how the weekend is at the facility, Resident #3 stated I try to stay out of their way or stay in my room. In an Interview on 7/19/2023 at 12:33PM with Resident #15: When asked if they have any concerns about abuse and neglect in the facility right now, Resident #15 replied I don't like how some of the staff holler at the residents. Resident #15 stated Charge RN, she gets mad at Resident #19 or Resident #29 and yells at them. When asked if they are afraid of Charge RN, Resident #15 replied I'm not afraid of her, I'll stand up for myself but I'm afraid if I say something they'll take it out on me. Charge RN yells at people that can't help themselves and that's not right. When asked how the weekend is at the facility, Resident #15 stated I stay in my room, so I don't get yelled at or caught up in it. Interview with Resident #14 on 7/19/2023 at 12:41PM: When asked if they could describe the incident that happened between Resident #29 and RN Charge RN in the dining room earlier this month, Resident #14 stated I was there. Charge RN kept yelling the louder Resident #29 got. It happens a lot. When asked if they have any concerns about abuse and neglect in the facility at this time, Resident #14 responded no concerns, just Charge RN and Resident #29. When asked if they are afraid of Charge RN, Resident #14 stated no I'm not. When asked if they are afraid of retaliation if they were to tell someone, Resident #14 stated well there's no one to tell because everyone see is, but no I'm not afraid of retaliation. Charge RN just isn't using any common sense, she's mean. When asked how the weekend is at the facility, Resident #14 stated it's ok. In an Interview on 7/19/2023 at 12:49PM with CNA B stated, Charge RN yells at Resident #29 only, it happens often. When asked what they think the tone of Charge RN is when this happens, CNA B responded, it's aggressive, it makes the other residents uncomfortable. Interview with Resident #29 on 7/19/2023 at 12:54PM: When asked if they remember the incident, Resident #29 stated not really. When asked if they like it here, Resident #29 stated it's ok. Resident #29 was asked if the staff treat them with dignity and respect and Resident #29 replied I guess so. When asked how Charge RN treat them, Resident #29 replied sometimes she yells but that's just Charge RN doing her thing. When asked how that makes them feel, Resident #29 responded sometimes bad or sad. When asked if they are afraid of Charge RN, Resident #29 replied I'm not afraid of her, she's a good nurse. Resident #29 was asked if they feel safe here and Resident #29 stated yeah. When asked if they remember if there have been past occurrences like this, Resident #29 replied no I don't. In an interview on 7/19/2023 at 1:01PM DON: DON was asked to describe the incident that occurred on 7/9/2023 and DON stated, Charge RN called me when it happened and told me that another resident was yelling 'abuse, abuse', so she called me to tell me that I needed to come and relieve her. When asked if the resident/perpetrator exhibited any behaviors that would provoke one another and if so, what actions were being taken to address this, DON stated no, but we interviewed Charge RN and issued her an EDR, it's like a write up. When asked if the perpetrator exhibited inappropriate behaviors to the resident or other residents in the past such as derogatory language, rough handling or ignoring residents while giving care, DON stated no. When asked if DON did a psychosocial assessment on all the residents the DON replied, only Resident #29. When asked if they were aware that some of the residents are afraid of Charge RN, DON replied no, I did not know that. In an interview on 7/19/2023 at 1:06PM Admin: When asked how long Charge RN was suspended, Admin stated she was suspended on Sunday and was allowed to come back on Tuesday, but she only works on the weekends. When asked how long the investigation lasted, Admin stated 2 days on Sunday and Monday. Admin was asked to describe the incident and Admin replied Resident #29 yells a lot and Charge RN was trying to tell her not to yell. You do have to raise your voice when talking to Resident #29. Charge RN is loud, and Resident #13 felt like the situation was out of hand. When asked if there were discrepancies and how this was investigated, Admin stated there were, yes. I went and spoke with each of them and none of them had the same story. Resident #13 has a thing against Charge RN. When asked did the resident/perpetrator exhibit any behaviors that would provoke one another and if so, what actions were being taken to address this, the Admin responded yes. I counseled with Charge RN and explained to her to tone it down. Admin was asked if the perpetrator exhibited inappropriate behaviors to the resident or other residents in the past such as derogatory language, rough handling or ignoring residents while giving care and Admin responded no. When asked if annual performance reviews identified issues with the provision of care, treatment or other concerns the Admin stated Charge RN's always been this way. I constantly tell her to be quiet. When asked what the result of your investigation was, Admin stated my result was she was not abusive. She was just trying to make the resident understand. Admin was asked if their previous warnings or incidents at the facility and Admin replied, yes it was between Resident #13 and about Charge RN yelling. When asked if they came up to the facility on the weekends to check in on Charge RN to see how she was doing after the incident the Admin stated, no I did not. When asked how they assure retaliation does not occur when a staff or resident reports an allegation of abuse the Admin stated, I go visit with the residents and assure them that door is always open. Admin was asked if anyone talked to all of the residents and the Admin responded no, we did not. When asked if they were aware that some of the residents are afraid of Charge RN, Admin responded no I was not aware of that. We did have a mention in our full book survey that the residents were afraid of retaliation, but we talked to the residents and did in-services with staff. Admin as asked what the EDR done for on Charge RN and Admin stated, it was for the incident about her voice and demeaner on that day. When asked if it was for the incident on 7/9/23 the Admin stated yes. Interview on 7/19/2023 at 1:31PM with Admin stated: When asked what they are doing on the weekends to ensure that the situation with Charge RN is no longer happening, the Admin replied I talked with Charge RN and let Residents know to come talk to me. When asked if the Admin has been up there on the weekends the Admin replied no. Interview on 7/19/2023 at 1:50PM with CNA : When asked if they have seen staff yell at residents before CNA B stated yes, all the time and Charge RN yells at Resident #29 all the time. She is loud but there's a difference between yelling at residents and being loud. When asked if they have intervened when they saw this happen, CNA B stated yes, I have, and we've had words about it. I'm very vocal with how she treats Resident #29. Interview on 7/19/2023 at 1:55PM with Admin: When asked on the EDR that was given to Charge RN on 7/12/2023 shows that there are 2 write ups in the last 12 months, Admin responded Oh no, there's no other write ups, that was a mistake, I had used a template to do that and forgo to erase it. When asked what the Admin did about the grievance filed on 5/29/2023 about Charge RN, Admin stated I counseled with her on her demeaner and voice tones. When asked if there were any other investigations about Charge RN the Admin stated no, I always talked to her about her voice and her demeanor with the residents. When asked if the Admin felt like they conducted an effective investigation of this incident on 7/9/2023, Admin stated I know she's a good nurse, she's good to the patients, she takes care of the residents. I don't see her as being abusive, but I know it comes across that way. Admin was asked why Charge RN is still employed, the Admin responded, I don't believe she's abusive. Admin was asked how they know that and Admin stated, Well I asked the residents. When asked if they understand that if the residents are afraid do they think they would be honest and Admin stated, they know Charge RN, but I didn't know anyone was afraid of her. Interview on 7/19/2023 at 2:14PM with Charge RN: Charge RN described the incident and stated I was at the nurse station charting, Resident #29 she was yelling for me at the top of her lungs as I was going down the hall. Resident #29 didn't have her hearing aids. I told her to stop yelling. When asked how they usually respond to the Residents behaviors requests for assistance, Charge RN stated I usually do it right away. I was caring for another Resident at the time. I tried to tell her that I would be back. Charge RN was asked to describe what contact they have with Resident #29 since the investigation and Charge RN replied I worked last weekend with her. When asked what type of training Charge RN had related to abuse and neglect they have received and Charge RN replied we had in-services about it and who to contact. Charge RN stated during the incident that there was a Resident yelling abuse going down