**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 25 was admitted to the facility on [DATE] with diagnoses which included dementia, history of falling, cervicalgia, and mucsle weakness. On 1/27/25 at 11:05 AM, a continual observation was made of resident 25 sitting at the nurses station under the call light alarm system that was alarming. At 11:09 AM, resident 25 stated he needed to use the bathroom and was wheeling himself toward his room. At 11:11 AM, resident stated he was going to the bathroom. The Activities Director (AD) walked past resident 25. At 11:12 AM, CNA 5 was observed to ask resident 25 if he needed assistance and helped him to the bathroom. On 1/28/25 at 3:00 PM, an observation was made of resident 25 asking Licensed Practical Nurse (LPN) 1 to be let into his room. An observation was made of LPN 1 telling resident 25 that he could not go into his room. On 2/5/25 at 10:20 AM, a continual observation was made of resident 25. Resident 25 was observed under the call light system at the nurses station with the call light system beeping. Resident 25 was observed with a drink and a magazine on a bedside table. At 10:48 AM, resident 25 was observed to look at the call light system alarming and removed his hearing aides. There were no staff at the nurses station. At 11:03 AM, resident 25 was wheeling away from the nurses station and asking LPN 1 if he could go into his room. At at 11:05 AM, an observation was made of resident 25 trying to open the door to his room. At 11:10 AM, resident 25 was sitting in hallway outside of his room. At 11:20 AM, resident 25 was observed outside his room with House Keeper (HK) 1. Resident 25 was pointing at the door to his room. HK 1 wheeled resident 25 back to the nurses station under the alarming call light panel. Resident 25 stated to HK 1 he did not want to go there and never asked to go there. HK 1 stated OK, one moment and left resident. HK 1 walked to the housekeeping cart and wheeled the cart down the hallway. Resident 25 was observed to be wheeling himself towards his room and asking HK 1 if he could go to his room. HK 1 was observed to put her hand up like a stop sign and stated ok. Resident 25 was wheeling himself toward his room and asked another staff member if he could go into his room. The staff member told him to ask his nurse and pointed toward the nurses station. At 11:23 AM, he waved toward HK 1 and stated Hey. HK 1 did not respond. At 11:24 AM, LPN 1 walked by resident 25 outside his room reaching for the door handle. LPN 1 stated, It's for your safety. At 11:26 AM, a CNA was observed to push resident to under the call light panel which was alarming. Resident 25 wheeled himself toward his room. At 11:27 AM, stated he was wondering if a surveyor was able to open his room. LPN 1 stated he was not allowed to go in his room and staff tried to re-direct him and see if they could distract him because he was not safe in there. At 11:28 AM, LPN 1 asked resident 25 if he needed to use the bathroom. Resident 25 stated yes, he needed to use the rest room. At 11:28 AM, resident 25 was taken to his room and assisted to the bathroom. On 2/5/25 at 11:31 AM, an interview was conducted with HK 1. HK 1 stated resident 25 needed to stay at nurses station so he can be watched by Certified Nursing Assistants (CNA). HK 1 stated a CNA had to be with him if he went into his room. HK 1 stated It's no good if he is in his room. HK 1 stated resident 25 had to stay at the front at the nurses station. On 2/5/25 at 2:19 PM, an observation was made of resident 25 sitting under the call light panel while the call light system was emitting a beeping sound. On 2/6/25 at 8:47 AM, an observation was made of resident 25 by the nurses station under the call light panel. Resident 25 was observed sitting under the call light panel with a bedside table. On the bedside table there was a nutritional drink, cereal and a mug. Resident 25 was observed to be wiping the table. CNA 5 was observed to put a towel over resident 25's legs and offered to get him a new applesauce. The call light panel was beeping intermittently. Resident 25's medical record was reviewed 1/27/25 though 2/6/25. A quarterly MDS dated [DATE] revealed resident had more than 2 falls with no injury since admission. A care plan dated 5/17/24 and revised on 8/27/24 revealed [Resident 25] has had falls at home. He has impaired cognition/dementia. He is impulsive. He has decreased strength, balance. [Resident 25] has had frequent falls while at the facility. He is at increased risk for fall, injury. The goal was Risk for fall, injury will be minimized with current interventions through next review. Interventions included the following: a. On 5/17/24, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. b. On 5/17/24, Ensure commonly used items (ice water, glasses if applicable, call light, phone, remote) are within reach of resident prior to leaving room. c. On 5/20/24, Fall mat on floor next to bed. d. On 5/28/24, Pressure alarm in bed. e. On 5/22/24, Staff to assist with toileting at regular intervals during day/evening hours. f. On 5/22/24, Staff to assist with toileting frequently during day/evening hours. g. On 5/17/24, [Resident 25] may sit behind the nurses station for increased interaction with nursing staff and supervision. h. On 5/28/24, [Resident 25] to be in a supervised area (up by the nurses station or in an activity) when up in wheelchair. Resident 25's incident reports, nursing progress notes and care plans revealed the following entries: a. On 6/2/24 at 10:30 AM, an incident and progress note revealed a CNA observed resident 25 stand up, alarm went off and CNA ran to resident but resident turned and fell backwards hitting head. Resident 25 experienced a bump to the back of his head. The intervention included 6/3/24 Patient will be offered toileting frequently. This was an intervention used on 5/28/24. b. On 6/7/24 at 3:51 PM, an incident report and progress note revealed that resident 25's alarm went off in his room, CNA went to the room, CNA came out of the room alerting nurse that the resident fell. Nurse into assess resident and resident on his buttocks with legs over the right foot plate. Resident 25 stated he was trying to get into bed. The wheelchair brakes were not locked. Resident did not have shoes on. Resident 25 experienced a red mark on his left side of his back form sitting against the chair on the ground. Resident 25 complained of pain in his left arm that had not been there before. An intervention dated 6/10/24 revealed staff to remove wheelchair foot rest when stationary to prevent tripping hazard. c. On 7/6/24 at 12:51 PM, an incident report and progress note revealed, Resident 25's alarm was going off in his room and the nurse found the resident on the floor in his bathroom. Resident 25 stated he needed to use the restroom. Resident 25 was assessed, no injuries, he did not hit his head. The immediate action taken was chair alarm was clipped to resident 25's shirt and was placed next to the nurse's station so he could be watched more. The intervention dated 7/8/24 revealed that Staff to be educated on patient needing to be in a supervised area while up in wheelchair and frequent toileting. This intervention was used on 5/22/24 and 5/25/24. d. On 7/14/24 at 1:10 PM an incident report and progress note revealed, resident slid out of wheelchair landing on buttocks at the nurses station. The immediate action taken revealed staff assisted resident back into wheelchair, brought resident behind the nurses station. The intervention dated 7/15/24 revealed . Staff to place a pressure alarm on wheelchair instead of a tab alarm. e. On 7/18/24 at 7:27 PM an incident report and nursing progress note revealed, Resident wife put resident in resident room and left even through she was asked to leave resident out by staff. Resident chair alarm was going off and watched resident self transfer from wheelchair to bed landing on his knees. Resident was brought safely back to bed with no injuries noted. The immediate action taken was Resident wife put resident in resident room and left even though she was asked to leave residents out my [sic] staff. The intervention dated 7/19/24 revealed .Staff reminded wife to not place pt in room unattended while he is in his wheelchair. f. On 7/22/24 at 10:00 PM an incident report and nursing progress note revealed, CNA reported they saw resident sliding off of chair onto his bottom on the ground. Resident had shoes on, alarm clip was on his jacket, and a fall mat was underneath the residents bottom. Resident did not hit head and denied pain. Alarm was going off when resident slid to his bottom. Resident was trying to get out of chair and into bed and was upset that he could not stand by himself. The immediate action taken was to educate resident to not get out of chair without help. The intervention dated 7/23/24 revealed resident was reviewed in clinical meeting. Staff moved resident closer to the nurses station. g. On 7/25/24 at 11:37 AM a nursing progress note revealed, RN found resident with business office manager with pt, who was sitting on foot rests of wheelchair (WC) in pt's previous room. Resident 25 stood up leaned forward, then tried to sit back down in WC. There was no incident report provided. h. On 7/25/24 at 8:55 PM an incident and nursing progress note revealed, resident was sitting in his wheelchair in his room in front of his bed trying to get up on his own. Resident was asked to please wait for the aide to help with needs. Resident would not wait and slipped out in front of his wheelchair. Resident was assisted by staff onto his bed. The intervention dated 7/26/24 revealed . Staff to ensure to not leave pt unattended when he is displaying want or need to get up. i. On 7/28/24 at 1:30 PM an incident report revealed, nurse heard a noise, turned to see resident sliding off his wheelchair, landing on feet rest on buttock and did not hit head. Resident 25 stated he did not know what happened, he just reached for the couch and ended up here. An intervention dated 7/29/24 revealed resident 25 was reviewed in clinical meeting. Staff to obtain labs related to falls within the past few days. There was no nursing progress note regarding the fall. j. On 7/28/24 at 4:30 PM an incident report and nursing progress note revealed, Nurse came out of room and found resident in hallway, on knees holding onto railing. The immediate action taken revealed the pressure and tab alarm was in place and functioning. An intervention dated 7/29/24 was staff to obtain labs related to multiple falls within the past few days. k. On 8/3/24 at 3:10 PM an incident report and progress note revealed, resident 25 was sitting in front of nurses station and chair alarm went off and nurse turned to see pt trying to stand and fell. There were no injuries or pain. The immediate action taken was to remind that he was not stable. The care plan intervention dated 8/3/24 revealed to have blank sheet music for him to fill out when he was sitting at the desk. l. On 8/4/24 at 10:02 AM an incident report and progress note revealed resident 25 was found on floor in his room. Pressure alarm did not go off. An intervention included to provide sheet music at the nurses station to occupy resident. This intervention was used for 8/3/24. m. On 8/10/24 at 