Based on record review and staff interview, the facility failed to ensure residents of the facility were free from abuse and neglect. For Residents #2 and #56, the facility failed to ensure they were free from sexual abuse, committed by Resident #214. For Residents #33, #50, #38, #43, #216, #51, #215, #46, #6, #35, and #17, the facility failed to ensure these residents were free of neglect related to medication administration. For Resident #33, the facility failed to ensure this resident was free from abuse due to misappropriation of medications. For Resident #1, the facility failed to transfer the resident in the correct manner, resulting in neglect. For Resident #20, the facility failed to ensure this resident was free from neglect by failing to ensure the seatbelt was fastened while being transferred in the van. This was true for 16 of 16 residents reviewed for abuse and neglect during the survey process. Resident identifiers: #2, #56, #33, #50, #38, #43, #216, #51, #215, #46, #6, #35, #17, #33, #1, #20. Facility census: 61. The State Agency (SA) determined psychosocial harm was caused to Residents #2 and #56 when Resident #214 sexually assaulted both residents. For Resident #2, the facility returned Resident #2 to the same room with Resident #214, following the incident, and failed to provide documentation that supervision occurred to prevent the issue from happening again. For Resident #56, the facility failed to maintain proper supervision on Resident #214, following an incident of sexual assault on Resident #2, allowing him to sexually assault Resident #56, who has a diagnosis of Post Traumatic Stress Disorder (PTSD) from being raped in prison, and failing to provide documentation showing supervision was held on Resident #214, despite Residents #56 and #214 being roommates. The reasonable person standard was applied to determine the psychosocial harm niether Resident #56 and #2 were not able to verbalize how this affected them due to cognitive impairment. A reasonable person is likely to suffer feelings including but not limited to anger, fear, depression, hopelessness, dispair, and frequent crying spells. Findings include: a) Resident #2 During review of a facility reported incident (FRI) on 03/04/25, it was discovered Resident #214 had sexually abused Resident #2 on 12/19/24. According to the facility investigation, on 12/19/24, Nurse Aide (NA) #65 noticed Resident #214 with his hand on the groin of Resident #2, under a blanket, while residents were waiting to see the podiatrist in the dining room. NA #65 told Resident #214 to get your hands off of him. At this point, NA #65 stated the resident then pulled his hand out and just looked at me with no response and no emotion. NA #65 stated she pulled Resident #2 away from Resident #214 and informed the unit manager of the incident. Resident #214 remained in the dining room, unsupervised, at this point. Resident #2 was then taken back into the dining room, with Resident #214, while another staff member observed them. Resident #214 was placed on line of sight (LOS) observation while out of bed, and fifteen minute checks. No documentation on LOS observation was provided. Fifteen minute check documentation provided by the facility revealed no one signed off on observing Resident #214. The fifteen minute checks list Resident #214 in bed and room from 12:00 AM on 12/19/224 until 11:45 AM, with the exception of 9:15 AM when the resident was documented as being located at shower. All of these have been signed off by an employee. 12:00 PM to 12:45 PM list the resident's location as bed. 1:00 PM to 1:30 PM lists the location of the resident as podiatry. 1:45 PM to 11:45 PM lists the resident's location as bed. No observation from 12:00 PM to 11:45 PM on 12/19/24 has been signed off on by an employee of the facility, with the initials section left blank. The facility stated the following in their five (5) day follow up investigation report for the incident on 12/19/24: (Resident #214's name) is a new resident who was placed in (facility name) from (correctional facility) because he had no other options. He is a registered sex offender and will remain on 1-1 (one on one observation) as long as necessary. However, there were no orders entered, nor as any documentation provided to support the resident was on one (1) on one (1) observation during this time. In fact, in an interview with the Director of Nursing (DON) on 3/4/25, at approximately 