the hall so I called the DON to relieve me and she called the Admin. When asked if they have any other information they wish to share in regards to the investigation, Charge RN stated Resident #29 is very hard of hearing. I wasn't being ugly to her. The kitchen supervisor was right there cleaning tables when it happened. Interview on 7/19/2023 at 2:25PM with LVN D: When asked if they have worked with RN Charge RN on the weekends, LVN D stated yes. When asked how Charge RN interacts with residents, LVN D replied I've known her a long time, we work together on Saturdays. She comes off very gruff and she's just loud. I don't think that she means harm or is bad. She just doesn't have any tone control. She's not mean spirited, she just doesn't have elderly gloves and she needs restraint. Interview on 7/19/2023 at 2:39PM with LVN A: When asked if they have worked with RN Charge RN on the weekends, LVN A stated yes. When asked how Charge RN interacts with residents, LVN A stated, I've heard more complains than what I've seen, the main thing is she's just loud, nothing physical. LVN A stated, she's loud and residents don't like it. Interview on 7/19/2023 at 2:47PM with LVN I: When asked if they have worked with RN Charge RN on the weekends, LVN I stated, I'm coming in as she's leaving. When asked how Charge RN interacts with residents, LVN I replied, I haven't seen any interactions, I haven't heard any complaints from the residents. When asked if they have any concerns about abuse and neglect in the facility at this time, LVN I stated I haven't seen anything, I've just heard stuff. I've heard that Charge RN yelled at a few resident, Resident #13 on the other side of the hall, other than that I heard she's always yelling back and forth with Resident #29. Interview on 7/19/2023 at 2:37PM with LVN J: When asked if they have worked with RN Charge RN on the weekends, LVN J responded, yes I do sometimes. When asked how Charge RN interacts with residents, LVN J stated, she's mean, and she yells at them. When asked if they have any concerns about abuse and neglect in the facility at this time, LVN J stated, just that but everyone knows about it, and they don't do anything about it. Interview on 7/19/2023 at 2:50PM with CNA G: When asked if they have seen any staff yell at residents, CNA G replied, Charge RN, yes she has and she has a rude attitude and a loud voice with residents. When asked if they have ever reported it, CNA G stated, well the residents haven't complained to me. When asked if they have seen Charge RN yell at residents, CNA G stated, I haven't seen it, but I always hear her. When asked if they have any concerns about abuse and neglect in the facility at this time, CNA G replied yes, it's degrading for the residents. This is their home. In an interview on 7/21/2023 at 11:31AM Admin: Admin was asked if there are other investigations on Charge RN and Admin stated, there are no other investigations, what's in her file is what I have. When asked if their investigation prevented further abuse, neglect or mistreatment of the resident, Admin replied well, yes because when I did interviews and tried to find out more information, I didn't get the same answers that you guys got. When asked if they felt that the investigation was adequate the Admin stated, yes I do. The Admin was asked if they think that they took appropriate corrective action as a result of the findings and Admin stated yes, I think I did. If I would have got different information, I would have done it differently. When asked if they interviewed other residents to ask them how the yelling/verbal abuse made them feel the Admin responded no. Admin was asked if they monitored Resident #29 and other residents at risk such as conducting unannounced management visits at different times and shifts and Admin replied Yeah, me and DON come in at different times, DON is good at popping up. When asked if on the weekends did the Admin specifically come in to monitor Charge RN's interactions with residents the Admin stated no, I did not come in to observe her. Admin was asked what actions were taken to protect the residents and the Admin replied, well we did the plan of removal after. Admin was asked if they felt that the facility's ANE policies and procedures are implemented well within the staff and the Admin replied they are now, but before it's hard to say really. I don't know. Admin was asked if they are conducting ongoing oversight and supervision of staff to assure that the ANE policies and procedures are implemented as written and Admin responded, I am now yes. When asked if they feel that the staff is able to identify, correct and intervene in situations in which abuse, neglect and exploitation is more likely to occur and the Admin stated now, yes. Record Review of staff in-services indicate that Charge RN was in-serviced on Abuse and Neglect on the following dates: 6/14/2023, 7/7/2023, and 7/19/2023. Record Review of staff in-services indicate that Charge RN was in-serviced on Resident Rights on 7/10/2023. Record review of facility's Grievance Log shows a grievance filed on 5/30/2023 by Resident #13 describes the incident as follows: Charge RN yells at Residents causing Resident #13 to feel uncomfortable. Resident #13 feels Charge RN yells at her and others. The Disposition of Complaint states: talk to RN about her loud voice dealing with Residents. The findings of the incident as follows: Charge RN has a very loud demeanor when dealing with anyone or anything. The Recommendations/Corrective Action states: Counsel with Charge RN on her demeanor and voice tones. Record Review of Facility Grievance Investigation Report dated 5/30/2023 shows a written statement as follows: Resident #13 states they feel like Charge RN verbal abusive to her and the other Residents. Resident #13 states that Charge RN yells at other Residents and makes them feel uncomfortable. Resident #13 states that Charge RN yelled at them for going into the dining room for smoke break and Charge RN yelled at them stating they were in the dining room too early for smoke break. Resident #13 states that sometimes in the dining room Charge RN is so loud that it makes them uncomfortable so they go back to their room. Record Review of Facility Notice of Disciplinary Action for Charge RN is dated 10/13/2022 is detailed as follows: Arguing with Resident in a non-professional manner in a loud tone. Record Review of Facility Notice of Disciplinary Action dated 10/13/2022 includes a witness statement from DON that states: Charge RN was in lobby and Resident #29 was yelling out at staff to come here. Charge RN went over to Resident and told them to stop yelling and Resident #29 told Charge RN that she was not their boss and to not tell them what to do. Charge RN continued to argue with Resident about this but I was talking to someone else at the time and didn't hear the whole conversation. MDS LVN stepped out of their office and told Charge RN to walk away and they did so. After Charge RN got back to their office, Resident #29 then yelled at Charge RN to come back over there. Charge RN did not do so. Earlier in the shift I was asking Resident #29 to stop yelling out and at the same time Charge RN came over and interrupted me to tell Resident #29 the same thing. Record Review of Facility Notice of Disciplinary Action dated 10/13/2022 includes a witness statement from Bus Office that states: This is what I heard but did not see from my office. Resident #29 was in the living area, requesting different things from everyone in a loud tone. Charge RN went up to Resident #29 and in their very loud voice tone told them that they needed to stop yelling and that someone would get to them. I'm not sure if Resident #29 told Charge RN she was not her boss, but Charge RN told Resident #29 you are not by boss, that they worked at the nursing home and cared for them. I then heard MDS LVN tell Charge RN to walk away. Record Review of Facility Notice of Disciplinary Action dated 10/13/2022 includes a witness statement from MDS LVN that states: Charge RN was working 6-2 as RN coverage. Resident #29 was in the lobby after breakfast, and they were wanting to go to bed. Charge RN was yelling at her tell her she had to stay up for 30 min. Charge RN kept arguing with Resident #29. DON told them that the yelling needs to stop and that they couldn't handle it anymore. Resident #33 was getting anxious and restless because of all the yelling. At lunch Resident #29 yelled for me to come there. Charge RN said just keep walking. I did ask them what they needed, and they wanted me to move Resident #17 to their table. I told them to give me a minute and I will. About 10 minutes later, Resident #29 was yelling for LVN G and Charge RN told them to keep going. LVN K did not listen, and Resident #29 wanted a pain pill. LVN G gave her the medicine. After lunch, Resident #29 told Charge RN to come here. Resident #29 wanted to be laid down. Charge RN told her that she had to wait 30 minutes. Resident #29 told Charge RN something I could not hear. Charge RN leaned over the table and to tell Resident #29 you are not by boss. Resident #29 said loudly I am your boss. Charge RN said no you are not my boss and you will not talk to me that way. I immediately got out of my