**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify allegations of abuse, ensure alleged abuse, neglect and/or unexpected deaths were reported, and thoroughly investigated for 8 of 9 residents (Residents 2, 3, 4, 5, 6, 7, 8 & 1) reviewed for abuse. Residents expresed fear of staff, not feeling safe, crying, nervous from the fear and not calling for assistance due to fear of being yelled at or pushed and pulled by staff. Although the facility was aware of these concerns, they were not identified, reported, or investigated as potential allegations of abuse, but were considered grievances. In addition, residents were not proteted when the facility allowed the alleged perpetrator(s) to have continued access to residents prior to determining if abuse or neglect occurred. This failure placed residents at serious risk for unidentified abuse and/or neglect and a diminished quality of life. On 08/31/2023 at 3:00 PM, the facility was notified of an Immediate Jeopardy at CFR 483.12(c)(2)-(4) F610, Alleged Violations-Investigate/Prevent/Correct, related to the facility's failure to identify allegations of abuse, ensure alleged abuse, neglect and/or unexpected deaths were reported, thoroughly investigated and protect residents during the investigation. The facility removed the immediacy on 09/05/2023 with an onsite verification from investigators by, conducting resident interviews, reporting and investigating all allegations of abuse or neglect, and placing residents on psychological monitoring. And re-educating all staff (prior to working their next scheduled shift) regarding abuse policies/procedures, which ensured an effective system was in place to safeguard, protect and prevent residents that were at risk for abuse. Findings included . Review of the facility policy titled, Abuse, Neglect and Exploitation, revised April 2023, showed the facility would develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, establish policies and procedures to investigate any such allegations and provide ongoing oversight and supervision of staff in order to assure that policies were implemented as written. According to the policy, the facility would identify, correct, and intervene in situations in which abuse, neglect .was more likely to occur with the deployment of staff on each shift in sufficient numbers to meet the needs of the residents. Investigation of Alleged Abuse, Neglect and Exploitation included identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation, focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment occurred, the extent, and cause, and providing complete and thorough documentation of the investigation. In addition, the facility would report all alleged violations to the state agency within required time frames. Review of the facility policy titled, Incidents and Accidents, revised March 2023, showed that an incident was defined as an occurrence or situation that was not consistent with the routine care of a resident or with the routine operation of the organization. This can involve a visitor, vendor, or staff member. The policy listed incidents that required an incident report which included allegations of abuse, neglect, mistreatment, combative behavior, falls, pressure injuries/ulcers, resident to resident altercations, and unexpected deaths. In the event of an unwitnessed fall, the nurse initiated neurological checks per protocol and documented on the neurological flow sheet. Abnormal findings were reported to the practitioner. If an incident was witnessed by other persons, the supervisor or designee obtained written documentation of the event by those that witnessed the incident. The facility would report to appropriate state and federal agencies according to regulatory requirements. <Resident 2> Review of a 07/26/2023 admission MDS showed Resident 2 admitted to the facility on [DATE] with diagnoses including arthritis, vascular disease, diabetes, and muscle weakness. Resident 2 was assessed as able to make their own decisions, with adequate hearing, clear speech, and required two person extensive assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of a Concern and Comment form, dated and signed 08/10/2023 by Resident 2 showed their concern was that a number of CNAs were very difficult to deal with, which caused Resident 2 to be reluctant to push their call button for help. The form showed a letter of explanation was included but was not attached to the concern and comment form when first requested from facility staff. Review of the requested letter of explanation showed Resident 2 documented Second shift had become difficult and makes me feel like a burden or nuisance, Third shift is very difficult, we get yelled at, moved around harshly, and are told no when we ask for help or for something we need, I don't push my button unless I am very wet, otherwise I am hiding in my bed, not all CNA's make me