11:42 AM an incident report and progress note revealed, resident slid forward out of wheelchair while traveling the hallway solo. The previous interventions were in place including pressure alarm. The intervention was to encourage staff to provide resident with activities while in wheelchair. n. On 8/17/24 at 2:37 PM an incident report and nursing progress note revealed, resident was sitting at the nurses station tried to stand and wheelchair slid out from behind him and he fell. The intervention was to provide a lap buddy but that was discontinued on 8/27/24. On 8/20/24 resident had an order for a cervical x-ray because of complaints of new pain. The x-ray was clear. o. On 8/22/24 at 7:30 PM, an incident report and nursing progress note revealed resident 25 fell in his room by his bathroom. The intervention was a different wheelchair was provided on 8/26/24. p. On 8/24/24 at 6:40 PM an incident report and a nursing progress note revealed, resident 25 was trying to stand from his wheelchair next to his bathroom door while the aide was passing meal trays. The aide asked the resident to please wait, but the resident did not wait and slipped out of his wheelchair onto the floor causing a small scratch on his left hand middle finger. The intervention was staff were encouraged to respond to resident needs if resident was seeking or attempting to stand. This intervention was used on 7/25/24. q. On 8/25/24 at 4:24 PM an incident report and progress note revealed, another resident got the aide and nurse. Resident 25's alarm was going off in the dining room and resident was on the floor. The intervention was to remind staff to bring resident into the lobby/near nurses station while he was awake. This intervention was used on 5/25/24. r. On 8/25/24 at 6:20 PM an incident report and progress note revealed, resident found on floor near restroom. The intervention was remind staff to toilet at regular intervals. This intervention was used on 5/22/24 and 7/8/24. s. On 8/26/24 at 8:15 PM an incident report and progress note revealed, resident 25 was found on the floor by a visitor. There was no information regarding if the alarm was alarming. The intervention was staff to obtain a new pressure alarm. The care plan intervention dated 5/22/24 and updated on 8/26/24 revealed staff to assist with toileting at regular intervals during day/evening hours. On 8/26/24, staff encouraged to respond to resident's need if resident was seeking or attempting to stand. The same intervention was used 7/8/24. t. On 8/28/24 at 3:31 PM an incident report, progress note and care plan revealed, resident fell out of chair sitting by wife at the nurses station. The intervention was to adjust residents wheelchair seat to help prevent him from leaning forward. u. On 9/28/24 at 12:42 PM, an incident report and a progress note revealed, resident's alarm was sounding and resident found on the floor in bathroom. The intervention was to educate staff and wife to keep door to room closed when resident was not in room. On 10/2/24 at 12:41 PM a social services progress note revealed, Resident moved to room [ROOM NUMBER] A. v. On 10/24/24 at 7:20 PM an incident report and progress note revealed, resident 25 had an unwitnessed fall. The nurse found resident lying on left side on floor in restroom. Resident 25 sustained a small abrasion to right hand. The care plan revealed an intervention of resident 25 was not to be left unattended when using the bathroom. w. On 10/31/24 at 5:57 PM an incident report and progress note revealed, a nurse was walking into resident room to find the medical records manager, Administrator, Recreational manager, and other nurse. The medical records manager stated there was an alarm going off and she found resident 25 sitting on the floor bleeding from the left side of his face. There was a laceration on the left side of his face next to his left eyebrow. The physician ordered steri-strips on the laceration. The immediate action was to educate staff that resident 25 was to be in sight of someone at all times, resident cannot be in his room by himself. Resident's wife was reminded that resident cannot be left in room whe she leaves the building. This intervention was used on 7/18/24. x. On 11/4/24 at 9:57 PM an incident report and progress note revealed, resident's fall alarm sounded and resident was found on his knees kneeling on his fall mat next to his bed. The intervention was education given to staff to toilet resident before going to bed. On 11/5/24, Education given to staff to toilet resident before going to bed. This intervention was used on 5/22/24. On 11/5/24 at 1:15 PM, a progress note revealed, resident complained of headache since hitting his left eyebrow from last fall. Tylenol was given with good relief. y. On 11/16/24 at 12:10 PM an incident report revealed, the nurse heard a loud bang and went to resident's room to find resident 25 on the floor in his room. Resident 25 was clutching his head by his left brow. There was no nurses note regarding the fall. The intervention was to have physician reviewed and adjusted medication. Resident 25's progress notes revealed he tested positive for COVID-19 on 11/30/24. It was documented resident was in bed on 12/1/24, 12/2/24 and 12/3/24. On 12/7/24 COVID precautions were in place. z. On 1/8/25 at 12:34 PM a progress note revealed, resident 25 had a recent unwitnessed fall. There was no incident report provided. There were no interventions. On 2/5/25 at 3:56 PM, an interview was conducted with resident 25 and his family member. Resident 25 stated they have stupid rules. Resident 25's family member stated staff closed the door to his room because he was not allowed in his room alone because he could fall down. Resident 25's family member stated that staff took resident 25 to the nursing desk to watch him all the time. Resident 25's family member stated when she was here he was able to go anywhere in the facility including his room. Resident 25's family member stated there were a couple of staff members who had a cocky attitude and say things like I can't help you now, I'm busy. Resident 25's family member stated a lot of staff did not understand how to be polite to residents. Resident 25 stated being locked out of his room, made him feel terrible. Resident 25's family member stated resident 25 should be able to go into his room and staff should check on him. Resident 25's family member stated staff tell her that he's into things and having falls in his room, but he was also falling by the nurses station. Resident 25's family member stated it felt like no one was really that concerned about resident 25 and the facility was understaffed and that was why resident 25 was put at the nurses station. Resident 25's family member stated if resident 25 had hearing aides adjusted then he heard the beeping at the nurses station. Resident 25's family member stated resident 25 had told her that he did not like to be at the nurses station. Resident 25's family member stated resident 25 was placed at the nurses station to make things easier for staff and staff were over worked because they were short tempered because they have a lot to do. On 2/6/25 at 8:54 AM, an interview was conducted with CNA 5. CNA 5 stated resident 25 could not be left alone, so a staff member always had an eye on him. CNA 5 stated when resident 25 was at the nurses station, he always had a staff member eyes on him. CNA 5 stated resident 25 had an alarm under him and he was could not go in his room alone. CNA 5 stated resident 25 thought there was a piano in his room. CNA 5 stated interventions to prevent resident 25 from falling were alarms, non-slip shoes, shut his room door becuase his hands were not strong enough to open the door to his room, and staff were to stand in the room waiting while in the bathroom. CNA 5 stated if resident 25 wanted to go in his room, then she had to go in there with. CNA 5 stated resident 25 had not complained about the call light panel alarming because he was hard of hearing. CNA 5 stated being under the call light panel, she Would imagine that would be annoying. On 2/6/25 at 8:56 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated resident 25 was a fall risk big time, so he was at the nurses station. LPN 2 stated if there was an activity resident 25 was taken to the activity. LPN 2 stated residen 25 usually slept in and then sat at the nurses station to eat breakfast. LPN 2 stated interventions to prevent resident 25 from falling included alarms, bed in the low position and mat on the floor by his bed. LPN 2 stated resident 25 asked to go to his room and staff usually told him they were making his bed and cleaning his room. LPN 2 stated she liked to watch resident 25 at all times and paid attention to where he was. LPN 2 stated CNAs made sure to know where resident 25 was at all times also. LPN 2 stated resident 25 was hard of heading, so she did not think he could hear the call light system beeping. LPN 2 stated there was no specific reason resident 25 was placed under the call light system. LPN 2 stated she had not noticed increased agitation to resident 25 when call lights are alarming. At 9:02 AM, an observation was made with LPN 2. The call light system was alarming. Resident 25 was observed to stop a staff member as they walked by when the system was alarming. On 2/6/25 at 11:47 AM, an interview was conducted with the DON. The DON stated one of the interventions was to increase supervision while resident 25 was in his wheelchair. The DON stated when resident 25 was unsupervised in his room he fell. The DON stated resident 25 being at the nurses station under the alarming call light system was a supervision thing. The DON stated resident 25 fell asleep at the nurses station and then when staff take him to his room he wakes up. The DON stated resident 25 asked staff to open his door but he only asked when he was wheeling himself to his room. The DON stated when resident 25 was asking to go to his room, staff were to ask him what he was trying to do. The DON stated if resident 25 tried to reach for his door handle of his room, his chair alarm went off. The DON stated staff should be assisting resident 25 with what he needs, like ask him if he wanted to go to bed or the restroom. The DON stated he had not noticed resident 25 was under the alarming call light system. The DON stated resident 25 was at the nurses station for increased supervision, not to be watched at all times. On 2/6/25 at 2:13 PM, an interview was conducted with Regional Nurse Consultant (RNC) 2. RNC 2 stated there were interventions to prevent residents from falling on their care plan and on incident reports. Resident 25's interventions were reviewed with RNC 2. RNC 2 stated resident 25 had the same interventions reused after falls. Based on observation, interview and record review it was determined, for 9 of 33 sampled residents, that the facility did not ensure that each resident's environment remained as free from accident hazards as was possible and each resident received adequate supervision and assistive devices to prevent accidents. Specifically, the facility failed to accurately assess resident's for safe smoking and failed to supervise residents to ensure they demonstrated safe smoking practices according to the facility smoking policy. These deficient