12:55 PM, it was confirmed there were only orders present for Resident #214 to be placed on LOS observation and 15 minute checks, not 1 on 1, following this incident. Resident #2 is nonverbal and a Brief Interview for Mental Status (BIMS) score was unable to be obtained due to the residents diagnoses, which are listed as follows: Spastic quadriplegia; dextrocardia; congenital cranial anomaly; microcephaly; seizure disorder; hyperthyroidism; multinodular goiter; GERD; profound intellectual disabilities. Due to the residents condition, the reasonable person standard was applied, in which it is assumed Resident #2 did not want to be sexually assaulted by Resident #214 and did not wish to be placed back in the same room with his abuser immediately following the incident. b) Resident #56 During review of the FRI involving Resident #214, it was noted a second incident occurred on 12/22/24 at approximately 8:30 AM, this time involving Resident #56. Despite Resident #214 being placed on LOS observation, 15 minute checks and, according to the 5 day follow up, 1 on 1 observation, he was found to have his hand on the groin area of Resident #56. According to the initial report from the facility, (Resident #214's name) moved over to (Resident #56's name) while he was asleep in his wheelchair. He fondled (Resident #56's name) when staff turned their head. The facility stated the following on the 5 day follow up report: (Resident #214's name) was on line of sight when not in bed. He moved his wheelchair close to another resident who was sleeping in his chair in the dayroom. Staff turned their head to check on another resident and when they turned around he was fondling the other resident over top his pants. They were immediately separated and a skin assessment was completed on (Resident #56's name). A review of Resident #56's medical record indicates he has a diagnosis of Post Traumatic Stress Disorder (PTSD) due to being raped in prison. There was no mention in the resident's care plan about the incident occurring on 12/22/24. Further review of Resident #56's medical record include psych notes, one dated 01/23/25, in which the resident states I'm not safe here. Another psych note dated 02/06/25, the resident states he is being raped and killed. The psych note states the resident's anxiety is rather high. At approximately 12:49 PM on 03/04/25, an interview was conducted with the facility Social Worker (SW), who is in charge of admissions and investigations. The SW stated He was, we did not feel, stable. He was throwing feces and had other issues. When asked about how the incident occurred on 12/22/24, the SW stated, Staff turned their backs on him. He did it because staff turned their backs and stopped watching him. The SW stated the police were called and during their interview with Resident #214, he stated he had been looking at the facility for cameras and did not notice any, and once he did not see cameras, he decided he was going to abuse someone. Following this incident, Resident #214 was placed on 1 on 1 observation and an order was obtained at 11:36 AM to send the resident to the hospital. The resident left for the hospital at approximately 12:00 PM on 12/22/24. Resident #214 and #56 resided in the same room. From the time of the incident at approximately 8:30 AM, until the time Resident #214 left for the hospital at approximately 12:00 PM, there is no documentation to support any observations taking place to verify the whereabouts of Resident #214. The 15-minute check forms end on 12/21/24, despite the resident not having an order to discontinue them. At approximately 4:00 PM on 3/4/25, one (1) on one (1) documentation was requested from the facility, showing Resident #214 was observed. The DON confirmed they do not do such documentation. The DON also acknowledged the absence of 15-minute check documentation for 12/22/24, the date of this incident. Under the Corrective action taken portion of the 5 day follow up, the facility states the following: (Resident #214's name) was on line of sight when not in bed. He has now been sent to (hospital) for a mental hygiene. (Facility) will not be taking him back due to being unable to protect our residents from (Resident #214's name). He fondled another resident on 12/19/24 which was reported. Staff interviews and Abuse Policy During an interview with Confidential Employee #1 on 3/4/25, they stated We didn't want to take him (Resident #214) but