sad but a few do, I would like to feel safe and secure and it is hard to feel good when you get ridiculed and shoved around when my brief is being changed. Review of a 08/11/2023 statement written by Staff G, showed Staff G interviewed Resident 2 on 08/11/2023, who stated concerns about Staff I, CNA and at times with Staff J, CNA. Resident 2 stated they [NAME] and puff when you need to be changed and tell me they don't have time or say they will come back and don't, and they yell in high pitch voices, throw things on the ground when they are mad, and Staff N, Registered Nurse (RN) yells at us, Staff I throws me around and had hurt my legs a few times, they act like they don't like me, and Staff I wants me to go to sleep at 8:00 PM but I prefer to stay up until at least 10:00 PM. Review of the August 2023 facility Abuse Log showed the facility did not log or make mandatory reports as required for Resident 2's allegations of neglect, verbal, and physical abuse. During an interview on 08/23/2023 at 12:25 PM, Staff G stated grievances or concern/comment forms were reviewed for potential allegations of abuse, when an allegation was suspected, the form was forwarded to the Director of Nursing (DNS) or in their absence the Administrator, the Administrator in training (AIT) or the Chief Nursing Officer (CNO). Staff G stated the concern/comment form for Resident 2 was forwarded to Staff C, AIT because the form showed an allegation of abuse and neglect and needed to be investigated. Review of a 08/14/2023 Summary of Resident 2's grievance/concerns completed by Staff B showed Resident 2 complained that aides make them feel uncomfortable because they talk loud and at times in a different language, which makes Resident 2 feel like the aides are taking about them and Resident 2 is reluctant to use their call button for help. The summary showed Staff I was removed from work on 08/11/2023 and 08/12/2023, and returned to work on 08/13/2023 on a different hallway from Resident 2. During an interview on 08/14/2023 at 11:55 AM, Resident 2 stated both Staff I and Staff J had been harsh and rough towards them and their previous roommate (Resident 3). Resident 2 stated they were shocked when Staff I showed up in their room during the night shift last night to help another Staff O, CNA, change the resident and their bed sheets. Resident 2 was informed that Staff I was suspended and thought they should not have been in the their room. Resident 2 stated that Staff J came into their room on a different occasion asking what they did to the resident, and informed them they were not allowed in their rooms anymore. Review of facility staffing sheets, dated 08/11/2023, showed Staff J worked with Resident 2 that evening shift. A 08/12/2023 staffing sheet showed Staff I worked on the same hallway as Resident 2. The 08/13/2023 staffing sheet showed Staff I worked evening and night shift on a different hallway. In an interview on 08/23/2023 at 1:01 PM Staff C stated Staff I was suspended Friday and Saturday and was brought back to work on Sunday (08/13/2023), after they received customer service training, they had to work in a different area of the building and was directed not to walk down the hall where both residents (Resident 2 and Resident 3) were or have contact with the residents. When asked if Resident 2's concerns were an allegation of abuse or neglect, how was abuse or neglect ruled out before allowing Staff I to have access to residents, Staff C replied that at the time they did not consider the concerns an allegation of abuse or neglect. Staff C was not sure and could not confirm what staff member educated Staff I on customer service or if the education was completed before Staff I returned to work with residents. When asked what was done with Staff J, Staff C stated that Staff I was the main focus of concern and they did not recall interviewing or re-educating, Staff J. Staff C stated that residents on the same hall as Resident 2 were interviewed for concerns, although the interviews were not dated and did not indicate when the interviews occurred. Review of a 08/14/2023 Education Record showed customer service training was provided on Monday 08/14/2023 to Staff I and Staff J, this was after Staff I had already worked the floor and had access to residents. During an interview on 08/23/2023 at 1:31 PM, Staff B stated when abuse or neglect were suspected they would expect staff to report the allegation immediately to required entities; abuse hotline, resident representatives, physician, and the administrator. Staff B would expect staff to log the allegation of abuse or neglect on the facility abuse log, and suspend staff involved until a investigation was completed to rule out abuse and neglect. Staff B acknowledged Resident 2's allegations of abuse or neglect were not logged, reported, or investigated as they would expect. Staff B stated Staff I was