practices were found to have occurred at the Immediate Jeopardy (IJ) level. Additionally, interventions were not put in place after a resident had a major fall with injury and another resident sustained falls with repeat interventions. Resident identifiers: 5, 12, 18, 23, 25, 27, 30, 34 and 293. Findings include: NOTICE On January 29, 2025 at 1:30 PM, an IJ was identified when the facility failed to implement the Centers for Medicare & Medicaid Services (CMS) recommended practices to identify hazard(s) and risk(s); evaluate and analyze the hazard(s) and risk(s); implement interventions to reduce hazard(s) and risk(s); and monitor for effectiveness and modify the interventions when necessary. Specifically, the facility failed to ensure that residents were evaluated for smoking safety, that interventions were identified, and that monitoring for safe smoking was implemented. Notice of IJ was given to the facility Administrator (ADM), Director of Nursing (DON), and the Regional Nurse Consultant (RNC), and they were informed of the findings of IJ pertaining to F689. On 1/29/25, the facility provided the following written abatement plan for the removal of the IJ effective on 1/29/25 at 4:30 PM. [Name of facility] is providing the following information to demonstrate that the immediacy of the cited deficiency F689 has been removed. Summary of Action Taken: Resident 12: -Resident had a skin assessment-no injury noted -Attending physician was notified - Resident was reassessed for smoking safety by the RNC/Nurse Manager, which included a return demonstration of smoking safety -Care plan reviewed and updated to supervised smoking and a smoking apron -Resident room was checked for smoking material-any smoking material found was removed and will be stored by nursing -Resident was educated on the Smoking Policy, which included storage of smoking material Resident 293: -Resident was reassessed for smoking safety by the RNC/Nurse Manager, which included return demonstration of smoking safety -Care plan was developed based on smoking safety screen -Resident room was checked for smoking material-any smoking material found was removed and will be stored by nursing -Resident was educated on the Smoking Policy, which included storage of smoking material Resident 23: -Resident was reassessed for smoking safety by the RNC/Nurse Manager, which included a return demonstration of smoking safety -Care plan was reviewed and updated based on smoking safety screen -Resident room was checked for smoking material-any smoking material found was removed and will be stored by nursing -Resident was educated on the Smoking Policy, which included storage of smoking material Resident 5: -Resident was reassessed for smoking safety by the RNC/Nurse Manager, which included a return demonstration of smoking safety -Care plan was reviewed and updated based on smoking safety screen -Resident room was checked for smoking material-any smoking material found was removed and will be stored by nursing -Resident was educated on the Smoking Policy, which included storage of smoking material Other Residents at Potential Risk: -All residents that smoke were reassessed for smoking safety by the RNC and/or nurse manager, which included a return demonstration of smoking safety -Care plans were reviewed and updated as applicable -All residents that smoke were assessed for smoking injuries -The smoking list was updated to reflect all smokers and level of supervision -Resident rooms were checked for smoking material-any smoking material found was removed and to be stored by nursing -Residents that smoke were reeducated on the smoking policy and storage of smoking material -All residents who smoke will be assessed for smoking safety upon admission/readmission, quarterly and with a change of condition, this assessment will include a return demonstration of smoking safety -Resident will be education upon admission/readmission of the facility's smoking policy and storage of smoking material Systemic Changes and Education: -Administrator, DON, and RNC reviewed smoking policy -Administrator, DON were educated by RNC regarding smoking policy -Specifically on smoking supervision, updated smoking list and level of supervision and storage of smoking material -Administrator, DON/designee will complete Smoking education with all staff, [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 3 sampled residents, that the facility failed to ensure that residents were free from abuse, neglect, and exploitation. Specifically, a resident was forcefully bathed by two staff members while refusing to bathe. A male Certified Nurse Assistant (CNA) held the resident's legs open as a licensed nurse cleaned the perineum (peri) area. The resident reported that she was molested in the shower while the CNA was cleaning her private parts. The Administrator did not complete an investigation of the incident nor report the allegation to the State Survey Agency or local law enforcement. Additionally, the alleged perpetrator was not suspended and was allowed to work on the resident's hallway. The identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifier: 1. On 12/5/22 at 11:00 AM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent abuse. Notice of IJ was given verbally via video conference to the facility Administrator (ADM), Director of Nursing (DON), and Corporate Resource Nurse (CRN) 1. On 12/6/22 at 10:15 AM, the Administrator provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 12/6/22 at 5:00 PM: 1. On 12/5/2022 the staff nurse who provided a shower to the affected resident on 09/26/2022 was placed on administrative leave. On 12/5/2022 the agency CNA who assisted in providing a shower to the affected resident on 09/26/2022 was placed on administrative leave from the facility and the agency was notified. 2. Identification of Others At Risk a. Administrator/Designee will conduct interviews of the following: i. Residents with a BIMS [Brief Interview for Mental Status] > [greater than or equal to] 9 ii. Resident Representatives of Residents with BIMS < [less than or equal to] 8 iii. Staff Members 1. Routinely scheduled North Canyon Staff Members 2. On-site Agency Staff b. Newly identified concerns will be addressed and reported if appropriate with an investigation to follow if necessary. 3. Education a. Administrator/Designee will provide Re-education: What is Abuse, to whom to report and timeliness of reporting i. Routinely scheduled North Canyon and agency staff members in the facility will be educated prior to end of day 12/05/2022 and ii. Routinely scheduled North Canyon and agency staff members not in the facility will be educated prior to their next shift b. Education of How to Approach a resident who is resistive to cares i. Routinely scheduled North Canyon and agency direct care staff in the facility will be educated prior to end of day 12/05/2022 and ii. Routinely scheduled North Canyon and agency direct care staff members not in the facility will be educated prior to their next shift c. Regional Nurse Consultant will provide re-education of NHA [Nursing Home Administrator]/DON on Reporting requirements for abuse and how to conduct a thorough investigation 4. Date of Alleged Compliance a. 12/06/2022 at 5:00 PM On 12/7/22, while completing an abbreviated complaint survey, surveyors conducted an onsite revisit to verify the removal of the Immediate Jeopardy. The surveyors determined that the Immediate Jeopardy was removed as alleged on 12/6/22 at 5:00 PM. After the Immediate Jeopardy was removed, the scope and severity were lowered to Actual harm that was not immediate at a G Level. IMMEDIATE JEOPARDY: Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included end stage renal disease, asthma, acute respiratory failure with hypoxia, type 2 diabetes mellitus, chronic pain, dependence on renal dialysis, hypothyroidism, morbid obesity, and hypertension. On 9/27/22, the facility initial entity report to the State Survey Agency (SSA) documented that resident 1 reported to the Social Service Director (SSD) that a CNA held her by her neck and pushed her up against the wall. Resident 1 stated that it happened sometime in the middle of the night. Resident 1 described the CNA as CNA 1 or CNA 2. The report documented that no physical harm or marks were noted on resident 1. Review of the SSA Incident Investigation Report revealed that the facility made the notification to the SSA on 9/27/22 at 3:23 PM. On 9/27/22 at 1:27 PM, the Adult Protective Services (APS) report documented, It was reported, by [name of resident 1 omitted] during a conversation with the facility's Social Services Director [name omitted], that a CNA held her by her neck and pushed her up against the wall. She stated it happened sometime in the middle of the night. She described the CNA as [name of CNA 1 omitted], and also stated [name of CNA 2 omitted]. No physical harm or marks on [resident 1's name omitted] was noted. The report further documented that resident 1 was unable to provide any more information. Upon further investigation, the facility is unable to verify any of the information The report went on to state that resident 1 presented with confusion and was not a clear historian and the facility concluded that the alleged abuse or harm was not committed by the CNAs as reported, due to no clear evidence of actual abuse or harm. Review of a typed copy of interviews with resident 1 and the Administrator (ADM) revealed the following: a. On 9/27/22, the ADM asked resident 1 to describe the incident reported. Resident 1 stated, a CNA, a black bald man, grabbed her by the neck and slammed her up against the wall, and pushed her back into her room. Resident 1 reported two different CNAs, CNA 1 and CNA 2. Resident 1 then .stated she was abused in the shower 'while the CNA was cleaning her private parts'. Resident 1 could not recall when that occurred. Resident 1 requested to only have female CNAs. Resident 1 stated she felt safe in the facility, but then requested to transfer to another facility. b. On 9/30/22, the ADM had a follow-up interview with resident 1. Resident 1 stated that she liked living at the facility but that she wanted a private room. The ADM educated resident 1 that Medicaid was paying for her stay at the facility and that she would need to have a roommate. Resident 1 then asked if she could leave for 2 weeks to visit family in another state. The resident stated that her adopted mother was in the other state. The interview documented that the adopted mother was a former roommate and friend of resident 1. The ADM again asked resident 1 if she felt safe with the alleged CNA working at the facility, and resident 1 did not answer the question. Instead, resident 1 stated she wanted to go on a trip to another state. On 9/27/22, the ADM documented a typed interview with CNA 1. The ADM asked CNA 1 if he helped resident 1 on the evening of 9/26/22 and CNA 1 replied yes. CNA 1 stated that resident 1 yelled at him when he asked the resident if she needed help and then told CNA 1 to get out of the room. CNA 1 stated that he did not touch resident 1 during this interaction. CNA 1 stated that there were no other interactions that night. The ADM asked CNA 1 if he had ever showered resident 1 and CNA 1 replied yes but always with another CNA. CNA 1 stated