Based on policy review, record review, and staff interview, the facility failed to protect a resident's right to be free from abuse that resulted in mental anguish for Resident #1. This was a random opportunity for a discovery made during a complaint investigation. Resident identifier: #1. Facility census: 107. Using the reasonable person concept, the facility's failure to protect a resident's right to be free from abuse resulted in mental anguish for Resident #1 and had the potential to cause serious harm and or death. This was true for Resident #1. Facility Census: 107. Findings included: a) West Virginia Abuse, Neglect and Misappropriation Policy Review of the facility's West Virginia Abuse, Neglect and Misappropriation Policy revealed the following details: - Abuse was defined as intimidation or punishment resulting in physical harm, pain, or mental anguish. It was noted that abuse included mental abuse. - Physical Abuse was noted to include, but not be limited to, hitting slapping, pinching, biting, and kicking. - Verbal Abuse was noted to include the use of gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples given included yelling or hovering over a resident, with the intent to intimidate. - An alleged violation was defined as a situation or occurrence that was observed or reported by staff, resident, relative, visitor, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse. - Section V of the policy, titled Investigation of Incidents, noted if the individual reporting perceived an event to be abuse, neglect or misappropriation, the facility must report the event. - Section III of the policy, titled Prevention, directed that an employee who was alleged or accused of being a party to abuse would immediately be removed from the area(s) of resident care, interviewed by facility leadership for a written statement and not left alone. -Section VII, titled Reporting of Incidents and Facility Response, indicated: 1. All alleged violations will be reported to the Administrator immediately 2. The Administrator / Designee will report appropriate incidents to OHFLAC (Office of Health Facility Licensure and Certification), APS (Adult Protective Services), the Regional Ombudsman, and other local authorities, including but not limited to local law enforcement (if appropriate), as required by State law. 3. If the event that caused the allegation involves abuse, the self-report must be made immediately, but not later than two (2) hours after the allegation is made. 4. The results of the facility's investigation must be reported to the Administrator / Designee, OHFLAC, APS, Regional Ombudsman, and other officials as required by State law, within five working days of the incident. b) Staff Interview with CNA #22 During a telephone interview on 12/26/23 at 6:30 PM, CNA #22 stated other CNAs working the evening shift will purposefully provoke Resident #1 until he becomes agitated, screams, and demonstrates behaviors then staff giggle about it. They will get in his face and shake his chair, pull his hat off his head, taunt him by holding it out of reach, or poke him repeatedly on the cheek until he screams out. They say he will sleep better after such outbursts. CNA #22 stated she reported this to LPN #30, on 12/20/23 at approximately 1:00 AM, and was told probably not much that would be done about it. CNA #22 stated she then sent a text message, at approximately 1:30 AM, to the DON and expressed concern by texting, He's (Resident #1) is screaming because they had him agitated intentionally. CNA #22 reported she never received any response from the DON. CNA #22 reported being very upset regarding the fact that such treatment was happening in the building and went on to say as a severely cognitively impaired resident, having someone in your face shaking your chair, pulling your hat off your head and taunting you by holding it out of reach, and poking you repeatedly on your cheek until you screamed out, would be very upsetting and confusing. A subsequent record review revealed Resident #1 is a resident with severely impaired cognition. He has been diagnosed with Alzheimer's Disease and Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Insomnia. Resident #1 has a BIMS score of 01, suggesting severe cognitive impairment. c) Staff Interview with CNA #118 During a telephone interview on 12/27/23 at 9:37 AM, CNA #118 stated she had personally observed other CNAs working the evening shift purposefully provoke Resident #1 until he becomes agitated, screams, and demonstrates behaviors. She went on to say, It angers me. They think it's funny. It's not. Then when he does have combative behaviors the same staff act upset with him. It's not right. CNA #118 relayed she has not reported any of her concerns for fear of retaliation. She said, It's common knowledge amongst CNAs that if you say something, you might as well be prepared to leave your job. CNA #118 also reported that she has witnessed CNA #24 has placed Resident #1 in the nook by the shower room and then blocked the chair so Resident #1 could not be mobile throughout the building. Allegedly, CNA #24 has stated, He gets on my nerves. I'm tired of his wandering. d) Review of the Facility Reportables Log Review of the facility's reportable log, completed on 12/27/23 at 9:55 AM, revealed the allegation of abuse had not been reported to appropriate state agencies. e) Interview with the Director of Nursing (DON) and