brought back to work before the investigation was completed and before abuse and neglect was ruled out and Staff J should have but was not suspended during the investigation as Staff B would expect, giving both staff members access to residents. <Resident 3> Review of a 08/03/2023 admission MDS, showed Resident 3 admitted to the facility on [DATE] with diagnoses including a leg fracture, heart failure, arthritis, and hip fracture. Resident 3 was assessed as able to make their own decisions, with minimal difficulty hearing, clear speech, and required two person extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Review of a Concern and Comment form dated and signed by Resident 3 on 08/10/2023, showed Resident 3 had concerns about the treatment of resident's by the CNAs. Resident 3 documented details to include; lack of respect, make me feel uncomfortable, and don't give messages to the nurse when I need something. Review of a four page handwritten letter by Resident 3 showed they had problems with Staff I and Staff J, when someone is constantly yelling at me, not changing my briefs, hurting me, and being very rough both physically and verbally it scares me, I cry, get nervous, and hyperventilate, then they yell at me again for crying. There was a time a CNA told me to stop laughing, and yelled, yes you are! I laid my head down and never talked again. I wasn't laughing, I was crying because they dropped my legs and it hurt really bad. I have asked to be changed and was told, no. I have had many times where my ice bag fell on the floor or leaked, the CNA yelled at me and threw my ice bag on my dresser, drenching my clothes. Review of a 08/11/2023 statement written by Staff G, showed Staff G interviewed Resident 3 on 08/11/2023 about their concerns. Resident 3 told Staff G that Staff I wipes me roughly and drops my legs all the time, I am scared of Staff I and Staff J is mean sometimes. Review of the August 2023 facility Abuse Log showed the facility did not log or make mandatory reports as required for Resident 3's allegations of neglect, verbal and physical abuse. Review of a 08/11/2023 facility staffing sheet showed Staff J worked with Resident 3 on evening shift. Review of 08/12/2023 staffing sheet showed Staff J worked day and evening shift on a separate hall from resident 3, but still had access to residents. Review of a 08/13/2023 staffing sheet showed Staff J worked day and evening shift on a separate hall from Resident 3 and Staff I worked a evening shift on the same hall as Resident 3 and worked a night shift on a separate hall from Resident 3. Review of a 08/14/2023 Summary of Resident 3's grievance/concerns completed by Staff B showed Resident 3 had concerns that Staff I pulled a pillow out from under their legs and did not set their feet lightly on the bed, felt rushed by Staff I and had concerns about the aide's heavy accent. Staff I was provided education on customer service, informed to limit their time in the hallway where Resident 2 and 3 resided, not to interact with Resident 2 and 3, and to not discuss grievances with resident or other staff. The summary did not include Resident 3's concerns about Staff J or address Resident 3's allegations of neglect, verbal and physical abuse. During an interview on 08/14/2023 at 12:15 PM, Resident 3 stated they had a rough night and woke up to a nurse yelling at them because the ice bag fell on the floor and leaked, how was I supposed to know, I was sleeping, then [Staff I] came to the door with another aide and just stared at me, I don't want them [Staff I] to come in my room I am not sure why they are back. I don't want [Staff I] or [Staff J] to provide care to me because they are rough and hurt my feet. In an interview on 08/23/2023 at 12:25 PM, Staff G stated Resident 3's grievance/concerns were reviewed for abuse allegations, once reviewed Staff G determined Resident 3's concerns were allegations of neglect and abuse. Staff G stated the concern/comment form for Resident 3 was forwarded to Staff C because the form showed an allegation of abuse and neglect and needed to be investigated. In an interview on 08/23/2023 at 1:01 PM, when asked if rough wiping, being mean, yelled at, and residents being scared of staff was an allegation of abuse or neglect, Staff C stated at the time they did not consider the concerns to be an allegation of abuse or neglect. When asked what was done with Staff J, Staff C stated that Staff I was the main focus of concern and they did not recall interviewing or suspending Staff J. Staff C stated they were not sure and could not confirm what staff member educated Staff J on customer service or if the education was completed. During an interview on 08/23/2023 at 1:31 PM Staff B stated when abuse or neglect are suspected they would expect staff to report the allegation immediately to required entities, abuse hotline, resident representatives, physician, and