that on the most recent shower, CNA 3 was the other aide assisting with the shower and that there were no issues during that shower. On 9/27/22, the ADM documented a typed interview with resident 2. Resident 2 was resident 1's roommate at the time of the alleged incident. The ADM asked resident 2 if she had witnessed any incidents between resident 1 and staff. Resident 2 stated that she had heard some arguing last night, but did not see anything due to the privacy curtain pulled forward. Resident 2 stated that it was a short conversation, loud voices, but did not understand what was being said. On 9/26/22, the staff schedule documented that CNA 1 worked the 2:00 PM to 10:00 PM shift. Review of CNA 1's timesheet for September and October 2022 revealed the following: a. On 9/26/22, CNA 1 clocked in at 2:08 PM and out at 10:14 PM. b. On 9/27/22, CNA 1 clocked in at 2:16 PM and out at 10:15 PM. c. On 9/28/22, CNA 1 clocked in at 2:12 PM and out at 10:00 PM. d. On 9/29/22, CNA 1 clocked in at 2:13 PM and out at 10:03 PM. e. On 10/2/22, CNA 1 clocked in at 6:03 AM and out at 10:02 PM. f. On 10/3/22, CNA 1 clocked in at 1:59 PM and out at 10:09 PM. g. On 10/5/22, CNA 1 clocked in at 2:03 PM and out at 10:12 PM. h. On 10/6/22, CNA 1 clocked in at 1:58 PM and out at 10 :07 PM. On 9/26/22, CNA 2's timesheet showed that he clocked in at 1:54 PM and out at 10:18 PM. CNA 2 did not work again until 9/30/22. On 10/3/22 at 2:43 PM, the facility submitted the final abuse investigation summary to the SSA. The summary documented the date of the incident as 9/26/22. The description of the incident documented that resident 1 informed the SSD that a CNA held her by her neck and pushed her up against the wall. Resident 1 stated that it happened in the middle of the night and described the aide as CNA 1 and CNA 2. The summary documented the interventions as CNA 1 was reassigned to different residents during the investigation. Suspension was deemed not necessary due to initial information provided and interview with [resident 1]. Resident 1 was examined by Registered Nurse (RN) 1 and no physical harm or marking were noted. The summary documented the determination of the investigation was that the allegation was unsubstantiated. Resident 1's initial interview identified the alleged perpetrator as CNA 1 or CNA 2. When resident 1 was interviewed again she stated it was a bald, black man. The summary stated that the facility did not have an employee or agency worker that fits that description. During multiple interviews, the details [resident 1] provided were not consistent, demonstrating confusion and difficulty recalling the information of the alleged incident. Review of resident 1's progress notes revealed the following: a. On 9/27/22 at 1:01 AM, RN 1 documented, CNA reported that she received in report another cna grabbed her by her neck and her back and threw her back into her room. Resident interviewed and initially stated that (named cna) that was balding grabbed her neck and back and shoulder and twisted the skin and told her she better go back to her room CNA described has gone home for the night, manager on call notified, continue to assess. b. On 9/27/22 at 3:03 PM, the social service note documented that resident 1 told the SSD that she would like to transfer to another facility and that she would be more comfortable there. c. On 9/27/22 at 3:46 PM, the Interdisciplinary Team (IDT) note authored by Unit Manager (UM) 1 documented that resident 1 wanted to leave and go to another facility because last time she was there she felt safe. Resident 1 reported an incident with CNA 1 last night. The note documented to see the incident report that was given to the ADM. UM 1 documented that they would investigate the incident further. The note further documented that resident 1 had requested female aides only. Will communicate this to nurses. d. On 9/28/22 at 9:58 PM, the nursing note documented, Pt'a [sic] caregiver called stating Pt [patient] was stating suicidal thoughts, Pt was in foyer and is not willing to come back into building, EMS [emergency medical services] called due to suicidal ideation [SI], upon EMS arrival Pt denied any suicidal ideations, EMS was able to convince Pt to come backinto [sic] building. It should be noted that no documentation was found of resident 1 expressing SI prior to this progress note. e. On 9/29/22 at 12:05 PM, the nursing note documented, Resident ambulates in her room and hallway, using her wheelchair for support. She prefers this over using a walker. Resident will often stand up by the front doors and look out, but has not tried to leave the facility. She has been better about sleeping in her room and not in the foyer. Resident wears pullups and has frequent episodes of incontinence. She prefers pull ups to briefs. Staff try to direct her to the bathroom frequently, but resident will only go into the bathroom when she wants to, not when someone suggests it. f. On 9/29/22 at 3:45 PM, the social service note authored by the SSD documented that the resident's previous roommate called and told social services that the resident said that she was having suicidal thoughts and planned to travel to another state and drink herself to death. The SSD followed up with the resident 1 and she stated she had no thoughts of suicide and no plan. The resident often referred to her friend or previous roommate as her mom. Resident 1 stated, my momma was just worried about me, but I'm not suicidal. g. On 10/6/22 at 1:49 PM, the nursing note documented that resident 1 was scheduled for cataract surgery on the right eye on 10/12/22. h. On 10/14/22 at 10:59 AM, the nursing note documented that resident 1 was moved to a different room on another hallway. Review of resident 1's physician note on 9/1/22, date of admission, documented that resident 1 was seen at the hospital for confusion related to Clostridium difficile (c-diff.) colitis. The note documented that resident 1 remained confused. On 9/6/22, resident 1's admission Minimum Data Set [MDS] assessment documented a BIMS score of 8 out of 15, which would indicate a moderate cognitive impairment. The Patient Health Questionnaire-9 (PHQ-9) for the Resident Mood Interview documented a score of 21, which would indicate severe depression. On 9/27/22 at 2:00 PM, resident 1's BIMS documented a score of 9 out of 15, which would indicate a moderate cognitive impairment. Review of resident 1's September 2022 Medication Administration Record (MAR) revealed an order for Vancomycin Capsule, give 125 milligrams by mouth every 6 hours for c-diff. The order was initiated on 9/1/22 and discontinued on 9/12/22. On 9/1/22, the Pre-admission Screening Application/Resident Review (PASRR) Level I documented no psychiatric diagnoses and that a Level I screen indicated that a Level II evaluation for serious mental illness (SMI) was not needed. The evaluation documented Resident expressed suicidal ideation. On 9/30/22, the PASRR office was contacted, and a behavioral health agency screened resident 1 out for a Level II assessment due to no apparent history of SMI and no current meds [medications]/treatment. On 10/13/22, the Psychiatric-Mental Health Nurse Practitioner (PMHNP) note documented that resident 1 was recently treated for encephalopathy. Patient was very pleasant and talkative during visit. She denies depression/sadness. Also denies anxiety. States she is sleeping okay and has a good appetite. She likes the facility and feels she is doing well here. She has no concerns regarding her mental health. The physical exam documented that resident 1 denied suicidal ideation, hallucinations, or delusions. The overall risk assessment indicated no risk of harm to self and others. It should be noted that the PMHNP visit occurred 15 days after resident 1 was noted by staff to have suicidal ideations. On 9/27/22, UM 1 handwritten IDT notes for resident 1 documented an incident report provided to the ADM. The incident was CNA 1 threw bra away and molested her in her private area. CNA 1 was described as bald and Indian/Mexican/and racial slur N word. The incident details further documented that resident 1 was thrown against the wall, shoulder squeezed, skin and arm were twisted against the wall. The meeting notes documented that resident 1 wanted female aides and not males. The notes documented that resident 1 was still reporting episodes of diarrhea. On 9/27/22 at 3:00 PM, UM 1 documented an incident report for resident 1. The report documented that the incident occurred on 9/26/22 during resident 1's shower. The report documented that resident 1 reported that CNA 1 had 'molested' her when he showered her yesterday, 9/26/22. She claims that he told her to 'Shut up and open your legs.' And proceeded to place his hands in her 'private areas'. She said it was the same 'balding man' that pushed had her up against the wall and pinched her skin on her shoulders. She said that he was a 'Mexican or a [racial slur] or something.' She stated that he would not allow her to put her bra back on and instead threw it in the garbage. She said we needed to buy her a new one. She claimed that [CNA 1] then stalked her throughout the night by looking in her room 'all of the time and looking at her.' I reassured her that we have video surveillance in the building to keep our residents and staff safe, so we would definitely look into this. She stated that she wanted to go to [name of another facility] instead because she felt safe last time she was there. She is requesting female aides only. I let her know we could accommodate that to make her feel safer. I also let her know that I would report her claims to admin and that this incident would be investigated through the proper channels. [SSD] was also in attendance at this IDT meeting and witnessed these claims. [CNA 4], the CAN (sic) last night, texted me when she was making a separate claim that was reported to the DON as well at 12:43am. Confirmed with the resident during IDT that there were two separate incidents, the shower incident and the 'throwing her up against the wall' incident. The incident report documented that the ADM and DON were informed. On 9/27/22, a Grievance/Complaint Report was documented by CNA 4. The report documented that resident 1 had told CNA 4 that CNA 1 who worked the 2:00 PM to 10:00 PM shift had grabbed her by her neck and her back and threw her back into her room. The report documented that CNA 1 was assigned to resident 1's room. CNA 4 documented a second interview was conducted with resident 1 and a nurse. In this interview resident 1 reported to CNA 4 and the nurse that he twisted her neck and back threw her into the room. She told him she was reporting him. She also stated that he was two different people with the hair and color skin. But she was very upset crying over the situation. On 11/28/22 at 11:16 AM, an interview was conducted with the SSD. The SSD stated that resident 1 initially reported that a black man had grabbed her in the hallway and hit her head against the wall multiple times. The SSD stated that when she asked resident 1 clarification about the man's appearance resident 1 reported that he was Mexican and was CNA 1. The SSD stated that resident 1 also reported that CNA 1 had twisted her back during the incident. The SSD stated that resident 1 also referred