chair and told Charge RN that they needed to walk away. Charge RN went to walk away, and Resident #29 was asking them something and Charge RN put her hand in the air and walked to the middle office up front. Record Review of Facility Notice of Disciplinary Action dated 10/13/2022 includes a witness statement from LVN G that states: I LVN G was working as a LVN at [facility] on 10/13/22. My RN supervisor was Charge RN. Charge RN has really stern assertive voice and sometimes yells a lot. On this particular day Charge RN was on a roll, Resident #29 was in the dining room yelling at me as I went to walk by them and Charge RN yelled at me and told me to keep walking however I stopped to see what they wanted and they asked me for Tylenol. So I went and got them medication. Then in about 30-45 minutes later Resident #29 was in the lobby and just sitting there in a wheelchair and they yelled at me again. I was at the computer doing my charting and I told Resident #29 it would be just a minute. I could visibly see that Resident #29 was not in any harm where I was sitting and they just wanting to talk to me or ask me something. Charge RN heard her from a office and Charge RN stormed out of that office and yelled at Resident #29 saying what do you need. Resident #29 said she wants to lay down Charge RN told it would be 30 minutes then they said I need to talk to my nurse. Charge R said your nurse is busy what do you need? Resident #29 looked at Charge RN and said just go back to your office and leave me alone and Charge RN stormed closer to Resident #29 and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents for 6 of 6 residents (Residents #3, #5, #13, #14, #26, #29) reviewed for abuse. The facility failed to implement written abuse and neglect policies to prohibit and prevent abuse for Residents #3, #5, #13, #14, #26 and #29. These failures place Residents at risk for psychosocial harm, fearful of retaliation, being uncomfortable, impaired quality of life and abuse as a result of the verbal abuse. An Immediate Jeopardy (IJ) was identified on 7/19/2023 at 5:08PM. While the immediate jeopardy was lifted on 7/21/2023 at 2:35PM, the facility remained out of compliance at a severity of actual harm with potential for more than minimal harm: and scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. Plan of removal of IJ will be included in findings. Findings included: Record review of Resident #3's face sheet revealed a [AGE] year old female with an admission date of 7/29/2019 with diagnoses including: chronic obstructive pulmonary disease, emphysema and acute kidney failure. Record review of Resident #3's MDS assessment dated [DATE] reflected a BIMS score of 13. Record review of Resident #5's face sheet reflected a [AGE] year old female with an admission date of 10/6/2022 and with diagnoses including chronic kidney disease, altered mental status, hyperparathyroidism, morbid (severe) obesity, unspecified dementia, moderate, with psychotic disturbance, delirium due to known physiological condition, schizophrenia, unspecified, delusional disorders, unspecified psychosis not due to a substance or known physiological condition, bipolar disorder, unspecified, major depressive disorder, recurrent, moderate anxiety disorder, unspecified, insomnia, unspecified, essential (primary) hypertension. Record review of Resident #5's MDS assessment dated [DATE] reflected a BIMS score of 15. Record review of Resident #13's face sheet reflected a [AGE] year old female with an admission date of 3/13/2023 and with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, alcohol use unspecified with alcohol-induced persisting dementia, essential (primary) hypertension, major depressive disorder, recurrent, unspecified, unspecified atrial fibrillation. Record review of Resident #13's MDS assessment dated [DATE] reflected a BIMS score of 8. Record review of Resident #14's face sheet reflected a [AGE] year old male with an admission date of 10/20/2016 and with diagnoses including acute upper respiratory infection, obesity, major depressive disorder, chronic obstructive pulmonary disease, dementia, unspecified severity, without behavioral, disturbance, psychotic disturbance, mood disturbance, and anxiety, schizoaffective disorder, bipolar type, unspecified psychosis not due to a substance or known physiological condition, bipolar disorder, current episode manic without psychotic features. Record review of Resident #14's MDS assessment dated [DATE] reflected a BIMS score of 15. Record review of Resident #26's face sheet reflected a [AGE] year old male with an admission date of 12/22/2021 and with diagnoses including chronic obstructive pulmonary disease, hypertensive chronic kidney disease with stage 1 through stage chronic kidney disease, or unspecified chronic kidney disease, other psychotic disorder not due to a substance or known physiological condition, bipolar disorder, unspecified, major depressive disorder, recurrent, moderate, anxiety disorder, unspecified, other seizures, essential (primary) hypertension, atherosclerosis of coronary artery bypass graft(s), unspecified with unstable angina pectoris, pneumonia due to coronavirus disease, gastro-esophageal reflux disease with esophagitis. Record review of Resident #26's MDS assessment dated [DATE] reflected a BIMS score of 15. Record review of Resident #29's face sheet revealed a [AGE] year old female with an admission date of 8/4/2016 with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, pressure ulcer of other site, stage 2, dysphagia, oral phase, diabetes mellitus, essential (primary) hypertension, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety bipolar disorder, unspecified, major depressive disorder, recurrent, unspecified, unspecified mood [affective] disorder, anxiety disorder. Record review of Resident #29's MDS assessment dated 6/9//2023 reflected a BIMS score of 14. During an interview on 7/19/2023 at 10:18AM with CNA F was asked when you see abuse and neglect who do you report it to and how soon do you report it and CNA F replied report it as soon as you see it, the abuse coordinator is Admin, if she isn't there you go up the chain of command. When asked if they have seen staff yell at residents before, CNA F stated yes, one in particular, she has a high-pitched voice, she doesn't yell at residents, but she talks loudly. When asked who, CNA F stated, Charge RN. CNA F was asked if they have any concerns about abuse and neglect in the facility at this time and CNA F replied, not right now. Interview with Resident #13 on 7/19/2023 at 10:32AM: Resident #13 was asked what occurred before, during and immediately after the incident and Resident #13 stated Charge RN was in there yelling at Resident #29 like always. All of the employees know. Charge RN told her to quit her damn yelling. Charge RN looks mean, she's intimidating. Very stern. When she goes past the line, I can recognize it. When asked what the tone of the perpetrator was Resident #13 replied she was ugly and horrible. When asked if they think retaliation has occurred, Resident #13 stated not that I know of. They take Resident #29 to her room to eat now. Its better now because of that. As for me, I've been getting some looks from some nurses. Nurse glares at me all the time. One of them ignored me when I tried to speak to her. Resident #13 was asked if this was reported to who and when, and Resident #13 stated to Admin, the administrator. I've gone to her before about issues that have happened, she just says that she knows, and she'll take care of it. When asked how the resident and the perpetrator interacted before and after the incident, Resident #13 stated just yelling like always since she got here and always at Resident #29. After- she's just a weekend nurse so she's only here 2 days a week. She doesn't interact with me at all now. Not everyone is Charge RN's favorite. On the weekend we all stay in our rooms, so we don't make her mad. Resident #13 was asked if the perpetrator exhibited inappropriate behaviors to the resident or other residents in the past such as derogatory language, rough handling or ignoring residents while giving care and Resident #13 stated no, no one else, just Resident #29. In an Interview on 7/19/2023 at 10:42AM with family member of Resident #13: Family member was asked while here have they seen any concerns about abuse and neglect and the family member of Resident #13 stated Resident #13 has had issues with Charge RN because of how she talks to the residents. She (Charge RN) just rubs people the wrong way. In an Interview on 7/19/2023 at 10:58AM with Charge LVN was asked when they see abuse and neglect who do they report it to and how soon do they report it and Charge LVN replied Admin and immediately. Charge LVN was asked how they watch the staff to ensure they are caring for residents and Charge LVN stated I watch them providing care at times. When asked if they seen staff yell at residents before, Charge LVN stated Charge RN, but she's just loud, I wouldn't consider it abuse, it's almost like she's hard of hearing. When asked if they have any concerns about abuse and neglect in the facility at this time, Charge LVN replied no. Interview with Resident #26 on 7/19/2023 at 11:05AM: Resident #26 was asked if they