the administrator. Staff B would expect staff to log the allegation of abuse or neglect on the facility abuse log, and suspend staff involved until an investigation is completed to rule out abuse and neglect. Staff B acknowledged Resident 3's allegations of abuse or neglect were not logged, reported, or investigated as they would expect. Staff B stated Staff I was brought back to work before the investigation was completed and before abuse and neglect was ruled out and Staff J should have but was not suspended during the investigation as Staff B would expect, giving both staff members access to residents. <Resident 4> Review of the 08/07/2023 admission MDS Resident 4 admitted to the facility 08/01/2023. The resident had no falls prior to admission or since admission. The resident exhibited verbal behaviors towards others, and rejected care, on one to three days of the look back period. The resident was assessed as a two-person physical extensive assist with bed mobility, transfers, dressing, toileting. Review of an 08/08/2023 11:30 AM Nurse's Note showed, Resident and roommate did not get along; screaming at each other, accusing each other's TV was too loud. The Roommate told the nurse they could not stand the other resident's attitude; the other resident heard, and shot back, Me either. Staff received a physician's order to transfer resident to another room. During an interview on 08/23/2023 at 1:31 PM, Staff B stated that if abuse occurred or was suspected staff were to protect the resident, report the incident up the chain of command, initiate an incident report, and report to the State Agency. During an Interview on 08/23/2023 at 2:07 PM Staff K, RN, stated that the residents were verbally abusing each other. Staff K stated she witnessed it she pulled Resident 4 out of the room. Staff K stated that she reported the incident to Staff L RN/Staff Development Coordinator, and she told Staff H, Social Services Assistant. Staff K stated she should have but did not complete an incident report or report the event to the Hotline (State Agency abuse reporting line) as required. During an interview on 08/23/2023 at 2:11 PM, Staff L stated that she received no reports from Staff K. During an interview on 08/23/2023 at 2:15 PM, Staff G stated she received a request for a room move, but she was not told it was a resident-to-resident altercation. At 2:20 PM, Staff G stated that Staff H was not on duty on 08/08/2023. During an interview on 08/23/2023 at 2:21 PM, Staff D, CNO, stated the resident-to-resident altercation with screaming and cursing should have been reported to the Hotline. During an interview on 08/23/2023 at 2:40 PM Staff B reviewed the 08/08/2023 progress note and stated, I'd expect them to report that. Review of the August 2023 Incident Reporting Log showed the resident-to-resident altercation was not reported nor investigated for abuse. Review of the August 2023 Incident Reporting Log showed Resident 4 sustained a non-injury fall on 08/14/2023 at 9:00 PM in their room. Actions taken to prevent recurrence included a care plan revision. The Hotline was not notified. On 08/23/2023 at 2:01 PM the facility investigation was requested and Staff B stated they did not have it completed. Staff B acknowledged the investigation was not completed within five days as required. Review of the Nurse's Notes showed an 08/14/2023 9:21 PM entry that Resident 4 was assessed with a bruise to their left face. A 08/15/2023 1:14 PM Nurse's Note showed Resident 4 had bruising to their left face, under the chin and neck area. Review of the Post Fall Observation dated 08/18/2023 showed there were reports of swelling, bruising, or other signs/symptoms of injury since the event. Review of the investigation summary dated 08/23/2023 at 2:21 PM showed the resident sustained an unwitnessed fall with no injury. During an interview on 08/23/2023 at 1:31 PM, Staff B stated that after a fall, Residents were placed on alert (documented monitoring) for latent injuries. If a Resident was noted with a bruise the nurse was expected to conduct a skin assessment weekly until resolved. During an interview on 08/23/2023 at 2:12 PM, Staff H, Registered Nurse (RN), Resident Care Manager (RCM) stated that Resident 4 sustained bruising and an injury to their head in the neck and chin area. Staff H stated when the bruising was noted the nurse should have but did not do a skin assessment. During an interview on 08/23/2023 at 2:40 PM Staff B stated that no one reported the bruising to her, it was not on the 24 hour report and should be reported on the log as a substantial injury. <Resident 5> Review of a 07/05/2023 admission MDS showed Resident 5 admitted to the facility on [DATE] and had diagnoses including a brain bleed, cancer, and weakness. The MDS assessed Resident 5 with moderate cognitive impairment, moderate difficulty hearing, clear speech, had no skin