to the individual as CNA 2 but then later verified that it was CNA 1 instead. The SSD stated that resident 1 later accused CNA 1 but said he was bald. The SSD stated that CNA 1 was not bald, but he did have thinning hair. The SSD stated that she did not document the reported incident anywhere, but instead went directly to the ADM to report the allegation of abuse. The SSD stated that she was newly hired at the time of the incident and understood that the protocol was to inform the ADM. The SSD stated that resident 1 reported the initial incident in the morning and said that it had happened the night before. The SSD stated that resident 1 then reported that CNA 1 had touched her inappropriately in the shower, he stuck his fingers up her vagina. The SSD stated that this was reported shortly after the initial incident was reported. The SSD stated that the allegation of sexual abuse was reported to her by resident 1 while passing her in the hallway. The SSD stated that resident 1 had also reported that she was going to another state and was going to drink herself to death. The SSD stated that when she followed up with resident 1, resident 1 did not have any suicidal ideations and no intention of hurting herself. The SSD stated that resident 1 was confused and constantly changed her story. The SSD stated that resident 1 again brought up the incident of hitting her head on the wall and the digital penetration touched inappropriately and stuck his fingers up there in the hallway and the ADM was walking by at the time and spoke with resident 1 about it. The SSD stated that she witnessed the ADM taking notes of this allegation. The SSD stated that she conducted resident 1's BIMS assessment and on 9/2/22 and resident 1 scored an 8 out of 15, which would indicate a moderate cognitive impairment. The SSD stated that she also conducted resident 1's Patient Health Questionnaire-9 (PHQ-9) for Mental Disorders assessment. The SSD stated that on 9/2/22 the PHQ-9 score was a 21/22 which would signify severe depression, but on 9/27/22 the resident scored a 6/22 which would indicate mild depression. The SSD stated that she made a referral for the inhouse psychologist to see resident 1, but resident 1 turned him away. The SSD stated that she did not have the date of that referral documented. The SSD stated that resident 1 had brought up the incident of sexual abuse on a couple of other occasions. The SSD stated that she believed that resident 1 wanted CNA 1 fired. The SSD stated that resident 1 would state, Have you fired him yet? I saw him again. Why is he working? The SSD stated that CNA 1 was working on resident 1's hall. The SSD stated that initially CNA 1 was instructed not to go into resident 1's room alone and he had to be with another aide. The SSD stated that then CNA 1 was reassigned to another hall. The SSD stated that once resident 1 was moved to another room in a different hallway she did not mention CNA 1 again. It should be noted that resident 1's room change did not occur until 10/14/22. The SSD stated that she did not interview any other staff or residents for the abuse investigation. The SSD stated that she reported the allegations to the ADM and he said he would handle it. The SSD stated that resident 1 was adamant that the individual who abused her was CNA 1 but she never pointed him out or physically identified him. On 11/28/22 at 11:59 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that she had worked at the facility multiple times as an agency nurse. RN 2 stated that resident 1 was alert and oriented times 4 to person, place, situation, and time. RN 2 stated that resident 1 was oriented to time because she knew her dialysis schedule. RN 2 stated that resident 1 tried to leave a lot and tried to find reasons to go home or leave the facility. RN 2 stated that resident 1 was non-compliant, and that medications in the morning were a struggle. RN 2 stated that resident 1 liked to put off, make an excuse, or tried to refuse treatments and care. RN 2 stated that resident 1 would even refuse dialysis treatment. RN 2 stated that she was not aware of resident 1 having made any allegations toward staff or other residents or allegations of abuse. RN 2 stated that resident 1 was difficult to work with but was in a good mood most of the time. RN 2 stated that resident 1 was not aggressive, but that she would refuse cares. On 11/28/22 at 12:10 AM, an interview was conducted with resident 1. Resident 1 stated that she had not been residing at the facility long. Resident 1 stated that staff were nice and treated her fine. Resident 1 stated that no staff were mean to her or treated her badly. Resident 1 stated that no aides had ever been mean to her or hurt her. Resident 1 did not make eye contact during the interview and was busy placing clothing items in white garbage bags. Resident 1 answered questions with full sentences but did not elaborate or talk further. On 11/28/22 at 12:15 PM, an interview was conducted with resident 2. Resident 2 stated that she had been at the facility since April. Resident 2 stated that staff were wonderful. Resident 2 stated that she did not have any concerns with staff being mean, rough, or hurting her in any way. Resident 2 stated that her last roommate was resident 1. Resident 2 stated that resident 1 had one incident with an aide. Resident 2 stated that resident 1 and CNA 1 were in the bathroom and CNA 1 wanted resident 1 to sit down. Resident 2 stated that she did not know what that was all about. Resident 2 stated that she heard them yelling at each other. Resident 2 stated that she heard CNA 1 say to sit down and resident 1 refused. Resident 2 stated that they were in a heated argument. Resident 2 stated that both of their voices were raised at each other. Resident 2 stated that CNA 1 was really good with her. I think they had a bad moment. Resident 2 stated that resident 1 had told some of the other aides that CNA 1 had touched her, and she was not happy about the behavior. Resident 2 stated that she was not aware of who the other aides were, only that she could hear them talking. Resident 2 stated that resident 1 had never talked to her about the incident. Resident 2 stated that she did not talk to the ADM about the incident and what she had heard. I didn't even think to tell anyone. On 11/28/22 at 12:59 PM, an interview was conducted with UM 1. UM 1 stated that resident 1 had informed her that CNA 1 had touched her in the private area while showering her and pushed her up against the wall. UM 1 stated that she made sure CNA 1 did not go into resident 1's room unless there was another aide present. UM 1 stated that they also advised all the other aides to have a partner when they entered resident 1's room. UM 1 stated that she documented the incident in a incident report on 9/27/22 at 3:00 PM. UM 1 then stated that she documented a progress note of the IDT meeting on 9/27/22 at 3:46 PM. UM 1 stated that she informed the ADM after she documented the progress note. UM 1 stated that resident 1 had discussed the incident in the IDT meeting on 9/27/22 at 2 PM. UM 1 stated that resident 1, SSD and herself were present when the incident was discussed. UM 1 stated that resident 1 kept changing between stories. There was one incident where resident 1 was up against the wall with the elbow and then there was the shower incident. UM 1 stated that resident 1 then said they happened at the same time. UM 1 stated that resident 1 had reported that while CNA 1 was showering her he placed his hands between her legs. UM 1 stated that at the time of the alleged incident CNA 1 was working as a nighttime aide on resident 1's hall. UM 1 stated that she spoke with CNA 1 on 9/27/22 and asked him if there were any incidents with resident 1 the night before. UM 1 stated that CNA 1 had stated that he knew that resident 1 was upset with him and did not want him in her room anymore. UM 1 stated that CNA 1 had reported that nothing out of the ordinary had occurred and that he had someone else with him, name of other individual was not provided. UM 1 stated that she informed CNA 1 to avoid resident 1's room and to make sure there was a partner with him. UM 1 stated that she also relayed this information to the nurse on shift but cannot recall who that nurse was. UM 1 stated that she relayed the information either directly to the nurse or wrote the information on a note for the nurse to read later. On 11/28/22 at 1:52 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 1 had said that CNA 1 had done something to her. The DON stated that when the ADM asked resident 1 about the incident, she told a story of a black man coming into her room and doing something to her, CNA 1 was white. The DON stated that he was informed of the incident by the ADM but was not involved in the investigation. The DON stated that during the week he was the on-call nurse, but that he was not the individual informed of the incident by the nurse on shift at the time the incident was reported. On 11/28/22 at 2:02 PM, an interview was conducted with UM 2. UM 2 stated that she was made aware of the allegation of sexual abuse but did not know the details. UM 2 stated that it was discussed the following morning in the standup meeting, that occurred between 9:30 AM and 10:00 AM. UM 2 stated that she recalled that the ADM, the business office manager (BOM), the Minimum Data Set (MDS) Coordinator, the SSD, activities director, maintenance director, housekeeping director, and the DON were present at the meeting. UM 2 stated that resident 1 had made an allegation of sexual abuse from a CNA the previous night. On 11/28/22 at 2:24 PM, an interview was conducted with CNA 2. CNA 2 stated that he was aware of resident 1's allegation of abuse and had heard of the incident with CNA 1. CNA 2 stated that supposedly CNA 1 had aggressively forced resident 1 into bed. CNA 2 stated that he had not talked to the ADM about the incident or any management staff. CNA 2 stated that resident 1's mood changed a lot depending on what her needs were and what she wanted. CNA 2 stated that resident 1 was alert and oriented times 2, she knew who she was and where she was at. CNA 2 stated t[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 3 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately, but not later than 2 hours after the allegation was made to the administrator, State Survey Agency (SSA) and adult protective services (APS). Specifically, an allegation of physical abuse was not reported to the facility administrator, SSA, and APS within 2 hours after the allegation was made. Additionally, a second allegation of sexual abuse was made by the resident and was never reported to the SSA, APS, or law enforcement. The identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifier: 1. On 12/5/22 at 11:00 AM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent abuse. Notice of IJ was given verbally via video conference to the facility Administrator (ADM), Director of Nursing (DON), and Corporate Resource Nurse (CRN) 1. On 12/6/22 at 10:15 AM, the Administrator provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 12/6/22 at 5:00 PM: 1. On 12/5/2022 the staff nurse who provided a shower to the affected resident on 09/26/2022 was placed on administrative leave. On 12/5/2022 the agency CNA who assisted in providing a shower to the affected resident on 09/26/2022 was placed on administrative leave from the facility and the agency was notified. 