like it here and Resident #26 replied it's alright. When asked if staff treat them with dignity and respect, Resident #26 stated mostly. Resident #26 was asked if they ever see staff yell at residents and Resident #26 replied they yell at Resident #29, it happens all the time, Resident #29 yells at people and staff yells back. When asked what the tone of the staff when they yell, Resident #26 stated I don't think it's in a mean or rude way. When asked if they have a problem or concern, who would they talk to, Resident #26 stated well the staff I would guess. Resident #26 asked if they feel comfortable going to staff to talk to them about your concerns and Resident #26 replied not extremely and said, well I don't want to get yelled at. Resident stated that they are familiar with Charge RN and when asked if they see her yell at residents Resident #26 responded sure, she yells at people. Staff and residents, mostly Resident #29. When asked if they are afraid of her, Resident #26 replied it's impossible not to be, she has a voice that says I'm right. Interview with Resident #5 on 7/19/2023 at 12:13PM: Resident #5 was asked if they see interactions between their roommate Resident #29 and staff and Resident #5 stated all the time. When asked how staff treat Resident #29, Resident #5 replied Charge RN yells at her and gets tough with her, but Resident #29 just takes it. Resident #5 stated it makes me feel bad for her. When asked if they have seen staff yell at any other residents, Resident #5 stated no. Interview with Resident #3 on 7/19/2023 at 12:20PM: Resident #3 was asked how they like living there and Resident #3 replied I like it here. When asked if the staff treat them with dignity and respect, Resident #3 stated yes they treat me good, but not everyone is treated well and it only happens on the weekends with Charge RN. When asked if they have seen it happen, Resident #3 replied yes, I've seen her yell at Resident #29, I've seen her yell at staff and stated, sometimes I'm afraid of Charge RN. When asked if they are afraid of retaliation Resident #3 stated yes I am. Resident #3 stated she's verbally abusive and it goes on all the time. When asked if this has been reported to staff, Resident #3 replied lots of people have, everyone knows about it, I don't think they'll ever do anything about it. When asked how the weekend is at the facility, Resident #3 stated I try to stay out of their way or stay in my room. In an Interview on 7/19/2023 at 12:33PM with Resident #15: When asked if they have any concerns about abuse and neglect in the facility right now, Resident #15 replied I don't like how some of the staff holler at the residents. Resident #15 stated Charge RN, she gets mad at Resident #19 or Resident #29 and yells at them. When asked if they are afraid of Charge RN, Resident #15 replied I'm not afraid of her, I'll stand up for myself but I'm afraid if I say something they'll take it out on me. Charge RN yells at people that can't help themselves and that's not right. When asked how the weekend is at the facility, Resident #15 stated I stay in my room, so I don't get yelled at or caught up in it. Interview with Resident #14 on 7/19/2023 at 12:41PM: When asked if they could describe the incident that happened between Resident #29 and RN Charge RN in the dining room earlier this month, Resident #14 stated I was there. Charge RN kept yelling the louder Resident #29 got. It happens a lot. When asked if they have any concerns about abuse and neglect in the facility at this time, Resident #14 responded no concerns, just Charge RN and Resident #29. When asked if they are afraid of Charge RN, Resident #14 stated no I'm not. When asked if they are afraid of retaliation if they were to tell someone, Resident #14 stated well there's no one to tell because everyone see is, but no I'm not afraid of retaliation. Charge RN just isn't using any common sense, she's mean. When asked how the weekend is at the facility, Resident #14 stated it's ok. In an Interview on 7/19/2023 at 12:49PM with CNA B stated, Charge RN yells at Resident #29 only, it happens often. When asked what they think the tone of Charge RN is when this happens, CNA B responded, it's aggressive, it makes the other residents uncomfortable. Interview with Resident #29 on 7/19/2023 at 12:54PM: When asked if they remember the incident, Resident #29 stated not really. When asked if they like it here, Resident #29 stated it's ok. Resident #29 was asked if the staff treat them with dignity and respect and Resident #29 replied I guess so. When asked how Charge RN treat them, Resident #29 replied sometimes she yells but that's just Charge RN doing her thing. When asked how that makes them feel, Resident #29 responded sometimes bad or sad. When asked if they are afraid of Charge RN, Resident #29 replied I'm not afraid of her, she's a good nurse. Resident #29 was asked if they feel safe here and Resident #29 stated yeah. When asked if they remember if there have been past occurrences like this, Resident #29 replied no I don't. In an interview on 7/19/2023 at 1:01PM DON: DON was asked to describe the incident that occurred on 7/9/2023 and DON stated, Charge RN called me when it happened and told me that another resident was yelling 'abuse, abuse', so she called me to tell me that I needed to come and relieve her. When asked if the resident/perpetrator exhibited any behaviors that would provoke one another and if so, what actions were being taken to address this, DON stated no, but we interviewed Charge RN and issued her an EDR, it's like a write up. When asked if the perpetrator exhibited inappropriate behaviors to the resident or other residents in the past such as derogatory language, rough handling or ignoring residents while giving care, DON stated no. When asked if DON did a psychosocial assessment on all the residents the DON replied, only Resident #29. When asked if they were aware that some of the residents are afraid of Charge RN, DON replied no, I did not know that. In an interview on 7/19/2023 at 1:06PM Admin: When asked how long Charge RN was suspended, Admin stated she was suspended on Sunday and was allowed to come back on Tuesday, but she only works on the weekends. When asked how long the investigation lasted, Admin stated 2 days on Sunday and Monday. Admin was asked to describe the incident and Admin replied Resident #29 yells a lot and Charge RN was trying to tell her not to yell. You do have to raise your voice when talking to Resident #29. Charge RN is loud, and Resident #13 felt like the situation was out of hand. When asked if there were discrepancies and how this was investigated, Admin stated there were, yes. I went and spoke with each of them and none of them had the same story. Resident #13 has a thing against Charge RN. When asked did the resident/perpetrator exhibit any behaviors that would provoke one another and if so, what actions were being taken to address this, the Admin responded yes. I counseled with Charge RN and explained to her to tone it down. Admin was asked if the perpetrator exhibited inappropriate behaviors to the resident or other residents in the past such as derogatory language, rough handling or ignoring residents while giving care and Admin responded no. When asked if annual performance reviews identified issues with the provision of care, treatment or other concerns the Admin stated Charge RN's always been this way. I constantly tell her to be quiet. When asked what the result of your investigation was, Admin stated my result was she was not abusive. She was just trying to make the resident understand. Admin was asked if their previous warnings or incidents at the facility and Admin replied, yes it was between Resident #13 and about Charge RN yelling. When asked if they came up to the facility on the weekends to check in on Charge RN to see how she was doing after the incident the Admin stated, no I did not. When asked how they assure retaliation does not occur when a staff or resident reports an allegation of abuse the Admin stated, I go visit with the residents and assure them that door is always open. Admin was asked if anyone talked to all of the residents and the Admin responded no, we did not. When asked if they were aware that some of the residents are afraid of Charge RN, Admin responded no I was not aware of that. We did have a mention in our full book survey that the residents were afraid of retaliation, but we talked to the residents and did in-services with staff. Admin as asked what the EDR done for on Charge RN and Admin stated, it was for the incident about her voice and demeaner on that day. When asked if it was for the incident on 7/9/23 the Admin stated yes. Interview on 7/19/2023 at 1:31PM with Admin stated: When asked what they are doing on the weekends to ensure that the situation with Charge RN is no longer happening, the Admin replied I talked with Charge RN and let Residents know to come talk to me. When asked if the Admin has been up there on the weekends the Admin replied no. Interview on 7/19/2023 at 1:50PM with CNA : When asked if they have seen staff yell at residents before CNA B stated yes, all the time and Charge RN yells at Resident #29 all the time. She is loud but there's a difference between yelling at residents