we weren't given a choice. We were told we had to take him. We tried to not take him. At approximately 1:00 PM on 3/4/25 an interview was conducted with the DON regarding the incidents. The DON stated the resident was denied at first, but the hospital sent more documentation that resulted in the resident being accepted to the facility. The DON stated the documentation supplied identified the resident needing assistance with ADLS, such as help with transferring, so the facility decided to accept him at this point. The DON stated during the second incident, the staff were further up the hallway when it occurred and they couldn't get to him before he assaulted Resident #56. Resident #214 was not placed on 1 on 1 observation (despite the 5 day follow up to the initial incident stating he would be, in order to keep others safe) until after the second incident, on 12/22/24, and was only placed on line of sight observation because The thought was if we can see him, we can intervene. The DON acknowledged staff were not able to keep an eye on Resident #214 and broke the line of sight, due to having to care for another resident, allowing him to abuse Resident #56. At approximately 1:25 PM on 03/04/25, an interview was conducted with Registered Nurse (RN) #5 regarding Resident #214. RN #5 was asked how well the resident was able to ambulate in his wheelchair, to which she responded He was agile like a cat, and that surprised me because we were told he needed a lot of assistance and had trouble getting around. I was in his room when he first got here and was waiting on a lift to come so we could get him up, and he just moved himself from his bed to his chair by himself. I was scared because I thought I was going to get in trouble when he did that. But he was a lot more agile than we thought and were told. During a review of the facility's resident to resident abuse policy, Section IV, titled procedure, Section C, states: If the patient is deemed dangerous, they will be placed on an observation level (which will be determined by the Care Team or nursing supervisor on weekends/holidays) until all referrals have been completed. Referrals will also be made to the staff Psychologist, Psychiatrist, and Medical Doctor for evaluation. The observation levels are as such: 1. 1:1 Strict One staff accompanies the patient at all times This one stuff must keep the patient within arms length at all times Document staff observations and patient activities every hour 2. 1:1 Line of Sight/Constant Awareness One staff assigned to keep patient in view at all times Document staff observations and patient activities every hour 3. Fifteen (15) minute checks At a minimum check every 15 minutes around the clock The patient will participate in all unit activities, being observed every 15 minutes by the assigned staff Documentation of staff at least every 15 minutes 4. Routine Observation Patient will participate in all unit and facility activities, being observed by assigned staff as normal The facility failed to have a person assigned to Resident #214, as stated in the aforementioned policy and, failed to keep documentation as required. During an interview with the DON at approximately 11:15 AM on 03/12/25, it was confirmed the facility did not follow the policy stated above, failing to take appropriate actions to keep residents safe from further incidents of abuse by another resident. The DON stated there is typically one staff member assigned to the resident, however, that staff member still helps assist with other residents as well, which would require them to leave their assigned resident they are observing. The DON stated if a Nurse Aide is not available to observe the assigned resident, they should ask the Unit Manager to observe them. If the unit manager is not available, they should ask a Nurse Aide from another unit to come down and observe their resident while they help, potentially pulling a staff member from another unit. c) Resident #33 On 03/03/25 at 2:32 PM, a review of a facility-reported incident (FRI) dated 07/17/24 found Licensed Practical Nurse (LPN) #134 did not follow physician's orders regarding medication administration and neurological (neuro) checks on the A wing. The following medications were ordered for 07/13/24 at 9:00 PM. The following medications were missed: --Cranberry Capsule --Aricept --Memantine --Remeron --Seroquel The following neuro checks were missed: --07/13/24 8:00 PM --07/14/24 12:01 AM --07/14/24 4:00 AM On 03/04/25 at approximately 11:00 AM, the Director of Nursing (DON) confirmed the incident did happen and LPN #134 was terminated for not completing her nursing duties. LPN #134 was found to be vaping and talking on her telephone in the medication room for multiple hours. Therefore, the incident was substantiated for neglect by the facility. d) Resident #33 On 03/03/24 at 3:00 PM, a review of an FRI was completed. The review found on 11/15/24 at 12:00 PM, Registered Nurse (RN) #26 and RN #3 were both in the medication room, which is verified by facility video. RN #3 was complaining about being sick to her stomach. RN #26 was told by RN #3 which resident had Zofran available. RN #26 looked at the resident's medication and none was available. Then, RN #3 told RN #26 that was the wrong resident and then proceeded to tell RN #26 another resident, who had Zofran available. RN #26 got the medication card and popped the pill out. The pill was dropped and RN #3 proceeded to pick the pill up from the floor, obtained some water and took the pill. Both RN #3 and RN #26 were suspended throughout the investigation. RN #3 signed a consent for a drug testing. The drug testing was found to be negative of any substances. On 03/04/25 at 12:50 PM, the DON was interviewed regarding this incident. The DON stated, both of the RNs are still working here, both were given education and discipline, and both were suspended for three (3) days without pay. Therefore, the incident was substantiated for misappropriation of resident property by the facility. e) Resident #50 On 03/03/25 at 2:32 PM, a review of a facility-reported incident (FRI) dated 07/17/24 found Licensed Practical Nurse (LPN) #134 did not follow physician's orders regarding medication administration on the A wing. The following medications were ordered for 07/13/24 at 9:00 PM. The following medications were missed: --Klonopin --Lithium --Melatonin --Zyprexa --Trileptal --Miralax On 03/04/25 at approximately 11:00 AM, the Director of Nursing (DON) confirmed the incident did happen and LPN #134 was terminated for not completing her nursing duties. LPN #134 was found to be vaping and talking on her telephone in the medication room for multiple hours. Therefore, the incident was substantiated for neglect by the facility. f) Resident #51 On 03/03/25 at 2:32 PM, a review of a facility-reported incident (FRI) dated 07/17/24 found Licensed Practical Nurse (LPN) #134 did not follow physician's orders regarding medication administration on the A wing. The following medications were ordered for 07/13/24 at 9:00 PM. The following medications were late: --Neurontin--2 hours and 10 minutes --Hydrocodone-Acetaminophen 5/325mg--2 hours and 10 minutes --Buspar--2 hours and 10 minutes --Robaxin--2 hours and 10 minutes --Metoprolol Tartrate--2 hours and 10 minutes --Wellbutrin XL--2 hours and 10 minutes On 03/04/25 at approximately 11:00 AM, the Director of Nursing (DON) confirmed the incident did happen and LPN #134 was terminated for not completing her nursing duties. LPN #134 was found to be vaping and talking on her telephone in the medication room for multiple hours. Therefore, the incident was substantiated for neglect by the facility. g) Resident #62 On 03/03/25 at 2:32 PM, a review of a facility-reported incident (FRI) dated 07/17/24 found Licensed Practical Nurse (LPN) #134 did not follow physician's orders regarding medication administration on the A wing. The following medications were ordered for 07/13/24 at 9:00 PM. The following medications were missed: --Acetaminophen --Zyprexa --Miralax --Depakote On 03/04/25 at approximately 11:00 AM, the Director of Nursing (DON) confirmed the incident did happen and LPN #134 was terminated for not completing her nursing duties. LPN #134 was found to be vaping and talking on her telephone in the medication room for multiple hours. Therefore, the incident was substantiated for neglect by the facility. h) Resident #46 On 03/03/25 at 2:32 PM, a review of a facility-reported incident (FRI) dated 07/17/24 found Licensed Practical Nurse (LPN) #134 did not follow physician's orders regarding medication administration on the A wing. The following medications were ordered for 07/13/24 at 9:00 PM. The following medications were missed: --Eliquis --Vitamin C --Depakote --Metoprolol Succinate --Zyprexa --Miralax --Hiprex On 03/04/25 at approximately 11:00 AM, the Director of Nursing (DON) confirmed the incident did happen and LPN #134 was terminated for not completing her nursing duties. LPN #134 was found to be vaping and talking on her telephone in the medication room for multiple hours. Therefore, the incident was substantiated for neglect by the facility. i) Resident #216 On 03/03/25 at 2:32 PM, a review of a facility-reported incident (FRI) dated 07/17/24 found Licensed Practical Nurse (LPN) #134 did not follow physician's orders regarding medication administration on the A wing. The following medications were ordered for 07/13/24 at 9:00 PM. The following medications were late: --Levsin--2 hours and 17 minutes late --Senna--2 hours and 17 minutes late --Claritin--3 hours and 18 minutes late On 03/04/25 at approximately 11:00 AM, the Director of Nursing (DON) confirmed the incident did happen and LPN #134 was terminated for not completing her nursing duties. LPN #134 was found to be vaping and talking on her telephone in the medication room for multiple hours. Therefore, the incident was substantiated for neglect by the facility. j) Resident #38 On 03/03/25 at 2:32 PM, a review of a facility-reported incident (FRI) dated 07/17/24 found Licensed Practical Nurse (LPN) #134 did not follow physician's orders regarding medication administration on the A wing. The following medications were ordered for 07/13/24 at 9:00 PM. The following medications were missed: --Acetaminophen/Codeine 30mg --Vitamin C --Bisacodyl suppository --Klonopin --Lamictal --Lithium --Risperdal --Symbicort inhaler On 03/04/25 at approximately 11:00 AM, the Director of Nursing (DON) confirmed the incident did happen and LPN #134 was terminated for not completing her nursing duties. LPN #134 was found to be vaping and talking on her telephone in the medication room for multiple hours. Therefore, the incident was substantiated for neglect by the facility. k) Resident #43 On 03/03/25 at 2:32 PM, a review of a facility-reported incident (FRI) dated 07/17/24 found Licensed Practical Nurse (LPN) #134 did not follow physician's orders regarding medication administration on the A wing. The following medications were ordered for 07/13/24 at 9:00 PM. The following medications were late: --Zyprexa--3 hours and 19 minutes --Coreg--2 hours and 20 minutes --Klonopin--2 hours and 21 minutes --Buspar--2 hours and 21 minutes --Latanoprost eye drops--2 hours and 22 minutes On 03/04/25 at approximately 11:00 AM, the Director of Nursing (DON) confirmed the incident did happen and LPN #134 was terminated for not completing her nursing duties. LPN #134 was found to be vaping and talking on her telephone in the medication room for multiple hours. Therefore, the incident was substantiated for neglect by the facility. l) Resident #6 On 03/03/25 at 2:32 PM, a review of a facility-reported incident (FRI) dated 07/17/24 found Licensed Practical Nurse (LPN) #134 did not follow physician's orders regarding medication administration on the A wing. The following medications were ordered for 07/13/24 at 9:00 PM. The following medications were late: --Neurontin--2 hours and 8 minutes On 03/04/25 at approximately 11:00 AM, the Director of Nursing (DON) confirmed the incident did happen and LPN #134 was terminated for not completing her nursing duties. LPN #134 was found to be vaping and talking on her telephone in the medication room for multiple hours. Therefore, the incident was substantiated for neglect by the facility m) Resident #35 On 03/03/25 at 2:32 PM, a review of a facility-reported incident (FRI) dated 07/17/24 found Licensed Practical Nurse (LPN) #134 did not follow physician's orders regarding medication administration on the A wing. The following medications were ordered for 07/13/24 at 9:00 PM. The following medications were late: --Hydrocodone/Acetaminophen 7.5/325mg--1 hour and 19 minutes --Trazodone--1 hour and 20 minutes --Fibercon--1 hour and 20 minutes --Buspar--2 hours and 22 minutes On 03/03/25 at 2:32 PM, a review of a facility-reported incident (FRI) dated 07/17/24 found Licensed Practical Nurse (LPN) #134 did not follow physician's orders regarding medication administration and neurological (neuro) checks on the A wing. The following medications were ordered for 07/13/24 at 9:00 PM. The following medications were missed: --Cranberry Capsule --Aricept --Memantine --Remeron --Seroquel The following neuro checks were missed: --07/13/24 8:00 PM --07/14/24 12:01 AM --07/14/24 4:00 AM On 03/04/25 at