Administrator During an interview on 12/27/23 at 10:17 AM, the DON reported she would need to check her messages to determine if she had ever been notified of possible abuse/mistreatment of Resident #1 on the evening shift. On 12/27/23 at 11:16 AM, the DON confirmed she did receive a text from CNA #22 on 12/20/23 at 1:47 AM. She states when she had read the text, she had not interpreted CNA #22's statement to be an allegation of abuse. The DON confirmed this issue had never been reported and had never been investigated. Both the DON and the Administrator acknowledged that the facility had never reported the allegations of abuse to appropriate state agencies, nor was it addressed in any fashion within the building to prevent further abuse from happening. The facility was notified of the IJ (Immediate Jeopardy) at 3:00 PM on 12/27/23. The facility submitted their initial abatement plan of correction (POC) at 4:36 PM on 12/27/23. The State Office requested revision and the POC was approved at 5:39 PM on 12/27/23. After observation, staff interview, review of facility documentation, and record review determining the implementation of the POC, the IJ was abated at 6:30 PM on 12/27/23. The IJ started on 12/27/23 at 3:00 PM and ended on 12/27/23 at 6:30 PM. The facility's approved abatement POC consisted of the following: 1. Resident #1 being assessed by NP (Nurse Practitioner) for any psychosocial effects from incident. CNA #24 was immediately removed from the schedule upon notification on 12/27/23 and suspended pending investigation. This incident was immediately reported on 12/27/23 at 1:11 pm to OHFLAC (Office of Health Facility Licensure and Certification), APS (Adult Protective Services), Ombudsman and Nurse Aide Registry by the DON (Director of Nursing). 2. All alert residents were interviewed by Social Worker on 12/27/23 to identify other concerns and no other issues were identified. 3. All Staff was immediately re-educated on reporting allegations of abuse, including perceived threats of involuntary seclusion, immediately to OHFLAC, Nurse Aide Registry, APS, and Ombudsman or other licensing board as warranted with posttest for validation of understanding. All staff in facility at this time were also re-educated on immediate reporting of abuse allegations and the definition of abuse and involuntary seclusion and staff not available at this time will be re-educated prior to start of next scheduled shift including post-test to validate understanding. Staff will be reassured that any and all reports will remain confidential and ensure understanding of timely reporting to supervisor. The DON will review all texts timely that are received from staff, follow up with a phone call to staff related to incident, and subsequently follow all reporting guidelines if the allegation rises to that level. 4. Administrator/designee will round with all residents daily for two weeks, then three times a week for two weeks then per month for three months to identify residents with concerns of abuse and any allegations will be reported immediately to OHFLAC, Ombudsman, APS, Nurse Aide registry and other licensing board as warranted. All allegations of abuse and neglect will be reviewed at the facilities QAPI (Quality Assurance and Performance Improvement) meeting each month.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to implement their written Abuse and Neglect policy as it related to reporting allegations of abuse and failed to follow procedures to investigate any such allegations. Their lack of action to investigate the abuse allegation placed Resident #1 at continued risk of staff abuse for six (6) days prior to Surveyor intervention. Review of facility records found that there were 30 other residents who had a BIMS (Brief Interview for Mental Status) score between 0-7, suggesting severe cognitive impairment. They also were at risk of staff abuse. Resident identifiers: #1, #3, #6, #10, #13, #14, #17, #26, #34, #36, #37, #38, #44, #49, #50, #53, #55, #57, #60, #66, #67, #68, #75, #87, #89, #95, #97, #99, #103, #104, #111. Facility Census: 107. Findings included: a) West Virginia Abuse, Neglect and Misappropriation Policy Review of the facility's West Virginia Abuse, Neglect and Misappropriation Policy revealed the following details: - Abuse was defined as intimidation or punishment resulting in physical harm, pain, or mental anguish. It was noted that abuse included mental abuse. - Physical Abuse was noted to include, but not be limited to, hitting slapping, pinching, biting, and kicking. - Verbal Abuse was noted to include the use of gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. Examples given included yelling or hovering over a resident, with the intent to intimidate. - An alleged violation was defined as a situation or occurrence that was observed or reported by staff, resident, relative, visitor, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse. - Section V of the policy, titled Investigation of Incidents, noted if the individual reporting perceived an event to be abuse, neglect or misappropriation, the facility must report the event. - Section III of the policy, titled Prevention, directed that an employee who was alleged or accused of being a party to abuse would immediately be removed from the area(s) of resident care, interviewed by facility leadership for a written statement and not left alone. -Section VII, titled Reporting of