and being loud. When asked if they have intervened when they saw this happen, CNA B stated yes, I have, and we've had words about it. I'm very vocal with how she treats Resident #29. Interview on 7/19/2023 at 1:55PM with Admin: When asked on the EDR that was given to Charge RN on 7/12/2023 shows that there are 2 write ups in the last 12 months, Admin responded Oh no, there's no other write ups, that was a mistake, I had used a template to do that and forgo to erase it. When asked what the Admin did about the grievance filed on 5/29/2023 about Charge RN, Admin stated I counseled with her on her demeaner and voice tones. When asked if there were any other investigations about Charge RN the Admin stated no, I always talked to her about her voice and her demeanor with the residents. When asked if the Admin felt like they conducted an effective investigation of this incident on 7/9/2023, Admin stated I know she's a good nurse, she's good to the patients, she takes care of the residents. I don't see her as being abusive, but I know it comes across that way. Admin was asked why Charge RN is still employed, the Admin responded, I don't believe she's abusive. Admin was asked how they know that and Admin stated, Well I asked the residents. When asked if they understand that if the residents are afraid do they think they would be honest and Admin stated, they know Charge RN, but I didn't know anyone was afraid of her. Interview on 7/19/2023 at 2:14PM with Charge RN: Charge RN described the incident and stated I was at the nurse station charting, Resident #29 she was yelling for me at the top of her lungs as I was going down the hall. Resident #29 didn't have her hearing aids. I told her to stop yelling. When asked how they usually respond to the Residents behaviors requests for assistance, Charge RN stated I usually do it right away. I was caring for another Resident at the time. I tried to tell her that I would be back. Charge RN was asked to describe what contact they have with Resident #29 since the investigation and Charge RN replied I worked last weekend with her. When asked what type of training Charge RN had related to abuse and neglect they have received and Charge RN replied we had in-services about it and who to contact. Charge RN stated during the incident that there was a Resident yelling abuse going down the hall so I called the DON to relieve me and she called the Admin. When asked if they have any other information they wish to share in regards to the investigation, Charge RN stated Resident #29 is very hard of hearing. I wasn't being ugly to her. The kitchen supervisor was right there cleaning tables when it happened. Interview on 7/19/2023 at 2:25PM with LVN D: When asked if they have worked with RN Charge RN on the weekends, LVN D stated yes. When asked how Charge RN interacts with residents, LVN D replied I've known her a long time, we work together on Saturdays. She comes off very gruff and she's just loud. I don't think that she means harm or is bad. She just doesn't have any tone control. She's not mean spirited, she just doesn't have elderly gloves and she needs restraint. Interview on 7/19/2023 at 2:39PM with LVN A: When asked if they have worked with RN Charge RN on the weekends, LVN A stated yes. When asked how Charge RN interacts with residents, LVN A stated, I've heard more complains than what I've seen, the main thing is she's just loud, nothing physical. LVN A stated, she's loud and residents don't like it. Interview on 7/19/2023 at 2:47PM with LVN I: When asked if they have worked with RN Charge RN on the weekends, LVN I stated, I'm coming in as she's leaving. When asked how Charge RN interacts with residents, LVN I replied, I haven't seen any interactions, I haven't heard any complaints from the residents. When asked if they have any concerns about abuse and neglect in the facility at this time, LVN I stated I haven't seen anything, I've just heard stuff. I've heard that Charge RN yelled at a few resident, Resident #13 on the other side of the hall, other than that I heard she's always yelling back and forth with Resident #29. Interview on 7/19/2023 at 2:37PM with LVN J: When asked if they have worked with RN Charge RN on the weekends, LVN J responded, yes I do sometimes. When asked how Charge RN interacts with residents, LVN J stated, she's mean, and she yells at them. When asked if they have any concerns about abuse and neglect in the facility at this time, LVN J stated, just that but everyone knows about it, and they don't do anything about it. Interview on 7/19/2023 at 2:50PM with CNA G: When asked if they have seen any staff yell at residents, CNA G replied, Charge RN, yes she has and she has a rude attitude and a loud voice with residents. When asked if they have ever reported it, CNA G stated, well the residents haven't complained to me. When asked if they have seen Charge RN yell at residents, CNA G stated, I haven't seen it, but I always hear her. When asked if they have any concerns about abuse and neglect in the facility at this time, CNA G replied yes, it's degrading for the residents. This is their home. In an interview on 7/21/2023 at 11:31AM Admin: Admin was asked if there are other investigations on Charge RN and Admin stated, there are no other investigations, what's in her file is what I have. When asked if their investigation prevented further abuse, neglect or mistreatment of the resident, Admin replied well, yes because when I did interviews and tried to find out more information, I didn't get the same answers that you guys got. When asked if they felt that the investigation was adequate the Admin stated, yes I do. The Admin was asked if they think that they took appropriate corrective action as a result of the findings and Admin stated yes, I think I did. If I would have got different information, I would have done it differently. When asked if they interviewed other residents to ask them how the yelling/verbal abuse made them feel the Admin responded no. Admin was asked if they monitored Resident #29 and other residents at risk such as conducting unannounced management visits at different times and shifts and Admin replied Yeah, me and DON come in at different times, DON is good at popping up. When asked if on the weekends did the Admin specifically come in to monitor Charge RN's interactions with residents the Admin stated no, I did not come in to observe her. Admin was asked what actions were taken to protect the residents and the Admin replied, well we did the plan of removal after. Admin was asked if they felt that the facility's ANE policies and procedures are implemented well within the staff and the Admin replied they are now, but before it's hard to say really. I don't know. Admin was asked if they are conducting ongoing oversight and supervision of staff to assure that the ANE policies and procedures are implemented as written and Admin responded, I am now yes. When asked if they feel that the staff is able to identify, correct and intervene in situations in which abuse, neglect and exploitation is more likely to occur and the Admin stated now, yes. Record Review of staff in-services indicate that Charge RN was in-serviced on Abuse and Neglect on the following dates: 6/14/2023, 7/7/2023, and 7/19/2023. Record Review of staff in-services indicate that Charge RN was in-serviced on Resident Rights on 7/10/2023. Record review of facility's Grievance Log shows a grievance filed on 5/30/2023 by Resident #13 describes the incident as follows: Charge RN yells at Residents causing Resident #13 to feel uncomfortable. Resident #13 feels Charge RN yells at her and others. The Disposition of Complaint states: talk to RN about her loud voice dealing with Residents. The findings of the incident as follows: Charge RN has a very loud demeanor when dealing with anyone or anything. The Recommendations/Corrective Action states: Counsel with Charge RN on her demeanor and voice tones. Record Review of Facility Grievance Investigation Report dated 5/30/2023 shows a written statement as follows: Resident #13 states they feel like Charge RN verbal abusive to her and the other Residents. Resident #13 states that Charge RN yells at other Residents and makes them feel uncomfortable. Resident #13 states that Charge RN yelled at them for going into the dining room for smoke break and Charge RN yelled at them stating they were in the dining room too early for smoke break. Resident #13 states that sometimes in the dining room Charge RN is so loud that it makes them uncomfortable so they go back to their room. Record Review of Facility Notice of Disciplinary Action for Charge RN is dated 10/13/2022 is detailed as follows: Arguing with Resident in a non-professional manner in a loud tone. Record Review of Facility Notice of Disciplinary Action dated 10/13/2022 includes a witness statement from DON that states: Charge RN was in lobby and Resident #29 was yelling out at staff to come here. Charge RN went over to Resident and told them to stop yelling and Resident #29 told Charge RN that she was not their boss and to not tell them what to do. Charge RN continued to argue with Resident about this but I was talking to someone else at the time and didn't hear the whole conversation. MDS LVN stepped out of their office