approximately 11:00 AM, the Director of Nursing (DON) confirmed the incident did happen and LPN #134 was terminated for not completing her nursing duties. LPN #134 was found to be vaping and talking on her telephone in the medication room for multiple hours. Therefore, the incident was substantiated for neglect by the facility. n) Resident #17 On 03/03/25 at 2:32 PM, a review of a facility-reported incident (FRI) dated 07/17/24 found Licensed Practical Nurse (LPN) #134 did not follow physician's orders regarding medication administration on the A wing. The following medications were ordered for 07/13/24 at 9:00 PM. The following medications were late: --Clozaril--2 hours and 58 minutes --Depakote 1 hour and 58 minutes --Coreg--1 hour and 58 minutes --Keppra--1 hour and 59 minutes --Tramadol--1 hour and 59 minutes On 03/03/25 at 2:32 PM, a review of a facility-reported incident (FRI) dated 07/17/24 found Licensed Practical Nurse (LPN) #134 did not follow physician's orders regarding medication administration and neurological (neuro) checks on the A wing. The following medications were ordered for 07/13/24 at 9:00 PM. The following medications were missed: --Cranberry Capsule --Aricept --Memantine --Remeron --Seroquel The following neuro checks were missed: --07/13/24 8:00 PM --07/14/24 12:01 AM --07/14/24 4:00 AM On 03/04/25 at approximately 11:00 AM, the Director of Nursing (DON) confirmed the incident did happen and LPN #134 was terminated for not completing her nursing duties. LPN #134 was found to be vaping and talking on her telephone in the medication room for multiple hours. Therefore, the incident was substantiated for neglect by the facility. n) Resident #1 On 03/04/25 at 9:20 PM Nurse Aide (NA) #107 was observed transferring Resident #1 from his recliner in the hallway to his wheelchair. NA #107 completed the transfer by himself and had the assistance of no other staff members. No devices were used for this transfer. The resident was wearing no skid sock during this transfer. On 03/04/25 at 9:29 PM, NA #107 was again observed transferring Resident #1 from his wheelchair to his recliner in the hallway. NA #107 again completed this transfer by himself with no assistance from any other staff member. At the time of this transfer Resident #1 was barefooted. No Devices were used for this transfer. At 9:32 PM a review of Resident #1's fall prevention care plan was completed. This review found the resident was to be assisted with two (2) staff members with all transfers. The care plan also indicated the resident was to be encouraged to wear special orthotic shoes for safer transfers and prevention of falls. Another focus statement on Resident #1's care plan read as follows, (First Name of Resident #1) requires 2 person assist with bed mobility, with transferring, and ambulation due to severe intellectual disabilities, cerebral palsey . At 9:35 PM on 03/04/25, NA #107 was asked to identify how he would know the transfer status of a resident he stated, We look at the kardex. Charge Nurse (CN) #12 was asked to review Resident #1's Kardex and to inform the surveyor how Resident #1 was to be transferred. She confirmed at 9:38 PM on 03/04/25 the resident was to be transferred with the assistance of two (2) staff members. She showed the surveyor this information on the Kardex. The kardex was located in the hallway and was accessible to NA #107. An interview with NA #107 at 9:40 PM confirmed he transferred the resident by himself. He reviewed the Kardex and stated, I did it wrong because I did it by myself. The surveyor then reviewed the Kardex for Resident #1. The kardex read as follows related to transfers: Transfer Dependent 2 assist Limited brief type transfer device to be used. Further review of the care plan comments found the following, 02/17/25 fall slid to floor during transfer from recliner to w/c (wheelchair) no injury interventions in place. A review of the ADL flow sheets on the morning of 03/10/25 for Resident #1, for the date of 02/17/25 confirmed the staff who was transferring the resident during this transfer documented the resident was transferred via extensive assist with the help of one (1) staff member. Further review of the ADL flow sheets for the remainder of February, 25 found for every night shift transfer the NA's were documenting Resident #1 was transferred via extensive assist with the assistance of one (1) staff member. This indicated a systemic failure in the