Incidents and Facility Response, indicated: 1. All alleged violations will be reported to the Administrator immediately 2. The Administrator / Designee will report appropriate incidents to OHFLAC (Office of Health Facility Licensure and Certification), APS (Adult Protective Services), the Regional Ombudsman, and other local authorities, including but not limited to local law enforcement (if appropriate), as required by State law. 3. If the event that caused the allegation involves abuse, the self-report must be made immediately, but not later than two (2) hours after the allegation is made. 4. The results of the facility's investigation must be reported to the Administrator / Designee, OHFLAC, APS, Regional Ombudsman, and other officials as required by State law, within five working days of the incident. b) Staff Interview with CNA #22 During a telephone interview on 12/26/23 at 6:30 PM, CNA #22 stated other CNAs working the evening shift will purposefully provoke Resident #1 until he becomes agitated, screams, and demonstrates behaviors then staff giggle about it. They will get in his face and shake his chair, pull his hat off his head, taunt him by holding it out of reach, or poke him repeatedly on the cheek until he screams out. They say he will sleep better after such outbursts. CNA #22 stated she reported this to LPN #30, on 12/20/23 at approximately 1:00 AM, and was told probably not much that would be done about it. CNA #22 stated she then sent a text message, at approximately 1:30 AM, to the DON and expressed concern by texting, He's (Resident #1) is screaming because they had him agitated intentionally. CNA #22 reported she never received any response from the DON. CNA #22 reported being very upset regarding the fact that such treatment was happening in the building and went on to say as a severely cognitively impaired resident, having someone in your face shaking your chair, pulling your hat off your head and taunting you by holding it out of reach, and poking you repeatedly on your cheek until you screamed out, would be very upsetting and confusing. A subsequent record review revealed Resident #1 is a resident with severely impaired cognition. He has been diagnosed with Alzheimer's Disease and Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Insomnia. Resident #1 has a BIMS score of 01, suggesting severe cognitive impairment. c) Staff Interview with CNA #118 During a telephone interview on 12/27/23 at 9:37 AM, CNA #118 stated she had personally observed other CNAs working the evening shift purposefully provoke Resident #1 until he becomes agitated, screams, and demonstrates behaviors. She went on to say, It angers me. They think it's funny. It's not. Then when he does have combative behaviors the same staff act upset with him. It's not right. CNA #118 relayed she has not reported any of her concerns for fear of retaliation. She said, It's common knowledge amongst CNAs that if you say something, you might as well be prepared to leave your job. CNA #118 also reported that she has witnessed CNA #24 has placed Resident #1 in the nook by the shower room and then blocked the chair so Resident #1 could not be mobile throughout the building. Allegedly, CNA #24 has stated, He gets on my nerves. I'm tired of his wandering. d) Review of the Facility Reportable Log Review of the facility's reportable log, completed on 12/27/23 at 9:55 AM, revealed the allegation of abuse had not been reported to appropriate state agencies. e) Review of Residents' Brief Interview for Mental Status (BIMS) Scores Resident #3's Quarterly Minimum Data Set (MDS), dated [DATE], reflected resident had a BIMS score of 03 suggesting severe cognitive impairment. Resident #6's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 07 suggesting severe cognitive impairment. Resident #10's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 05 suggesting severe cognitive impairment. Resident #13's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 07 suggesting severe cognitive impairment. Resident #14's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 06 suggesting severe cognitive impairment. Resident #17's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 99 suggesting severe cognitive impairment. Resident #26's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 04 suggesting severe cognitive impairment. Resident #34's Annual MDS, dated [DATE], reflected resident had a BIMS score of 06 suggesting severe cognitive impairment. Resident #36's admission MDS, dated [DATE], reflected resident had a BIMS score of 05 suggesting severe cognitive impairment. Resident #37's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 05 suggesting severe cognitive impairment. Resident #38's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 04 suggesting severe cognitive impairment. Resident #44's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 04 suggesting severe cognitive impairment. Resident #49's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 04 suggesting severe cognitive impairment. Resident #50's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 07 suggesting severe cognitive impairment. Resident #53's Annual MDS, dated [DATE], reflected resident had a BIMS score of 05 suggesting severe cognitive impairment. Resident #55's Medicare - 5 Day MDS, dated [DATE], reflected resident had a BIMS score of 99 suggesting severe cognitive impairment. Resident #57's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 07 suggesting severe cognitive impairment. Resident #60's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 03 suggesting severe cognitive impairment. Resident #66's Annual MDS, dated [DATE], reflected resident had a BIMS score of 07 suggesting severe cognitive impairment. Resident #67's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 03 suggesting severe cognitive impairment. Resident #68's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 03 suggesting severe cognitive impairment. Resident #75's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 04 suggesting severe cognitive impairment. Resident #87's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 03 suggesting severe cognitive impairment. Resident #89's admission MDS, dated [DATE], reflected resident had a BIMS score of 05 suggesting severe cognitive impairment. Resident #95's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 03 suggesting severe cognitive impairment. Resident #97's Significant Change MDS, dated [DATE], reflected resident had a BIMS score of 04 suggesting severe cognitive impairment. Resident #99's Annual MDS, dated [DATE], reflected resident had a BIMS score of 05 suggesting severe cognitive impairment. Resident #103's Annual MDS, dated [DATE], reflected resident had a BIMS score of 07 suggesting severe cognitive impairment. Resident #104's Annual MDS, dated [DATE], reflected resident had a BIMS score of 03 suggesting severe cognitive impairment. Resident #111's Quarterly MDS, dated [DATE], reflected resident had a BIMS score of 03 suggesting severe cognitive impairment. f) Interview with the Director of Nursing (DON) and Administrator During an interview on 12/27/23 at 10:17 AM, the DON reported she would need to check her messages to determine if she had ever been notified of possible abuse/mistreatment of Resident #1 on the evening shift. On 12/27/23 at 11:16 AM, the DON confirmed she did receive a text from CNA #22 on 12/20/23 at 1:47 AM. She states when she had read the text, she had not interpreted CNA #22's statement to be an allegation of abuse. The DON confirmed this issue had never been reported and had never been investigated. Both the DON and the Administrator acknowledged that the facility had never reported the allegation of abuse to appropriate state agencies, nor was it addressed in any fashion within the building to prevent further abuse from happening. The facility was notified of the IJ (Immediate Jeopardy) at 3:00 PM on 12/27/23. The facility submitted their initial abatement plan of correction (POC) at 4:36 PM on 12/27/23. The State Office requested revision and the POC was approved at 5:39 PM on 12/27/23. After observation, staff interview, review of facility documentation, and record review determining the implementation of the POC, the IJ was abated at 6:30 PM on 12/27/23. The IJ started on 12/27/23 at 3:00 PM and ended on 12/27/23 at 6:30 PM. The facility's approved abatement POC consisted of the following: 1. Resident #1 being assessed by NP (Nurse Practitioner) for any psychosocial effects from incident. CNA #24 was immediately removed from the schedule upon notification on 12/27/23 and suspended pending investigation. This incident was immediately reported on 12/27/23 at 1:11 pm to OHFLAC (Office of Health Facility Licensure and Certification), APS (Adult Protective Services), Ombudsman and Nurse Aide Registry by the DON (Director of Nursing). 2. All alert residents were interviewed by Social Worker on 12/27/23 to identify other concerns and no other issues were identified. 3. All Staff was immediately re-educated on reporting allegations of abuse, including perceived threats of involuntary seclusion, immediately to OHFLAC, Nurse Aide Registry, APS, and Ombudsman or other licensing board as warranted with posttest for validation of understanding. All staff in facility at this time were also re-educated on immediate reporting of abuse allegations and the definition of abuse and involuntary seclusion and staff not available at this time will be re-educated prior to start of next scheduled shift including post-test to validate understanding. Staff will be reassured that any and all reports will remain confidential and ensure understanding of timely reporting to supervisor. The DON will review all texts timely that are received from staff, follow up with a phone call to staff related to incident, and subsequently follow all reporting guidelines if the allegation rises to that level. 4. Administrator/designee will round with all residents daily for two weeks, then three times a week for two weeks then per month for three months to identify residents with concerns of abuse and any allegations will be reported immediately to OHFLAC, Ombudsman, APS, Nurse Aide registry and other licensing board as warranted. All allegations of abuse and neglect will be reviewed at the facilities QAPI (Quality Assurance and Performance Improvement) meeting each month.