and told Charge RN to walk away and they did so. After Charge RN got back to their office, Resident #29 then yelled at Charge RN to come back over there. Charge RN did not do so. Earlier in the shift I was asking Resident #29 to stop yelling out and at the same time Charge RN came over and interrupted me to tell Resident #29 the same thing. Record Review of Facility Notice of Disciplinary Action dated 10/13/2022 includes a witness statement from Bus Office that states: This is what I heard but did not see from my office. Resident #29 was in the living area, requesting different things from everyone in a loud tone. Charge RN went up to Resident #29 and in their very loud voice tone told them that they needed to stop yelling and that someone would get to them. I'm not sure if Resident #29 told Charge RN she was not her boss, but Charge RN told Resident #29 you are not by boss, that they worked at the nursing home and cared for them. I then heard MDS LVN tell Charge RN to walk away. Record Review of Facility Notice of Disciplinary Action dated 10/13/2022 includes a witness statement from MDS LVN that states: Charge RN was working 6-2 as RN coverage. Resident #29 was in the lobby after breakfast, and they were wanting to go to bed. Charge RN was yelling at her tell her she had to stay up for 30 min. Charge RN kept arguing with Resident #29. DON told them that the yelling needs to stop and that they couldn't handle it anymore. Resident #33 was getting anxious and restless because of all the yelling. At lunch Resident #29 yelled for me to come there. Charge RN said just keep walking. I did ask them what they needed, and they wanted me to move Resident #17 to their table. I told them to give me a minute and I will. About 10 minutes later, Resident #29 was yelling for LVN G and Charge RN told them to keep going. LVN K did not listen, and Resident #29 wanted a pain pill. LVN G gave her the medicine. After lunch, Resident #29 told Charge RN to come here. Resident #29 wanted to be laid down. Charge RN told her that she had to wait 30 minutes. Resident #29 told Charge RN something I could not hear. Charge RN leaned over the table and to tell Resident #29 you are not by boss. Resident #29 said loudly I am your boss. Charge RN said no you are not my boss and you will not talk to me that way. I immediately got out of my chair and told Charge RN that they needed to walk away. Charge RN went to walk away, and Resident #29 was asking them something and Charge RN put her hand in the air and walked to the middle office up front. Record Review of Facility Notice of Disciplinary Action dated 10/13/2022 includes a witness statement from LVN G that states: I LVN G was working as a LVN at [facility] on 10/13/22. My RN supervisor was Charge RN. Charge RN has really stern assertive voice and sometimes yells a lot. On this particular day Charge RN was on a roll, Resident #29 was in the dining room yelling at me as I went to walk by them and Charge RN yelled at me and told me to keep walking however I stopped to see what they wanted and they asked me for Tylenol. So I went and got them medication. Then in about 30-45 minutes later Resident #29 was in the lobby and just sitting there in a wheelchair and they yelled at me again. I was at the computer doing my charting and I told Resident #29 it would be just a minute. I could visibly see that Resident #29 was not in any harm where I was sitting and they just wanting to talk to me or ask me something. Charge RN heard her from a office and Charge RN stormed out of that office and yelled at Resident #29 saying what do you need. Resident #29 said she wants to lay down Charge RN told it would be 30 minutes then they said I need to talk to my nurse. Charge R said your nurse is busy what do you need? Resident #29 looked at Charge RN and said just go back to your office and leave me alone and Charge RN stormed closer to Resident #29 and said you are not my boss. Charge RN said yes I am your boss. You could tell in the tone of Charge RN voice that the statement Resident #29 made Charge RN rea[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 12 residents (Resident #29) reviewed for accident hazards. CNA A transferred Resident #29 by herself from a wheelchair to a shower chair in preparation for bathing when Resident #29 required two staff participation with transfers. Resident #29 sustained a fall during the transfer resulting in a right leg fracture (broken bone in leg), right elbow fracture, and hematoma (bleeding outside of blood vessels, due to trauma.) Resident #29 was sent to the hospital and subsequently placed on hospice care (type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) when she returned to the facility. An Immediate Jeopardy (IJ) was identified on 04/26/22 at 5:30 PM. While the IJ was removed on 04/27/22 at 10:36 AM, the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility need to evaulate the effectiveness of their corrective systems. This failure could place residents that require two-person staff assistance with transfers at risk for falls, injury, and/or death. Findings include: Record review of Resident #29's Face Sheet, dated 4/26/22, indicated a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses that included a fracture of unspecified part of neck of the right femur initial encounter of a closed fracture (break of right leg bone), displaced fracture of olecranon process with intraarticular extension of the right ulna (bone in elbow broke in two places), unspecified fall, cognitive-communication deficit (comprehension and communication disorder resulting from damage or injury to the specific area in the brain), morbid obesity, reduced mobility, chronic kidney disease, diabetes (high sugar levels for prolonged periods of time), memory deficit, cerebral infarction (stroke), aphasia (difficulty with speech), lack of coordination, abnormalities of gait (walking) and mobility, hemiplegia and hemiparesis following cerebral infarction affecting right dominate side (loss of strength in right arm, right leg, right side of face), epilepsy (seizures), pain right hip, unspecified dementia (group of symptoms that affects memory, thinking and interferes with daily life), and hypertension (high blood pressure). Record review of Resident #29's 5-Day Medicare Part A MDS, dated [DATE], revealed she had a BIMS score of 7 out of 15 which indicated her cognition was severely impaired. Section G of the MDS revealed Resident #29 required two plus-person extensive physical assistance with transferring. The MDS defined a transfer as, how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position . Section G also revealed Resident #29 was not steady, only able to stabilize with staff assistance during surface-to-surface transfers, which the MDS defined as a transfer between bed and chair or wheelchair. Record review of Physical Therapy Plan of Care dated 10/26/2021-12/20/21 indicated a referral reason of Patient is [AGE] year-old female who is current LTC (long-term care) resident of this facility who has been referred to PT due to recent sudden onset of severe pain right lower extremity about 2 weeks ago (X-rays on 10/20 were negative). She has declined in all her transfers-even requiring Hoyer lift for transfers or 2 person assist. She is having increased difficulty pivoting or moving her legs for transfers according to nursing. Record review of Resident #29's Care Plan, dated 02/15/22, indicated, in part: .Focus: The Resident has an ADL Self Care Performance Deficit related to confusion, hemiplegia, impaired balance, limited mobility, limited ROM, stroke, unaware of safety needs, poor communication/comprehension, memory deficit, convulsions, vision problems, and psychomotor deficit .Interventions/Tasks: Transfer: The resident requires (2) staff participation with transfers. Record review of a progress note in Residents #29's electronic chart dated 02/23/22 at 1:01 AM indicated the following, res has had a decrease in activity due to swelling. She is requiring more help with transfers, needs assistance x2 due to increased weakness. Res continues to decline. Record review of a progress note in Residents #29's electronic chart dated 02/23/22 at 3:13 PM indicated the following, res has had a decrease in activity due to swelling. She is requiring more help with transfers, needs assistance x2 due to increased weakness. Res continues to decline. Record review of a progress note in Residents #29's electronic chart dated 02/26/22 at 8:40 AM indicated the following, Resident was assisted from bed to wheelchair with two CNAs for her bath, [CNA-A] assisted her to shower room, where she assisted her to stand holding to handrail, moved wheelchair and placed shower chair behind resident. CNA was assisting her to turn and sit down on shower chair, when her right leg gave out and she started to fall. CNA attempted to prevent fall, but unable to. Pulled on emergency call light. This nurse and LVN went to see what was wrong and found resident laying on floor between cabinet and the sink in shower room, assessed resident found 6cmX6cm hematoma on head, resident complain of pain to right hip area. Obtained orders to send to ER for X-Ray, Ambulance called, Family called, and ADM, and DON notified. Record review of incident