transfers of Resident #1 which should have been identified and address by the facility prior to the IJ situation. However this was not identified by the facility staff prior to the surveyor alerting the Nursing Home Administrator of the ADL flow sheet documentation on 03/10/25 at 11:00 am. No reeducation of staff was completed nor was this aide reported for neglect prior to the IJ situation on 03/04/25. NA #107 and NA #81 both neglected Resident #1 by not transferring him in a manner which met his needs as it was reflected in his plan of care. The resident is at risk for injury as a result of their neglectful behavior. o) Resident #20 On 03/10/25 at 10:19 AM, a review of the facility's reportable of an unusual occurrence found the following, Resident #20 was taken to an appointment on 04/04/24 the resident was being transported to an appointment and refused to wear his seat belt and the resident slid out of the seat when they went around a sharp curve. An interview with the NHA on 03/10/25 confirmed they did some education that if they refuse to wear the seatbelt that they should not go on the transport. The NHA was unable to provide evidence this training was completed. She was unable to find the sign in sheets. The NHA provided the surveyor with the facility incident report related to this incident. A review of the incident found that NA #94 and NA #93 were the staff which went on the transport with Resident #20 on this date. NA #94 was driving and NA #93 was in the back of the van with Resident #20. The incident report contained the following under the heading Comments: Resident was in the van going to his Dr.'s appointment. Resident refused to put seat belt on. While going around a sharp turn resident slid off his seat and into the floor. Resident stated, Get me back in my seat. The comments under the heading findings found the following, Resident was not secured by seatbelt during transport, thus slid to floor during sharp turn. Resident was sitting in van seat during transport. The actions taken by the facility were listed as, Had resident sit in his w/c (wheelchair) on return back. Resident is to be secured by seatbelt during all transportation. The NHA was asked if any statements were obtained from staff related to this incident. The NHA confirmed in the afternoon of 03/11/25 that no statements were obtained. She provided a list of all staff who assist resident with van transfers. The following staff from the list provided were interviewed beginning at 1:30 PM on 03/11/25: Activity Director, Recreation Specialist (RS) #48 and RS #1, all indicated if a resident refuses to wear their seatbelt they should not be transported. RS #48 and RS #1 stated they would report it to the Activity Director and the resident would not be allowed to go on the trip. All three (3) agreed it has always been this way. The activity director has worked at the facility since 1989, RS #48 has worked at the facility since 1999. RS # has worked at the facility since 2022. NA #31 who works in the special needs program at the facility indicated if a resident was to refuse to wear their seatbelt, she would not take them on the transport. She indicated the vehicle cannot move until the resident is secured. She stated it has always been this way and not something that had recently came about. She has been an employee of the facility since 2017. Office Assistant #64 stated, If they refuse to wear their seatbelt then they can not go on a transport. OA #64 was then asked if this was a change since the incident or has it always been this way and she stated, I have been doing transports for a little over two (2) years and it has always been that way. The NHA was again interviewed at 1:45 PM on 03/11/25 and was made aware of the above interviews. She stated, Well that tells me they knew better. When asked if NA #94 and NA #93 were reported for neglect for not ensuring Resident #20 was wearing a seatbelt she stated they were not. She was asked to provide any training to the staff who go on transports prior to transporting. Later in the afternoon she stated, They only receive training on the state vehicle use policy. A review of the state vehicle use policy found the following, .Seat Belts must be worn at all times On the morning of 03/12/25 the two (2) staff accompanying Resident #20 on this trip was interviewed. NA #93 confirmed she was in the back of the van with Resident #20. She stated she had assumed[TRUNCATED]