2. Identification of Others At Risk a. Administrator/Designee will conduct interviews of the following: i. Residents with a BIMS [Brief Interview for Mental Status] > [greater than or equal to] 9 ii. Resident Representatives of Residents with BIMS < [less than or equal to] 8 iii. Staff Members 1. Routinely scheduled North Canyon Staff Members 2. On-site Agency Staff b. Newly identified concerns will be addressed and reported if appropriate with an investigation to follow if necessary. 3. Education a. Administrator/Designee will provide Re-education: What is Abuse, to whom to report and timeliness of reporting i. Routinely scheduled North Canyon and agency staff members in the facility will be educated prior to end of day 12/05/2022 and ii. Routinely scheduled North Canyon and agency staff members not in the facility will be educated prior to their next shift b. Education of How to Approach a resident who is resistive to cares i. Routinely scheduled North Canyon and agency direct care staff in the facility will be educated prior to end of day 12/05/2022 and ii. Routinely scheduled North Canyon and agency direct care staff members not in the facility will be educated prior to their next shift c. Regional Nurse Consultant will provide re-education of NHA [Nursing Home Administrator]/DON on Reporting requirements for abuse and how to conduct a thorough investigation 4. Date of Alleged Compliance a. 12/06/2022 at 5:00 PM On 12/7/22, while completing an abbreviated complaint survey, surveyors conducted an onsite revisit to verify the removal of the Immediate Jeopardy. The surveyors determined that the Immediate Jeopardy was removed as alleged on 12/6/22 at 5:00 PM. After the Immediate Jeopardy was removed, the scope and severity were lowered to No actual harm with potential for more than minimal harm that was not immediate jeopardy at a D Level. IMMEDIATE JEOPARDY: Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included end stage renal disease, asthma, acute respiratory failure with hypoxia, type 2 diabetes mellitus, chronic pain, dependence on renal dialysis, hypothyroidism, morbid obesity, and hypertension. On 9/27/22 at 1:01 AM, resident 1's nursing progress note documented, CNA [certified nurse assistant] reported that she received in report another cna grabbed her by her neck and her back and threw her back into her room. Resident interviewed and initially stated that (named cna) that was balding grabbed her neck and back and shoulder and twisted the skin and told her she better go back to her room CNA described has gone home for the night, manager on call notified, continue to assess. Review of the SSA investigation report revealed, On 9/27/22 at 3:23 PM, the facility reported that on 9/27/22 after midnight the Resident reported that a CNA held her by the neck and pushed her up against the wall. It should be noted that the SSA notification was approximately 14 hours after the initial allegation was made to staff. On 9/27/22 at 1:27 PM, the APS report documented, It was reported, by [name of resident 1 omitted] during a conversation with the facility's Social Services Director [name omitted], that a CNA held her by her neck and pushed her up against the wall. She stated it happened sometime in the middle of the night. It should be noted that APS notification was approximately 12 hours after the initial allegation was made to staff. Review of the facility's Freedom From Abuse, Neglect and Exploitation Policy documented, In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will: a. Report immediately, but not later than 2 hours, all alleged violations involving abuse, neglect, exploitation, or mistreatment, The policy was last revised on 9/12/22. On 11/28/22 at 2:45 PM, an interview was conducted with the administrator (ADM). The ADM stated that he was informed of the incident the next morning on 9/27/22 by Unit Manager (UM) 1 and the Social Service Worker (SSW), time undetermined. The ADM stated that the allegation of sexual abuse was made on 9/27/22 during the resident's IDT meeting. The ADM stated that resident 1 had alleged that CNA 1 had molested her in the shower and placed his hands in her private area. The ADM stated that he did not mention the sexual abuse allegation in the investigation summary that was submitted to the State Survey Agency (SSA). The ADM stated that the police were never informed of the allegations of abuse. The ADM stated that he did not believe he completed a second entity report to the SSA with the additional allegation of sexual abuse. [Cross-refer F600]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 3 sampled residents, that the facility did not have evidence that all alleged violations were thoroughly investigated, and that the facility prevented further potential abuse while the investigation was in progress. Specifically, an allegation of physical and sexual abuse was made by a resident and the facility did not have evidence that the allegations were investigated thoroughly. Additionally, the alleged perpetrator was not suspending pending the facility investigation. The identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifier: 1. On 12/5/22 at 11:00 AM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent abuse. Notice of IJ was given verbally via video conference to the facility Administrator (ADM), Director of Nursing (DON), and Corporate Resource Nurse (CRN) 1. On 12/6/22 at 10:15 AM, the Administrator provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 12/6/22 at 5:00 PM: 1. On 12/5/2022 the staff nurse who provided a shower to the affected resident on 09/26/2022 was placed on administrative leave. On 12/5/2022 the agency CNA who assisted in providing a shower to the affected resident on 09/26/2022 was placed on administrative leave from the facility and the agency was notified. 2. Identification of Others At Risk a. Administrator/Designee will conduct interviews of the following: i. Residents with a BIMS [Brief Interview for Mental Status] > [greater than or equal to] 9 ii. Resident Representatives of Residents with BIMS < [less than or equal to] 8 iii. Staff Members 1. Routinely scheduled North Canyon Staff Members 2. On-site Agency Staff b. Newly identified concerns will be addressed and reported if appropriate with an investigation to follow if necessary. 3. Education a. Administrator/Designee will provide Re-education: What is Abuse, to whom to report and timeliness of reporting i. Routinely scheduled North Canyon and agency staff members in the facility will be educated prior to end of day 12/05/2022 and ii. Routinely scheduled North Canyon and agency staff members not in the facility will be educated prior to their next shift b. Education of How to Approach a resident who is resistive to cares i. Routinely scheduled North Canyon and agency direct care staff in the facility will be educated prior to end of day 12/05/2022 and ii. Routinely scheduled North Canyon and agency direct care staff members not in the facility will be educated prior to their next shift c. Regional Nurse Consultant will provide re-education of NHA [Nursing Home Administrator]/DON on Reporting requirements for abuse and how to conduct a thorough investigation 4. Date of Alleged Compliance a. 12/06/2022 at 5:00 PM On 12/7/22, while completing an abbreviated complaint survey, surveyors conducted an onsite revisit to verify the removal of the Immediate Jeopardy. The surveyors determined that the Immediate Jeopardy was removed as alleged on 12/6/22 at 5:00 PM. After the Immediate Jeopardy was removed, the scope and severity were lowered to No actual harm with potential for more than minimal harm that was not immediate jeopardy at a D Level. IMMEDIATE JEOPARDY: Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included end stage renal disease, asthma, acute respiratory failure with hypoxia, type 2 diabetes mellitus, chronic pain, dependence on renal dialysis, hypothyroidism, morbid obesity, and hypertension. On 9/27/22, the facility initial entity report to the State Survey Agency (SSA) documented that resident 1 reported to the Social Service Director (SSD) that a Certified Nurse Assistant (CNA) held her by her neck and pushed her up against the wall. Resident 1 stated that it happened sometime in the middle of the night. Resident 1 described the CNA as CNA 1 or CNA 2. The report documented that no physical harm or marks were noted on resident 1. Review of the SSA Incident Investigation Report revealed that the facility made the notification to the SSA on 9/27/22 at 3:23 PM. On 9/27/22 at 1:27 PM, the Adult Protective Services (APS) report documented, It was reported, by [name of resident 1 omitted] during a conversation with the facility's Social Services Director [name omitted], that a CNA held her by her neck and pushed her up against the wall. She stated it happened sometime in the middle of the night. She described the CNA as [name of CNA 1 omitted], and also stated [name of CNA 2 omitted]. No physical harm or marks on [resident 1's name omitted] was noted. The report further documented that resident 1 was unable to provide anymore information. Upon further investigation, the facility is unable to verify any of the information The report went on to stated that resident 1 presented with confusion and was not a clear historian and the facility concluded that the alleged abuse or harm was not committed by the CNAs as reported, due to no clear evidence of actual abuse or harm. Review of a typed copy of interviews with resident 1 revealed the following: a. On 9/27/22, the administrator (ADM) asked resident 1 to describe the incident reported. Resident 1 stated, a CNA, a black bald man, grabbed her by the neck and slammed her up against the wall, and pushed her back into her room. Resident 1 reported two different CNAs, CNA 1 and CNA 2. Resident 1 then .stated she was abused in the shower 'while the CNA was cleaning her private parts'. Resident 1 could not recall when that occurred. Resident 1 requested to only have female CNAs. Resident 1 stated she felt safe in the facility, but then requested to transfer to another facility. b. On 9/30/22, the ADM had a follow-up interview with resident 1. Resident 1 stated that she liked living at the facility but that she wanted a private room. The ADM educated resident 1 on what Medicaid was paying for her stay at the facility and that she would need to have a roommate. Resident 1 then asked if she could leave for 2 weeks to visit family in another state. The resident stated that her adopted mother was in the other state. The interview documented that the adopted mother was a former roommate and friend of resident 1. The ADM again asked resident 1 if she felt safe with the alleged CNA working at the facility, and resident 1 did not answer the question. Instead, resident 1 stated she wanted to go on a trip to another state. On 9/27/22, the ADM documented a typed interview with CNA 1. The ADM asked CNA 1 if he helped resident 1 on the evening of 9/26/22 and CNA 1 replied yes. CNA 1 stated that resident 1 yelled at him when he asked the resident if she needed help and then told CNA 1 to get out of the room. CNA 1 stated that he did