impairments, and required extensive assistance from two staff members for bed mobility, transfers, dressing, and toileting. Review of three grievances/concern forms, dated 08/15/2023, showed Resident 5's collateral contact (CC1) had concerns that Resident 5 was not being turned every four hours and now has two bedsores. The resident had a swollen hand, and when CC1 requested an x-ray, was told that x-rays were not done at the facility, no one followed up, and the resident did not receive an x-ray. The resident was only receiving one bath a week and was told by facility staff that was because they were a fall risk. All three concern forms showed staff left the question blank regarding the concerned party's response to the action plan or outcome. During an observation and interview on 08/23/2023 at 3:05 PM, Resident 5 was observed lying in bed on their back with their left hand elevated on a pillow and stated staff only repositioned them when they called and asked the staff to turn them, at times staff said they will go get another aide to help and never return to reposition them, and that it happened often. Resident 5 stated they were told by facility staff they had blood clots in their hand. Resident 5 could not recall if an x-ray was done. In an interview on 08/23/2023 at 3:15 PM, Staff B stated they did not follow up with CC1 regarding their concerns of neglect and acknowledged the concerns should have but were not identified as neglect, or logged, reported, and investigated as required. <Resident 6> Review of a Concern and Comment form dated 08/20/2023 showed Resident 6 provided a handwritten letter to Staff G. Review of the letter showed Resident 6 reported that three staff, who identified as either Physical or Occupational Therapists, began to pull and push on me I became frightened because of my pain! They hollered at me! They were not professional people! . Further review of the concern form showed the facility identified the resident's concern as Stating therapy was unprofessional. Review of the August 2023 Concern Log and the August 2023 Incident Reporting Log on August 23, 2023, showed that Resident 6's allegations of abuse were not logged. During an interview on 08/23/2023 at 12:44 PM, Staff D stated that the allegation should have been investigated. <Resident 7> Review of a 08/12/2023 admission MDS, Resident 7 admitted to the facility on [DATE] with diagnoses including cancer, depression, and post spinal surgery. Resident 7 was assessed to be able to make their own decisions, with adequate hearing, clear speech, and required extensive assistance of two staff members for bed mobility, transfers and toilet use. Review of a 08/11/2023 grievance/concern form showed Resident 7 had concerns of being left in a wheelchair for two hours after working with therapy. Review of a 08/11/2023 statement from Staff G showed Resident 7 was interviewed by Staff G, and stated on 08/11/2023 at lunch time a therapist brought them into their room and Resident 7 agreed to eat lunch in their wheelchair. Resident 7 put their call light on, was left in the wheelchair during that time which caused Resident 7 pain, and no one answered the call light for two hours. A 08/16/2023 statement by Staff B showed that Resident 7 complained of being in their wheelchair and the therapist asked the resident to remain in the wheelchair for lunch. Per Staff B's statement staff returned resident to bed after one hour and the resident's perception was longer than the actual time they waited. Review of the August 2023 facility Abuse Log showed the facility did not log or make mandatory reports as required for Resident 7's allegations of neglect. The facility did not identify the concern as an allegation of neglect, therefore did not log, report, or investigate Resident 7's allegation of neglect as required. <Resident 8> Review of the 08/01/2023 Annual MDS, Resident 8 was alert and oriented, did not exhibit behaviors which interfered with care, was always incontinent of bowel and bladder, had Moisture Associated Skin Damage, and was dependent on two persons for mobility, transfers, dressing, and toileting. According to a facility reported incident, on 08/24/2023 during morning rounds, Resident 8 told Staff L that they requested to be changed on 08/23/2023 at 9:55 PM and was told by the evening shift aid, Staff U, CNA, that Resident 8 had to wait for the night shift staff as the resident required two person assist. During an interview on 09/01/2023 at 10:30 AM, when asked how the incident made them feel, Resident 8 responded, Like I am not worth it. Review of the 08/25/2023 facility investigation showed that it took two aids to change this resident as they were care in pairs. During an interview on 09/01/2023 at 1:23 PM, Staff B stated Resident was a two person assist with mobility as the resident could not assist. When questioned regarding the investigation stating