Based on record review and staff interview, the facility failed to complete a thorough investigation of a staff member's allegation of resident abuse, maintain documentation that alleged violation was thoroughly investigated, and report the results to Adult Protective Services and the State Survey Agency, within five (5) working days of the incident in accordance with State law. The facility's failure to complete a thorough investigation of a staff member's allegation of resident abuse left residents who were deemed to be severely cognitively impaired at risk of further abuse. In addition, the facility failed to ensure the victim was protected from further abuse which put the residents at risk for additional serious harm and or death. Findings included: a) Staff Interview with CNA #22 During a telephone interview on 12/26/23 at 6:30 PM, CNA #22 stated other CNAs working the evening shift will purposefully provoke Resident #1 until he becomes agitated, screams, and demonstrates behaviors then staff giggle about it. They will get in his face and shake his chair, pull his hat off his head, taunt him by holding it out of reach, or poke him repeatedly on the cheek until he screams out. They say he will sleep better after such outbursts. CNA #22 stated she reported this to LPN #30, on 12/20/23 at approximately 1:00 AM, and was told probably not much that would be done about it. CNA #22 stated she then sent a text message, at approximately 1:30 AM, to the DON and expressed concern by texting, He's (Resident #1) is screaming because they had him agitated intentionally. CNA #22 reported she never received any response from the DON. CNA #22 reported being very upset regarding the fact that such treatment was happening in the building and went on to say as a severely cognitively impaired resident, having someone in your face shaking your chair, pulling your hat off your head and taunting you by holding it out of reach, and poking you repeatedly on your cheek until you screamed out, would be very upsetting and confusing. A subsequent record review revealed Resident #1 is a resident with severely impaired cognition. He has been diagnosed with Alzheimer's Disease and Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Insomnia. Resident #1 has a BIMS score of 01, suggesting severe cognitive impairment. b) Review of the Facility Reportable Log Review of the facility's reportable log, completed on 12/27/23 at 9:55 AM, revealed the allegation of abuse had not been reported to appropriate state agencies. c) Interview with the Director of Nursing (DON) and Administrator During an interview on 12/27/23 at 10:17 AM, the DON reported she would need to check her messages to determine if she had ever been notified of possible abuse/mistreatment of Resident #1 on the evening shift. On 12/27/23 at 11:16 AM, the DON confirmed she did receive a text from CNA #22 on 12/20/23 at 1:47 AM. She states when she had read the text, she had not interpreted CNA #22's statement to be an allegation of abuse. The DON confirmed this issue had never been reported and had never been investigated. Both the DON and the Administrator acknowledged that the facility had never reported the allegation of abuse to appropriate state agencies, nor was it addressed in any fashion within the building to prevent further abuse from happening. The facility was notified of the IJ (Immediate Jeopardy) at 3:00 PM on 12/27/23. The facility submitted their initial abatement plan of correction (POC) at 4:36 PM on 12/27/23. The State Office requested revision and the POC was approved at 5:39 PM on 12/27/23. After observation, staff interview, review of facility documentation, and record review determining the implementation of the POC, the IJ was abated at 6:30 PM on 12/27/23. The IJ started on 12/27/23 at 3:00 PM and ended on 12/27/23 at 6:30 PM. The facility's approved abatement POC consisted of the following: 1. Resident #1 being assessed by NP (Nurse Practitioner) for any psychosocial effects from incident. CNA #24 was immediately removed from the schedule upon notification on 12/27/23 and suspended pending investigation. This incident was immediately reported on 12/27/23 at 1:11 pm to OHFLAC (Office of Health Facility Licensure and Certification), APS (Adult Protective Services), Ombudsman and Nurse Aide Registry by the DON (Director of Nursing). 2. All alert residents were interviewed by Social Worker on 12/27/23 to identify other concerns and no other issues were identified. 3. All Staff was immediately re-educated on reporting allegations of abuse, including perceived threats of involuntary seclusion, immediately to OHFLAC, Nurse Aide Registry, APS, and Ombudsman or other licensing board as warranted with posttest for validation of understanding. All staff in facility at this time were also re-educated on immediate reporting of abuse allegations and the definition of abuse and involuntary seclusion and staff not available at this time will be re-educated prior to start of next scheduled shift including post-test to validate understanding. Staff will be reassured that any and all reports will remain confidential and ensure understanding of timely reporting to supervisor. The DON will review all texts timely that are received from staff, follow up with a phone call to staff related to incident, and subsequently follow all reporting guidelines if the allegation rises to that level. 4. Administrator/designee will round with all residents daily for two weeks, then three times a week for two weeks then per month for three months to identify residents with concerns of abuse and any allegations will be reported immediately to OHFLAC, Ombudsman, APS, Nurse Aide registry and other licensing board as warranted. All allegations of abuse and neglect will be reviewed at the facilities QAPI (Quality Assurance and Performance Improvement) meeting each month.