report dated 02/26/22, completed by RN D, the RN called to assess Resident #29 after the fall, revealed an incident date and time of 02/26/22 at 8:26 AM. The section labeled, Incident Description revealed, Nursing Description: Called to shower room, noted resident on floor, assessed 6 cm x 6 cm hematoma on side of head, complain of right hip area hurting, order to send to ER for x-ray. Resident Description: States my right hip area is hurting, and side of my head hurting. In the section labeled, Agencies/People Notified, a family member was listed as well as the physician, DON and ADM. In the section labeled, Witnesses CNA A was the only person listed. The incident report only contained a description of events of the fall; it contained no documentation of actions taken to investigate why the incident occured or a collection of evidence that would allow the ADM to determine what actions were necessary (if any) for the protection of residents. During an observation and attempted interview on 04/25/22 at 11:14 AM, Resident #29 was lying in bed. When attempting to speak with Resident #29, resident would only grunt, no comprehensible language spoken. During an interview with ADON on 04/25/22 at 3:11 PM, ADON stated, she was not at the facility during the incident when Resident #29 fell during a transfer on 02/26/22. ADON stated, it was her understanding that Resident #29 had fallen during a transfer that occurred in shower room. During an interview with CNA A on 04/26/22 at 11:32 AM, she stated she was assisting Resident #29 in the shower room the day that she fell on [DATE]. CNA A stated Resident #29 was holding the grab bar and I moved the wheelchair and pulled the shower chair over to Resident #29 when resident's hand slipped and her leg went out. Resident #29 then fell and hit her head. CNA A was asked if she knew where to find Resident #29's transfer assistance requirements, she stated, I don't know I am just a CNA. Asked CNA A if she considered moving from a wheelchair to a shower chair a transfer and she stated yes. CNA A stated she was following transfer assistance requirements as I was told by staff. CNA A stated she pulled the call light for assistance with Resident #29 and multiple staff came. CNA A stated, the ambulance was called, and she was taken to the ER. CNA A stated she received no training or disciplinary action following Resident #29's fall. CNA A stated, I usually just transfer her [Resident #29] from wheelchair to the shower chair. CNA A stated she transferred residents like that, all the time and she did that with everyone except for a few residents who were totally dependent for assistance. According to CNA A, she was told by staff that if a resident can stand holding a grab bar, that it was ok to transfer residents without any help and Resident #29 was standing during physical therapy with a grab bar. During an interview with RN D on 04/26/22 at 11:43 AM, the RN who was called to assess Resident #29 after her fall, she stated, it was bath day, two aides got her to her wheelchair she (Resident #29) is paralyzed. RN D stated CNA A had stated that CNA A was assisting Resident #29 to the shower chair from the wheelchair. She stated Resident #29 was able to hold the grab bar and Resident #29's leg gave way and she fell. RN D stated, I assessed [Resident #29] and her leg was pointing out and [Resident #29] was complaining of pain to her right elbow. RN D stated, Therapy had been working with [Resident #29] and told us she could grab the bar, we go with what therapy says. RN D stated this statement by PT could be found, in the therapy notes. During an interview with PTA on 04/26/22 at 1:10 PM, she was asked if Resident #29 was on services with physical therapy, she stated Resident #29 was on a break from physical therapy. PTA stated a break from physical therapy meant, for one reason or another she was not on services with PT. PTA was then asked if it was acceptable practice to transfer residents that required two-person assistance to instead be transferred with only one-person assistance if a grab bar was available, to which PTA replied, max 2 assist means two staff are in the room with the resident. PTA was then asked if she would instruct staff differently and PTA stated, I am speaking for myself I would never tell them to use a bar as replacement person. During an interview with DON on 04/26/22 at 2:02 PM, when asked about Resident #29's fall on 02/26/22, DON stated she only knew what she had been told. DON stated she was told that when attempting to get Resident #29 to the shower chair from the wheelchair by CNA A, Resident #29 fell. DON stated, She (Resident #29) was a two-person assist with transfers. Regarding Resident #29's Care Plan which indicated she required two-person assistance with transfers, DON stated, 'I didn't necessarily write all of her care plan. If it's wrote in the care plan, that is what they should have been doing. DON stated, if it says two-person, it should have been two-person. When asked if moving from a wheelchair to a shower chair was considered a transfer, DON stated, of course it's a transfer. DON was asked if there was in-servicing or counseling done for CNA A after the incident, DON stated, I am not sure if in-servicing was done, and [CNA A] did not get counseling, per se. DON stated she did not think the incident was reported to the State Survey Agency since it was a witnessed incident. DON confirmed Resident #29 sustained a femur fracture and a small fracture in her right elbow from the incident. DON confirmed these would have been considered significant injuries, because it was a fracture. I consider anything more than a bruise a significant injury. DON stated she believed the incident caused Resident #29's admission to hospice to happen a little sooner. DON stated, I don't know [if it should have been reported]. During an interview with ADM on 04/26/22 at 2:32 PM, she stated, Some days she (Resident #29) she could help [with transferring herself], some days she could not help; she was getting weaker. ADM stated, regarding the incident on 02/26/22, Resident #29's leg just gave out before she made it to the shower chair. ADM stated she was told by CNA A Resident #29 was holding on to the grab bar and fell in the shower room. ADM stated if Resident #29's Care Plan indicated she required two-person assist with transfers, ADM would have expected her staff to transfer Resident #29 with two people assisting. When asked if ADM thought moving Resident #29 from her wheelchair to the shower chair was considered a transfer, ADM stated, Well yeah, that's a transfer. ADM stated there were no in-services in response to Resident #29's fall. ADM stated on the day of the incident, she was called and notified that Resident #29 had fallen in the shower room. She stated she had witness statements written. ADM stated, we sent her [Resident #29] out and all that. In my investigation, I came over here [to the facility] and got some stuff and went back to the house and did it on the computer. She stated she had a personal emergency and was unavailable two days after the incident. ADM stated, I normally have this big book of what happened [during an investigation] but I was out. ADM stated, since the incident was witnessed by a staff member, that is why she did not report it to the State Survey Agency. ADM stated there were times Resident #29 was doing well, and sometimes she was weaker. The morning of the fall, Resident #29 was doing better. ADM stated Resident #29 was seen by a physician on 02/22/22 or 02/24/22, he looked at Resident #29's right leg because she had been having pain and he thought she had been having nerve issues. ADM stated she was not sure if that was why Resident #29's leg gave out during the transfer. ADM stated CNA A tried to get the shower chair where it would help keep Resident #29 from falling but she could not. She again stated she did not report the incident, I kind of felt like it was witnessed. ADM was asked to provide the witness statements and any other documentation regarding an investigation of the incident at that time.The only documentation provided regarding an investigation into Resident #29's fall on 02/26/22 was the one witness statement previously referenced by CNA A and the incident report previously referenced. During an interview with PT Director on 04/26/22 at 3:13 PM, she stated Resident #29 was a max assist when transferring from her bed to wheelchair. PT Director stated that Resident #29 was doing good for a while but then started to decline. Asked PT Director when the decline started with Resident #29 PT Director stated, I cannot recall. PT Director was asked if she had told staff if a resident required two-person assistance for transferring, they would only need one-person assistance and PT Director stated, I don't tell them (staff) that they don't need to use a second person. When PT Director was asked if she would consider the grab bar a second person, PT Director stated, the grab bar did not count as a second person for transferring her (Resident #29) to the toilet or to the shower chair. During an interview with PTA on 4/26/22 at 3:25 PM, PTA was asked for clarification on what substantial/maximal assistance versus partial/moderate assistance during resident