the resident was care in pairs, Staff B noted that Resident 8 was both, care in pairs and two person assist with mobility. Review of the 08/25/2023 facility investigation showed no statement by, or interview with the Licensed Nursing Staff working on 08/23/2023 to determine if Staff U requested assistance from the nurse or notified the nurse. Review of the statement written by Staff U Staff U told the resident that as it took two CNAs to change them, and Staff U's co-worker went home, night shift CNA would be in at 10:00 PM and Staff U would let them know Resident 9 needed to be changed. Review of the 08/24/2023 facility investigation showed it did not identify the nursing assistant that left work before the end of shift, did not include statements to determine if the absence was known, approved, or covered by the nurse on duty. During an interview on 09/01/2023 at 1:23 PM, Staff B stated that staff were not allowed to leave early. Review of the 08/25/2023 facility investigation showed that Staff U was working at the time of the resident's complaint Thursday morning. Staff U was removed from their assignment pending investigation. The investigation did not identify what time Resident 8 notified Staff L, or what time Staff U was removed from the floor. During an interview on 09/01/2023 at 1:23 PM, Staff B stated that they did not know when Staff L was aware of the allegation, but Staff L was delayed in reporting the allegation to Staff B. Review of the 08/25/2023 facility investigation showed residents on D Hall were interviewed and the resident's felt safe and their needs were met. Review of the Resident Abuse/Allegation Questionnaires dated 08/24/2023 showed they asked the residents the following questions: Has any staff been physically or verbally abusive towards you? Have you seen any of the staff being physically or verbally abusive towards any other residents? Do you feel safe in the facility? Do you feel the staff transfer you correctly? None of the questions asked pertained to the allegation being investigated - neglect, refusal to provide care requested, delay in care due to requiring two staff, and/or care provided by Staff U specifically. <Resident 1> Review of the 05/24/2023 Significant Change in Status Minimum Data Set (MDS - an assessment tool), showed Resident 1 admitted to the facility 09/06/2022, with multiple medical diagnoses. During an interview on 07/18/2023 at 11:50 AM, Resident 1's family member, CC2 stated staff at the facility were keeping them away from the facility. CC2 recalled that he had been at the facility on 06/19/2023 with his family, had an altercation with the Social Worker and they called the cops on us. CC2 denied having been served with any written notice, letter or court order and stated since then they hadn't called with any changes or updates and if he called to speak to Resident 1 staff said the phone was broken. CC2 stated, I want to be able to see my dad, and I'd like to pick him up and go take him out to eat. Review of a Social Services Note dated 06/19/2023 at 1:50 PM showed an intense argument/verbal abuse that occured between facility staff and CC2 in front of residents. Staff A, Administrator (Executive Director - ED), called the police. According to the note, they were told they could not return as they were volatile and it's no longer safe for them to come to the building. During an interview on 08/01/2023 at 2:58 PM, Staff B stated CC2 threatened Staff G and Staff A, Administrator. They had to call police and he left before they came. Staff B stated, He was asked to not come back because he was threatening staff. The faciltiy failed to provide support or assist Resident 1 to cope with the cope with the potential emotional stress as a result of witnessing verbal abuse and having their family members banned from the facility. During an interview on 08/23/2023 at 3:34 PM, Staff A stated that CC2 stated mouthing off, using vulgar words and yelling at Staff G. Staff A stated that he told CC2 that he was being disruptive and inappropriate and they would call police. When Staff A started to call the police, Resident 1's family left the facility. Staff A stated, I didn't tell him he couldn't come back. Staff G put Resident 1's roommate on alert for potential psychosocial harm. Review of a 07/20/2023 8:06 AM Nurse's Note showed Staff F received a phone call from CC2, who was yelling at Staff F saying, you guys killed Resident 1, he has 24 hours someone to watch him, how can he be dead? The nurse documented in the resident's record that CC2 stated the facility kicked him out, and wouldn't let him come to see his dad. Review of the June 2023 Incident Reporting Log showed no entry for a 06/19/2023 incident. Review of the July 2023 Incident Reporting Log showed no entry for the 07/20/2023 allegation of abuse by the son against facility. REFERENCE WAC: 388-97-0640(5)(a)(6)(a)(b)(c)(7)(a). .