not touch resident 1 during this interaction. CNA 1 stated that there were no other interactions that night. The ADM asked CNA 1 if he had ever showered resident 1 and CNA 1 replied yes but always with another CNA. CNA 1 stated that on the most recent shower, CNA 3 was the other aide assisting with the shower and that there were no issues during that shower. On 9/27/22, the ADM documented a typed interview with resident 2. Resident 2 was resident 1's roommate at the time of the alleged incident. The ADM asked resident 2 if she had witnessed any incidents between resident 1 and staff. Resident 2 stated that she had heard some arguing last night but did not see anything due to the privacy curtain pulled forward. Resident 2 stated that it was a short conversation, loud voices, but did not understand what was being said. On 9/26/22, the staff schedule documented that CNA 1 worked the 2:00 PM to 10:00 PM shift. Review of CNA 1's timesheet for September and October 2022 revealed the following: a. On 9/26/22, CNA 1 clocked in at 2:08 PM and out at 10:14 PM. b. On 9/27/22, CNA 1 clocked in at 2:16 PM and out at 10:15 PM. c. On 9/28/22, CNA 1 clocked in at 2:12 PM and out at 10:00 PM. d. On 9/29/22, CNA 1 clocked in at 2:13 PM and out at 10:03 PM. e. On 10/2/22, CNA 1 clocked in at 6:03 AM and out at 10:02 PM. f. On 10/3/22, CNA 1 clocked in at 1:59 PM and out at 10:09 PM. g. On 10/5/22, CNA 1 clocked in at 2:03 PM and out at 10:12 PM. h. On 10/6/22, CNA 1 clocked in at 1:58 PM and out at 10 :07 PM. On 9/26/22, CNA 2's timesheet showed that he clocked in at 1:54 PM and out at 10:18 PM. CNA 2 did not work again until 9/30/22. On 10/3/22 at 2:43 PM, the facility submitted the final abuse investigation summary. The summary documented the date of the incident as 9/26/22. The description of the incident documented that resident 1 informed the SSD that a CNA held her by her neck and pushed her up against the wall. Resident 1 stated that it happened in the middle of the night and described the aide as CNA 1 and CNA 2. The summary documented the interventions as CNA 1 was reassigned to different residents during the investigation. Suspension was deemed not necessary due to initial information provided and interview with [resident 1]. Resident 1 was examined by Registered Nurse (RN) 1 and no physical harm or marking were noted. The summary documented the determination of the investigation was that the allegation was unsubstantiated. Resident 1's initial interview identified the alleged perpetrator as CNA 1 or CNA 2. When resident 1 was interviewed again she stated it was a bald, black man. The summary stated that the facility did not have an employee or agency worker that fits that description. During multiple interviews, the details [resident 1] provided were not consistent, demonstrating confusion and difficulty recalling the information of the alleged incident. On 9/27/22, UM 1 handwritten Interdisciplinary Team (IDT) notes for resident 1 documented an incident report provided to the ADM. The incident was CNA 1 threw bra away and molested her in her private area. CNA 1 was described as bald and Indian/Mexican/and racial slur N word. The incident details further documented that resident 1 was thrown against the wall, shoulder squeezed, skin and arm were twisted against the wall. The meeting notes documented that resident 1 wanted female aides and not males. The notes documented that resident 1 was still reporting episodes of diarrhea. On 9/27/22 at 3:00 PM, UM 1 documented an incident report for resident 1. The report documented that the incident occurred on 9/26/22 during resident 1's shower. The report documented that resident 1 reported that CNA 1 had 'molested' her when he showered her yesterday, 9/26/22. She claims that he told her to 'Shut up and open your legs.' And proceeded to place his hands in her 'private areas'. She said it was the same 'balding man' that pushed had her up against the wall and pinched her skin on her shoulders. She said that he was a 'Mexican or a [racial slur] or something.' She stated that he would not allow her to put her bra back on and instead threw it in the garbage. She said we needed to buy her a new one. She claimed that [CNA 1] then stalked her throughout the night by looking in her room 'all of the time and looking at her.' I reassured her that we have video surveillance in the building to keep our residents and staff safe, so we would definitely look into this. She stated that she wanted to go to [name of another facility] instead because she felt safe last time she was there. She is requesting female aides only. I let her know we could accommodate that to make her feel safer. I also let her know that I would report her claims to admin and that this incident would be investigated through the proper channels. [SSD] was also in attendance at this IDT meeting and witnessed these claims. [CNA 4], the CAN (sic) last night, texted me when she was making a separate claim that was reported to the DON as well at 12:43am. Confirmed with the resident during IDT that there were two separate incidents, the shower incident and the 'throwing her up against the wall' incident. The incident report documented that the ADM and DON were informed. On 9/27/22, a Grievance/Complaint Report was documented by CNA 4. The report documented that resident 1 had told CNA 4 that CNA 1 who worked the 2:00 PM to 10:00 PM shift had grabbed her by her neck and her back and threw her back into her room. The report documented that CNA 1 was assigned to resident 1's room. CNA 4 documented a second interview was conducted with resident 1 and a nurse. In this interview resident 1 reported to CNA 4 and the nurse that he twisted her neck and back threw her into the room. She told him she was reporting him. She also stated that he was two different people with the hair and color skin. But she was very upset crying over the situation. On 11/28/22 at 11:16 AM, an interview was conducted with the SSD. The SSD stated that resident 1 initially reported that a black man had grabbed her in the hallway and hit her head against the wall multiple times. The SSD stated that when she asked resident 1 clarification about the man's appearance resident 1 reported that he was Mexican and was CNA 1. The SSD stated that resident 1 also reported that CNA 1 had twisted her back during the incident. The SSD stated that resident 1 also referred to the individual as CNA 2 but then later verified that it was CNA 1 instead. The SSD stated that resident 1 later accused CNA 1 but said he was bald. The SSD stated that CNA 1 was not bald, but he did have thinning hair. The SSD stated that she did not document the reported incident anywhere, but instead went directly to the ADM to report the allegation of abuse. The SSD stated that she was newly hired at the time of the incident and understood that the protocol was to inform the ADM. The SSD stated that resident 1 reported the initial incident in the morning and said that it had happened the night before. The SSD stated that resident 1 then reported that CNA 1 had touched her inappropriately in the shower, he stuck his fingers up her vagina. The SSD stated that this was reported shortly after the initial incident was reported. The SSD stated that the allegation of sexual abuse was reported to her by resident 1 while passing her in the hallway. The SSD stated that resident 1 had also reported that she was going to another state and was going to drink herself to death. The SSD stated that when she followed up with resident 1, resident 1 did not have any suicidal ideations and no intention of hurting herself. The SSD stated that resident 1 was confused and constantly changed her story. The SSD stated that resident 1 again brought up the incident of hitting her head on the wall and the digital penetration touched inappropriately and stuck his fingers up there in the hallway and the ADM was walking by at the time and spoke with resident 1 about it. The SSD stated that she witnessed the ADM taking notes of this allegation. The SSD stated that she conducted resident 1's BIMS assessment and on 9/2/22 resident 1 scored an 8 out of 15, which would indicate a moderate cognitive impairment. The SSD stated that she also conducted resident 1's Patient Health Questionnaire-9 (PHQ-9) for Mental Disorders assessment. The SSD stated that on 9/2/22 the PHQ-9 score was a 21/22 which would signify severe depression, but on 9/27/22 the resident scored a 6/22 which would indicate mild depression. The SSD stated that she made a referral for the inhouse psychologist to see resident 1, but resident 1 turned him away. The SSD stated that she did not have the date of that referral documented. The SSD stated that resident 1 had brought up the incident of sexual abuse on a couple of other occasions. The SSD stated that she believed that resident 1 wanted CNA 1 fired. The SSD stated that resident 1 would state, Have you fired him yet? I saw him again. Why is he working? The SSD stated that CNA 1 was working on resident 1's hall. The SSD stated that initially CNA 1 was instructed not to go into resident 1's room alone and he had to be with another aide. The SSD stated that then CNA 1 was reassigned to another hall. The SSD stated that once resident 1 was moved to another room in a different hallway she did not mention CNA 1 again. It should be noted that resident 1's room change did not occur until 10/14/22. The SSD stated that she did not interview any other staff or residents for the abuse investigation. The SSD stated that she reported the allegations to the ADM and he said he would handle it. The SSD stated that resident 1 was adamant that the individual who abused her was CNA 1 but she never pointed him out or physically identified him. On 11/28/22 at 12:59 PM, an interview was conducted with UM 1. UM 1 stated that resident 1 had informed her that CNA 1 had touched her in the private area while showering her and pushed her up against the wall. UM 1 stated that she made sure CNA 1 did not go into resident 1's room unless there was another aide present. UM 1 stated that they also advised all the other aides to have a partner when they entered resident 1's room. UM 1 stated that she documented the incident in a incident report on 9/27/22 at 3:00 PM. UM 1 then stated that she documented a progress note of the IDT meeting on 9/27/22 at 3:46 PM. UM 1 stated that she informed the ADM after she documented the progress note. UM 1 stated that resident 1 had discussed the incident in the IDT meeting on 9/27/22 at 2 PM. UM 1 stated that resident 1, SSD and herself were present when the incident was discussed. UM 1 stated that resident 1 kept changing between stories. There was one incident where resident 1 was up against the wall with the elbow and then there was the shower incident. UM 1 stated that resident 1 then said they happened at the same time. UM 1 stated that resident 1 had reported that while CNA 1 was showering her he placed his hands between her legs. UM 1 stated that at the time of the alleged incident CNA 1 was working as a nighttime aide on resident 1's hall. UM 1 stated that she spoke with CNA 1 on 9/27/22 and asked him if there were any incidents with resident 1 the night before. UM 1 stated that CNA 1 had stated that he knew that resident 1 was upset with him and