transfers. Per PTA, substantial/maximal assistance was when the therapist needed to use all their force to lift the resident. PTA was then asked if this decision was the RNs or CNAs to decide how many people to use for a resident transfer, PTA stated, it would be on physical therapy to decide if it was one-person, or two-person assist for transfers. During an interview on 04/27/22 at 10:00 AM, CNA A clarified that the incident with Resident #29 happened in the shower room, just prior to Resident #29's shower. She stated Resident #29 still had on her shoes and a robe and she had just unfastened her brief prior to transferring her from the wheelchair to the shower chair. CNA A stated, I did it like we've always done it. CNA A stated Resident #29 reached with one hand up as CNA A had the shower chair to the side so when Resident #29 had her balance, she could put the shower chair under her. CNA A stated Resident #29 was standing great when suddenly, her right leg buckled at the knee, I'm assuming it was the knee, that would have been her weak side. CNA A stated Resident #29 fell to the right, on her right side. She stated Resident #29 was a very heavy woman, you couldn't lift her if you tried. CNA A stated, I feel like I failed her. I tried really hard to catch her. She was really top heavy. During an interview on 04/27/22 at 2:27 PM with ADON, she stated there were no facility policies regarding preventing accidents and hazards. Record review of Physical Therapy notes dated 10/26/2021-12/20/21 revealed no documentation that Resident #29 was a one-person transfer if a grab bar was available, and no other documentation was provided by the facility which stated the same. Record review of a facility policy titled, Safe Patient Handling Policy and Procedure revised on 12/30/05, revealed, in part, Resident will be evaluated on admission and as needed for alternative means of lifting, transferring repositioning, and other movement to minimize risk of injury .Nurses will be educated regarding correct safe handling procedures, to report concerns or the inability to perform resident handling or movement that the nurse believe in good faith will expose a resident or nurse to an unacceptable risk of injury. The ADM and DON were informed on 04/26/22 at 5:30 PM that an Immediate Jeopary (IJ) was identified due to the above failures. A Plan of Removal was requested. The facility's Plan of Removal was accepted on 04/27/22 at 8:15 AM and included the following: Noncompliance: Facility failed to provide care based off their care plan and MDS. Both care plan and MDS required two persons assist for transfer however only one C.N.A assisted with transfer from wheelchair to shower chair. Resident fell and sustained multiple fractures and a hematoma. Root cause: Definition on care plan for bathing and transfers not clearly defined leading to C.N.A transferring resident to the shower chair alone. Necessary Changes: 1. Fall risk assessments are completed on all residents . 2. Incident reports monitored for falls; anyone who has falls will be care planned as a two-person transfer. 3. Gait belts will be used by nursing staff while transferring residents. 4. Resident [NAME] will be updated and readily available to staff with updates to care planning . Training: 1. All staff will be in-serviced: a. Abuse and neglect b. Falls c. Fall prevention d. Safe Patient Handling 2. Nursing staff will be in-serviced: a. Gait belt use b. Transfers: use of two persons when indicated on [NAME]/Care plan c. Resident [NAME] use Employee of the facility will not be allowed to return to work until they have completed all in-serving required as stated above. RN staff are doing the fall risk assessments on 4/26/2022. ADON staff are in-servicing all staff via phone or in person on 4/26/2022. Therapy department will be doing transfer and gait belt training on 4/27/2022 for all nursing staff able to attend. Those not attending will have to be trained before being allowed to do patient care. Resident [NAME] in PCC will be updated and available to staff on 4/26/2022. All in-servicing of staff will be done on 4/26/2022 unless unavailable therefore in-serviced before caring for residents. Nursing staff will know what bathing and transfers clearly mean on the care plan and [NAME] system. Monitoring of the systems and trainings will be done by DON or designee twice weekly for 4 weeks. No further problems monitoring will be weekly for 8 weeks. Continued compliance will initiate random checks thereafter. Our QAPI committee will discuss the monitoring at our monthly meeting implementing an action plan. On 04/27/22 at 10:36 AM, the surveyors confirmed the facility implemented their Plan of Removal sufficiently to remove the Immediate Jeopardy by the following observations, interview and record reviews: During an observation on 04/27/22 at 8:40 AM, in-servicing was being conducted by physical therapists, ADM, ADON, and DON regarding Falls, Safe Handling, Abuse + Neglect, Gait Belts, [NAME]/Care Plan, and Transfers. During an interview with on 04/27/22 at 8:44 AM with LVN E, she stated that in-servicing had been provided that morning and in the evening on 04/26/22 regarding two-person transfers for all residents that could not walk unassisted or have had an unsteady gait. During an interview on 04/27/22 at 8:46 AM, LVN E confirmed that she had attended an in-service on the evening of 04/26/22 on two-person transfers with the use of a gait belt. During an interview on 04/27/22 at 9:52 with DON, she was asked how she thought the IJ occurred, and DON stated, This probably occurred because of a communication issue, communication between nursing staff and the CNAs. DON was asked how they planned to prevent similar incidents in the future, and DON stated, We could have made it clearer on the care plan, updated care plans with better wording, In-services are being done and educating the staff that residents that are dependent should be transferred by two people at all times. During an interview on 04/27/22 at 9:55 AM with ADM, she was asked how she thought the IJ occurred, and she stated, I think it was the wording in the care plan; it (care plan) was not clear what was required for each of the residents. ADM was asked how they planned to prevent similar incidents in the future, and ADM stated, updated care plans with better wording, In-servicing, physical therapy showed staff how to correctly transfer and staff did re-demonstration, and phone in-servicing. During an interview on 04/27/22 at 10:20 AM with CNA C , she stated in-servicing had been provided that morning regarding how to properly transfer residents. She stated that to look up a resident's transfer status, it would be in the [NAME] or the plan of care. During an observation on 04/27/22 at 10:30 AM, CNA A and CNA C transferred a resident from wheelchair to bed properly using a Hoyer-lift. During an interview and record review on 04/27/22 at 10:33 AM with ADON, she stated on 04/26/22, all staff were contacted either in person or by phone (except for one staff member they could not reach) and were in-serviced regarding, STAFF IS TO WEAR GAIT BELTS AT ALL TIMES AND USE WHEN TRANSFERRING RESIDENT .THERE IS A [NAME] UNDER THE POC UNDER EACH RESIDENT THAT WILL INFORM YOU OF THE ASSISTANCE THE RESIDENT NEEDS WITH ADLS .POLICY OVER ABUSE AND NEGLECT .POLICY OVER FALLS .SAFE HANDLING OF A RESIDENT. Reviewed in-service signed by most staff. ADON stated the in-service to be done that day was for nursing staff which included demonstration on safe transfers by PT. Review of that in-service, dated 04/27/22, revealed a subject of, Transfers, gait belt Training .[NAME]/Careplan .safe handling .went back over falls .abuse .neglect .gait belts .safe handling. In-service contained multiple staff signatures. ADON stated all CNAs were informed about the [NAME] system, which was to inform staff of a resident's transfer requirements. She stated CNAs were to look at the [NAME] daily. ADON stated nurses had access to Care Plans and the [NAME] for information regarding resident transfer requirements. During an interview on 04/27/22 at 11:05 AM with CNA B, she stated she was provided in-servicing on how to properly transfer residents that morning and she had to use two people when transferring residents. During an observation and interview on 04/27/22 at 11:45 AM, LVN E and CNA B were conducting a transfer in the shower room with a resident . CNA B stated, this is the new process, I would have gotten resident up on my own prior to today. Asked CNA B if, prior to in-service, she was transferring residents that required two-person assistance without help and CNA B stated, yes. When asked if a resident's Care Plan indicated two-person assistance was required for transfers, would CNA B still have got resident up on her own and CNA B stated, yes I would have got her up in the shower by myself because of the shower bar. Record review of a random sample of resident's fall risk assessments indicated resident fall risk assessments were completed on 04/26/22. The administrator was notified on 4/27/22 at 10:36 AM that the IJ was removed. The facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate due to the facility need to evaluate the effectiveness of their corrective systems.