did not want him in her room anymore. UM 1 stated that CNA 1 had reported that nothing out of the ordinary had occurred and that he had someone else with him, name of other individual was not provided. UM 1 stated that she informed CNA 1 to avoid resident 1's room and to make sure there was a partner with him. UM 1 stated that she also relayed this information to the nurse on shift but cannot recall who that nurse was. UM 1 stated that she relayed the information either directly to the nurse or wrote the information on a note for the nurse to read later. On 11/28/22 at 2:45 PM, an interview was conducted with the administrator (ADM). The ADM stated that he was informed of the allegation of abuse the next morning on 9/27/22 by Unit Manager (UM) 1 and the SSD, time undetermined. The ADM stated that the SSD had reported that resident 1 had said that she was held by her neck and pushed up against the wall by a CNA. The ADM stated that resident 1 had reported that it was CNA 1 and CNA 2 who did this to her. The ADM stated that UM 1 had reported essentially the same thing in the incident report. The ADM stated that UM 1 had given him the grievance report filled out by CNA 4 which stated that CNA 1 grabbed resident 1 by the back and threw her into the room. The ADM stated that the allegation of sexual abuse was made on 9/27/22 during resident 1's IDT meeting. The ADM stated that resident 1 had alleged that CNA 1 had molested her in the shower and placed his hands in her private area. The ADM stated that he conducted the interview with resident 1 on 9/27/22 and it must have been after the IDT meeting. The ADM stated that resident 1 had reported to him that she was abused in the shower while cleaning her private parts. The ADM stated that after he was informed, he continued with the investigation and then interviewed resident 1's roommate, resident 2. The ADM stated that resident 2 had heard arguing but did not see anything because the privacy curtain was closed. The ADM stated that he then interviewed CNA 1 and the aide had said he had interacted with resident 1 on 9/26/22, that she had yelled at him and told him to get out of the room. The ADM stated that CNA 1 had denied touching resident 1 that evening. CNA 1 had stated that he had showered resident 1 with the assistance of CNA 3. The ADM stated that he did not interview any of the other residents in the facility and did not recall why he chose not to interview anyone else. The ADM stated that CNA 1 had never had any other allegations and was one that was praised a lot by other residents. The ADM stated that he could not recall who had praised the aide, and that this was through conversations with residents and other staff prior to the incident. The ADM stated that they had video surveillance in the hallways, and it showed CNA 1 going in and out of rooms providing cares. The ADM stated that he did not keep the recording. The ADM stated that CNA 1 was assigned to resident 1's room that night and it did not seem like he was in the room long enough, but he did not time anything. The ADM stated he was not sure if CNA 1 had provided resident 1 with a shower that day. The ADM stated that he did not suspend CNA 1 during the investigation due to his previous experience with the aide, and because of resident 1's confusion with who the alleged perpetrator was. The ADM stated that stories of an allegation of a black man had come to his attention during the first interview and then resident 1 had said it was CNA 1. The ADM stated that with observing resident 1's gait it seemed hard that she would be thrown up against the wall and it would be difficult for her to get back up from the ground. The ADM stated that with resident 1's allegation of two different individuals, and the aide's history of great performance they determined that it was unsubstantiated. The ADM stated that additionally resident 1 had alleged that her skin had been pinched, but the progress note documented that no discoloration was noted. The ADM stated that he did not interview RN 1 who was on shift the night of the incident and who conducted the skin assessment. The ADM stated that on 9/30/22 when he conducted a second interview with resident 1, he had asked her if she felt safe with CNA 1 and resident 1 did not reply. The ADM stated that resident 1 had acted almost like he had not asked the question. The ADM stated that he determined that the residents were safe around CNA 1 and that was based on the inconsistent reports from resident 1, other resident reports of him being good, and response from other staff with how good he was with residents. The ADM stated that these conversation occurred before the allegation was made against CNA 1. The ADM stated that after the incident he spoke with CNA 3 and she had said that CNA 1 was a great worker, was great with the residents, was friendly, and liked to talk to a lot with the residents. The ADM stated that he did not mention the sexual abuse allegation in the investigation summary that was submitted to the State Survey Agency (SSA). The ADM was asked how the SSA would know that the allegation of sexual abuse had been investigated if it was not disclosed in the investigation report, and the ADM stated he did not have an answer for that. The ADM stated that he was not aware that resident 1 had reported that CNA 1 had digitally penetrated her vagina. The ADM stated that had he been informed of this information he would have called the police, had a sexual assault exam done, reported it to the SSA, and would have definitely suspended CNA 1. The ADM stated that the police were never informed of the allegations of abuse. The ADM stated that since the incident they had completed a lot of abuse education to the agency staff. The ADM stated that the facility staff should have known to report allegations of abuse to him, but they used this opportunity to remind them. The ADM stated that he did not believe he completed a second entity report to the SSA with the additional allegation of sexual abuse. On 11/28/22 at 3:25 PM, an interview was conducted with CNA 3. CNA 3 stated that she had tried to shower resident 1 in the past and had offered her bath cleansing wipes. CNA 3 stated that resident 1 was only allowing staff to clean her with wipes. CNA 3 stated that she had offered to assist resident 1 with a shower, but she had refused. CNA 3 stated that she never provided resident 1 with a shower, and that she had never assisted any other aides with showering resident 1. It should be noted, that during the ADM interview with CNA 1, CNA 1 had reported that CNA 3 had assisted him with showering resident 1. CNA 3 had stated that resident 1 had requested not to have male CNAs shower her. CNA 3 stated that from what she had heard, CNA 1 was told to give resident 1 a shower and resident 1 had accused CNA 1 of being sexual around her. CNA 3 stated that other people had told her that resident 1 had accused CNA 1 of being sexually inappropriate with her, but that there was another aide present. CNA 3 stated that she did not know who that other aide was that assisted CNA 1 with resident 1's shower. CNA 3 stated that she could not recall who informed her of resident 1's allegation of abuse. CNA 3 stated that she had spoken with CNA 1 about the incident because CNA 1 was her boyfriend. On 11/28/22 at 4:15 PM, an interview was conducted with CNA 5. CNA 5 stated that she worked for agency but had worked at the facility 4 days a week since summertime. CNA 5 stated that resident 1 needed help with toileting, she would let herself get filthy with a bowel movement and would not let staff clean her up. CNA 5 stated that she provided resident 1 with a shower with the assistance of a licensed nurse. CNA 5 stated that the nurse was present due to allegations that she (CNA 5) and CNA 1 had raped resident 1 while providing incontinence care. CNA 5 stated that the allegation was made in October sometime. It should be noted that review of the staff schedule revealed that on 9/26/22 both CNA 5 and CNA 1 had worked the 2:00 PM to 10:00 PM shift. CNA 5 stated that CNA 1 was removed from providing care for resident 1, and she continued to be scheduled as resident 1's aide. CNA 5 stated that she thought it was weird that she was allowed to provide resident 1 with care because she had also been accused of sexually abusing resident 1. CNA 5 stated that she never talked to anyone in management from the facility about the allegation and had heard of the allegation by rumor. CNA 5 stated that she could not recall who had told her about the allegation that she and CNA 1 had tried to rape resident 1. CNA 5 stated that the Administrator, DON nor anyone from management had not talked to her about the allegation. CNA 5 stated that she assisted resident 1 with toileting because for a time she had c-diff. and explosive diarrhea. CNA 5 stated that resident 1 was able to toilet independently at one point. CNA 5 stated that she recalled assisting CNA 1 with providing incontinence care to resident 1 on 1-2 occasions. CNA 5 stated that during those cares resident 1 was reluctant to be cleaned up and refused cares. CNA 5 stated that resident 1 would refuse incontinence care and showering care. CNA 5 stated that it was through body language that she felt resident 1's reluctance, like she was bothered by them constantly on her about getting cleaned up. CNA 5 stated that this was during the time when resident 1 had c-diff and she was not feeling well, and it was also at the time of resident 1's room change. CNA 5 stated that she recalled informing resident 1 in a stern voice that they were just trying to get her cleaned up. CNA 5 stated that at the time resident 1 had diarrhea and the stool had soiled her pants, down her legs and on her shoes. CNA 5 stated that a lot of times resident 1 would try to toilet herself independently and would not make it. CNA 5 stated that she did not recall CNA 1 raising his voice but could see he was getting frustrated. CNA 5 stated that she never said anything that was unkind or mean and did not yell at resident 1. On 11/29/22 at 7:24 AM, a telephone interview was conducted with RN 1. RN 1 stated that the resident was at baseline with episodes of agitation at the time of the reporting of the incident. RN 1 stated that the resident was upset but was not crying or yelling. RN 1 stated that the resident reported that it was CNA 1 who grabbed her. RN 1 stated that she did a skin assessment of the torso and did not observe any discoloration, bruising or redness. RN 1 stated that resident 1 had said that the incident had occurred on that shift, her assumption was that it had just happened. It occurred during the 2-10 shift, but she did not document until 1 AM on 9/27/22. RN 1 stated that she was informed on 9/26/22, time undetermined, and followed up on the it immediately. RN 1 stated that she informed management, but she does not recall who she informed. RN 1 stated that the nurse managers had an on-call schedule and that was most likely who she informed. RN 1 stated that she does not recall if she notified the ADM, but she definitely notified the management team. RN 1 stated that she did not provide any statement or have any additional interviews with management after the initial notification. RN 1 stated that resident 1 had [NAME][TRUNCATED]